REPRODUCTIVE HEALTH

FOR

Health Science Students

Lecture Note

Feleke Worku (MD)

Samuel Gebresilassie (MD)

University of Gondar
REPRODUCTIVE HEALTH
For

Health Science Students

Lecture Note
Feleke Worku (MD) Lecturer
Samuel Gebresilassie (MD)

Associate Professor of Gynecology and

Obstetrics

2008

In collaboration with
The Carter Canter (EPHTI) and The Federal
Democratic Republic of Ethiopia Ministry
of Education and Ministry of Health

University of Gondar
 PREFACE

This lecture note lecture note in reproductive health for health

science students is prepared in accordance with the current
curriculum, which we think will be of help to meet the millennium
development goals in the health perspective, which is broader in
scope and extensive in contents than the already existing maternal
on child health. It will help students and other readers to understand
the current reproductive health understandings.

Starting with the definition, we have gone through its components.

Each component was dealt with extensively as a chapter. Emphasis
was given to the service provision and challenges and on how to
overcome the challenges which most of the time is not easily
available and accessible for the students. In each reproductive health
component, we tried to address important national and international
up-dated figures and evidence based and practical reproductive
health and related issues.

The authors

i
 ACKNOWLEDGEMENT
We would like to express our deepest gratitude to The Carter Center,
Ethiopian Public Health Training Initiative to take the initiative and
sponsor the development of this lecture note. We would like to thank
the internal reviewers of the University of Gondar staff, W/t
Alemtsehay Mekonnen from the Department of Midwifery and Dr.
Desalegn Tigabu, Department of epidemiology.

We would like to express our appreciation to the external

reviewers: ACCESS JHPIEGO for the excellent comments they
gave us.

We would like to thank the reviewers of inter institution:

Dr. Nega Jimma University

Dr. Million Debub University Ato
Araya Mekelle University
Ato Anteneh Haremaya University
Finally, we thank all individuals and institutions who helped us in
making this invaluable material to come to a reality.
 Table of content

Preface.................................................................................................i
Acknowledgement..............................................................................ii
Table of Content................................................................................iii
List of Table.....................................................................................vii
List of Figures.................................................................................viii
CHAPRTER 1: Introduction to Reproductive Health......................1
1. Definition and introduction.....................................................1
1.1. Historical development of the concept.....................2
1.2. Development of Reproductive Health......................8
1.3. Magnitude of Reproductive Health Problem..........10
1.4. Components of Reproductive Health.....................12
2. Reproductive health indicators.............................................13
2.1. CRITERIA FOR SELECTING INDICATORS........14
2.2. Sources of data..........................................................18
2.3. Reproductive Health Indicators for Global Monitoring
................................................................................19
3. Gender and Reproductive Health..........................................24
3.1. Gender differences:................................................29
4. REPRODUCTIVE HEALTH AND DEFINING TARGET
POPULATION.....................................................................34

CHAPRTER 2: Material Health.....................................................40

1. Introduction...........................................................................40
2. The Safe Motherhood Initiative............................................42
2.1. Essential Services for Safe Motherhood...................43
2.2. Causes of Maternal Mortality and Morbidity............49
2.3 Maternal health services..............................................61
2.4. Estimation of maternal mortality............................91

CHAPRTER 3: Abortion..............................................................108
3.1. Public Health Importance of Abortion....................110
3.2. Why Women Find Themselves with Unwanted
Pregnancy?...........................................................113
3.3 Why does induced Abortion Occur?........................115
3.4 Legislation and policies............................................118
3.5 Inadequate services..............................................119
3.6 What can be done about unwanted pregnancies and
unsafe abortions?..................................................120
3.7 Grounds on Which Abortion is Permitted, revised
abortion law of Ethiopia, (House of Parliament, 2005)
..............................................................................125

CHAPRTER 4: Family Planning.................................................127

4.1. Origins and Rationale for Family Planning Programs in
Developing Countries..........................................129
4.2. Family Planning methods.....................................133
4.3. Fertility Trends and Contraceptive Use...............135
4.4. Men’s Attitude towards FP..................................138
 4.5. Fertility among Different Groups.........................138
4.6. Counseling in Family Planning............................139
4.7. Trends in Contraceptive Use in Ethiopia.............144
4.8. Family Planning Delivery Strategies...................145
4.9. Reasons for Not Using Contraceptives................148

CHAPRTER 5: Sexually Transmitted infections.........................151

5.1 Introduction..........................................................151
5.2 Classification of STIs...........................................158
5.3 Traditional Approaches to STI Diagnosis............160
5.4 The STI Syndromes and the Syndromic Approach to
Case Management................................................161
5.5 Why Invest in STI Prevention and Control Now?...................165
5.5. STI Control Strategies..............................................166
5.6 Obstacles to Provision of Services for STI Control
..............................................................................169

CHAPRTER 6: HIVIDS and Reproductive Health.....................173

6.1. Introduction..........................................................173
6.2. Modes of Transmission of HIV...........................179

CHAPRTER 7: Harmful Traditional Practices............................219

7.1. Introduction.............................................................219
7.2. Violence against Women........................................222
7.3. Female genital mutilation (FGM)...........................236
7.4. Early Marriage (EM):..............................................239
CHAPRTER 8: Adolescent Reproductive Health........................246
8.1. Global Youth Today.............................................248
8.2. Reproductive Health Risks and consequences for
adolescents...........................................................256
8.3 Causes for early unprotected sexual intercourse in
adolescents...........................................................268
8.4 Effects of gender roles.........................................269
8.5 Adolescents’ contraceptive use............................270
8.6 Adolescent Reproductive Health Services...........271

CHAPRTER 9: Child Health.......................................................284

9.1. Introduction.............................................................285
9.2. The objectives of child survival and child health
of ICPD are:.........................................................288
9.3. Diarrhoeal Diseases.................................................293
9.4. Respiratory Infections.............................................319
9.5. Vaccine Preventable Diseases.................................329
9.6. The Expanded Program Of Immunization..............368
9.7. Growth Monitoring.................................................393
 List of Table

Table .1 Women's Lifetime Risk of Death from

Pregnancy, 2000................................................................50

Table .2 Global ‘Summary of the HIV. AIDS Epidemic, December

2007.................................................................................107

Table 3 Global Summary of the HIV/AIDS Epidemic,

December 2007.....................................................177

Table 4 describes the rateof Mother-to- child Transmission

in the absence of intervenition........................................184

Table 5 Effects of social environment on adolescent RH

behavior................................................................254

Table 6 Unsafe abortion: Regional Estimates of Mortality

and Risk of Death.................................................260

Table 7 Tetanus Toxoid Immunization for Women..........347

vii
 List of Figures

Figure 1: A Conceptual Framework for Monitoring and

Evaluating Reproductive Health Programme
Components.........................................................17

Figure 2: The Life Cycle approach in Women's and Men's

Health:.................................................................32

Figure 3: The reproductive life cycle....................................33

Figure 4: The Life Cycle of Violence Against Women and its

Effects on Health*.............................................227

Figure 5: Distribution of 10.5 million deaths among

children less than 5 years old in all
developing countries, 1999................................291

Figure 6: Proportion of Global Burden of Selected Diseases

Borne by Children Under 5 Years (Estimated, Year
2000)*................................................................292

vii
Reproductive Health

CHAPTER 1
INTRODUCTION TO
REPRODUCTIVE HEALTH

Learning objectives:
 To define reproductive health
 To know the historical development of RH
 Understand magnitude of RH problems
 Understand RH indicators and criteria for
selection of indicators
 To understand the relationship of
reproductive health and gender
 Know the targets of reproductive health

1. Definition and introduction

Reproductive health is defined as” A state of complete

physical, mental, and social well being and not merely the
absence of disease or infirmity, in all matters related to the
reproductive system and to its functions and process”. This
definition is taken and modified from the WHO definition of
health. Reproductive health

1
addresses the human sexuality and reproductive processes,
functions and system at all stages of life and implies that
people are able to have “a responsible, satisfying and safe sex
life and that they have the capability to reproduce and the
freedom to decide if, when and how often to do so.”

Men and women have the right to be informed and have

access to safe, effective, affordable and acceptable methods of
their choice for the regulation of fertility which are not
against the law, and the right of access to appropriate health
care services for safe pregnancy and childbirth and provide
couples with the best chance of having a healthy infant.
Reproductive health is life-long, beginning even before
women and men attain sexual maturity and continuing beyond
a woman's child-bearing years.

1.1. Historical development of the

concept

It is helpful to understand the concept and to examine its

origins. During the 1960s, UNFPA established with a mandate
to raise awareness about population “problems” and to assist
developing countries in
addressing them. At that time, the talk was of “standing room
only”, “population booms, demographic entrapment” and
scarcity of food, water and renewable resources. Concern
about population growth (particularly in the developing world
and among the poor) coincided with the rapid increase in
availability of technologies for reducing fertility - the
contraceptive pill became available during the 1960s along
with the IUD and long acting hormonal methods.

In 1972, WHO established the Special Program of Research,

Development and Research Training in Human Reproduction
(HRP), whose mandate was focused on research into the
development of new and improved methods of fertility
regulation and issues of safety and efficacy of existing
methods. Modern contraceptive methods were seen as
reliable, independent of people’s ability to practice restraint,
and more effective than withdrawal, condoms or periodic
abstinence. Moreover, they held the promise of being able to
prevent recourse to abortion (generally practiced in dangerous
conditions) or infanticide. Population policies became
widespread in developing countries during the 1970s and
1980s and were supported by UN
agencies and a variety of NGOs of which international
planned parenthood federation (IPPF) is perhaps the most well
known.

The dominant paradigm argued that rapid population growth

would not only hinder development, but was itself the cause
of poverty and underdevelopment. Almost without exception,
population policies focused on the need to restrain population
growth; very little was said about other aspects of population,
such as changes in population structure or in patterns of
migration. Given their genesis among the social and economic
elites, it is perhaps hardly surprising that the family
planning programs that resulted were based on top-down
hierarchical models and that their success was judged in terms
of numeric goals and targets – numbers of family planning
acceptors, couple-years of protection, numbers of tubal
ligations performed. Donors, anxious to demonstrate that their
aid money was being well-spent, encouraged such
performance evaluation indicators. In the drive for efficiency
and effectiveness, they supported the establishment of free-
standing “vertical” family planning bodies, generally quite
separate from other related government sectors such as
health, often,
indeed, set up within the office of the president or the prime
minister as a mark of their importance.

The 1994 ICPD has been marked as the key event in the
history of reproductive health. It followed some important
occurrences that made the world to think of other ways of
approach to reproductive health. What was the impetus
behind the paradigm shift that Cairo represents and that has
been reinforced in the recent special session of the UN
General Assembly? Three elements are of particular
importance.

 The first was the growing strength of the women’s

movement and their criticism of the over-emphasis
on the control of female fertility - and by extension,
their sexuality - to the exclusion of their other needs.

 A second key development was the advent of the

HIV/AIDS pandemic; suddenly it became imperative
to respond to the consequences of sexual activity
other than pregnancy, in particular sexually
transmitted diseases. But perhaps more important, it
became possible (and essential) to talk about sex,
about sexual
 relations outside of marriage as well as within it, and
about the sexuality of young people.

 A third development, that brought a unity to the

others, was the articulation of the concept of
reproductive rights. An interpretation of international
human rights treaties in terms of women’s health in
general and reproductive health in particular
gradually gained acceptance during the 1990s.

Three rights in particular were identified:

 The right of couples and individuals to decide freely

and responsibly the number and spacing of children
and to have the information and means to do so;

 The right to attain the highest standard of sexual and

reproductive health; and,

 The right to make decisions free of discrimination,

coercion or violence.

Subsequent articulations of reproductive rights have gone

further, so that, for example, maternal death is defined as a
“social injustice” as well as a “health
disadvantage” thus, placing an obligation on governments to
address the causes of poor maternal health through their
political, health and legal systems. These strands became
fused in the concept of reproductive health, which was first
clearly articulated in the preparations for Cairo and which has
become a central part of the language on population. The new
paradigm reflects a conceptual linking of the discourse on
human rights and that on health. It proposes a radical shift
away from technology-based, directive, top-down approaches
to programme planning and implementation. It argues that it
is possible to achieve the stabilization of world population
growth, while attending to people’s health needs and
respecting their rights in reproduction. It reinforces and gives
legitimacy to the language of health and rights, and validates
concerns raised by the international women’s movement and
by health professionals who had recognized the needs of
people in sexuality and reproduction beyond fertility
regulation.
1.2. Development of Reproductive
Health

Before 1978 Alma-Ata Conference

 Basic health services in clinics and health
centers
Primary health care declaration 1978

 MCH services started with more

emphasis on child survival
 Family planning was the main focus for
mothers

Safe motherhood initiative in 1987

 Emphasis on maternal health

 Emphasis on reduction of maternal
mortality

Reproductive health, ICPD in 1994

 Emphasis on quality of services

 Emphasis on availability and accessibility
 Emphasis on social injustice
 Emphasis on individuals woman's needs and rights
Millennium development goals and reproductive
health in 2000

 MDGs are directly or indirectly related to health

 MDG 4, 5 and 6 are directly related to health, while

MDG 1,2,3, and 7 are indirectly related to health

 World Summit 2005, declared universal access to

reproductive health

 “Sexual and reproductive health is fundamental

to the social and economic development of
communities and nations, and a key component
of an equitable society.”

The Lancet 2006

1.3. Magnitude of Reproductive Health
Problem

The term “Reproductive Health “is most often equated with

one aspect of women’s lives; motherhood. Complications
associated with various maternal issues are indeed major
contributors to poor reproductive health among millions of
women worldwide.

Half of the world’s 2.6 billion women are now 15 – 49 years

of age. Without proper health care services, this group is
highly vulnerable to problems related to sexual intercourse,
pregnancy, contraceptive side effects, etc. Death and illnesses
from reproductive causes are the highest among poor women
everywhere. In societies where women are disproportionately
poor, illiterate, and politically powerless, high rates of
reproductive illnesses and deaths are the norm. Ethiopia is not
an exception in this case. Ethiopia has one of the highest
maternal mortality in the world; it is estimated to be between
566
– 1400 deaths per 100,000 live births. Ethiopian DHS survey
of 2005 indicates that maternal mortality is 673per 100,000
live births. In Ethiopia, contraception use in women is 14.7%
and about 34% of women want
to use contraceptive, but have no means to do so according to
the Ethiopian Demographic and Health Survey (EDHS 2005).

Women in developing countries and economically

disadvantaged women in the cities of some industrial nations
suffer the highest rates of complications from pregnancy,
sexually transmitted diseases, and reproductive cancers. Lack
of access to comprehensive reproductive care is the main
reason that so many women suffer and die. Most illnesses and
deaths from reproductive causes could be prevented or treated
with strategies and technologies well within reach of even the
poorest countries. Men also suffer from reproductive health
problems, most notably from STIs. But the number and scope
of risks is far greater for women for a number of reasons.
1.4. Components of Reproductive
Health

 Quality family planning services

 Promoting safe motherhood: prenatal, safe delivery

and post natal care, including breast feeding;

 Prevention and treatment of infertility

 Prevention and management of complications of

unsafe abortion;

 Safe abortion services, where not against the law;

 Treatment of reproductive tract infections, including

sexually transmitted infections;

 Information and counseling on human sexuality,

responsible parenthood and sexual and reproductive
health;

 Active discouragement of harmful practices, such as

female genital mutilation and violence related to
sexuality and reproduction;

 Functional and accessible referral

The approach recognizes the central importance of gender
equality, men's participation and responsibility.

2. Reproductive health indicators

Following on a number of international conferences in the

1990s, in particular the 1994 ICPD, many countries have
endorsed a number of goals and targets in the broad area of
reproductive health. Most of these goals and targets have been
formulated with quantifiable and time-bound objectives.

Evidence for monitoring: Reproductive health

indicators

A health indicator is usually a numerical measure which

provides information about a complex situation or event.
When you want to know about a situation or event and cannot
study each of the many factors that contribute to it, you use an
indicator that best summarizes the situation. For example, to
understand the general health status of infants in a country, the
key indicators are infant mortality rates and the proportion of
infants of low birth weight. Maternal health care quality,
availability
and accessibility can be measured using maternal mortality.

Reproductive health indicators summarize data which have

been collected to answer questions that are relevant to the
planning and management of RH programs. The indicators
provide a useful tool to assess needs, and monitor and
evaluate program implementation and impact. Indicators are
expressed in terms of rates, proportions, averages, categorical
variables or absolute numbers.

2.1. CRITERIA FOR SELECTING

INDICATORS

Indicator selection raises technical questions about the

implications of data collection as well as other operational
issues. A good indicator has a number of important attributes,
and those recommended by the World Health Organization
(WHO, 1997c) are outlined below.
1. To be useful, an indicator must be able to act as a
“marker of progress” towards improved reproductive
health status, either as a direct or proxy measure of
impact or as a measure of progress towards specified
process goals.

2. To be scientifically robust, an indicator must be a

valid, specific, sensitive and reliable reflection of that
which it purports to measure. A valid indicator must
actually measure the issue or factor it is supposed to
measure. A specific indictor must only reflect changes
in the issue or factor under consideration. The
sensitivity of an indicator depends on its ability to
reveal important changes in the factor of interest. A
reliable indicator is one which would give the same
value if its measurement was repeated in the same way
on the same population and at almost the same time.

3. To be representative, an indicator must adequately

encompass all the issues or population groups it is
expected to cover.
 4. To be understandable, an indicator must be simple
to define and its value must be easy to interpret in terms
of reproductive health status.

5. To be accessible the data required for an indicator

should be available or relatively easy to acquire by
feasible data collection methods that have been
validated in field trials.

6. To be ethical, an indicator requires data which are

ethical to collect process and present in terms of the
rights of the individual to confidentiality, freedom of
choice in supplying data, and informed consent
regarding the nature and implications of the data
required.

These indicators can be input, process, out-put and impact

indicators.
 Figure 1: A Conceptual Framework for Monitoring and
Evaluating Reproductive Health Programme Components

Inputs Process Outputs Outcomes

Resources Services Results Impacts

Manpower Contacts Knowledge Fertility

Material Visits Acceptance Mortality
Finance Examinations Practice Morbidity
Morbidity Utilization

Referrals Prevalence
Policies & Products

Procedures Advocacy and IEC

National policies Contraceptives

and legislation Logistics

Source: A.T.P.L. Abeykoon (1999).

2.2. Sources of data

 Routine service statistics: summaries of health

service records can give information and it is very
cheap, but may be incomplete or sometimes may not
give enough information. It gives input and process
indicators.

 Population Census: The data collected at population

censuses such as population by age and sex, marital
status, and urban and rural residence provide the
denominator for the construction of process, output
and impact indicators.

 Vital statistics reports: The vital registration system

collects data on births, deaths and marriages. These
data are available by age, sex
 and residence. These data provide the numerator for
the construction of process, output and impact
indicators.

 Special studies: collection and summarization of

information for a particular purpose.

 Sample surveys : For Example Demographic and

Health survey

2.3. Reproductive Health Indicators for

Global Monitoring

There are seventeen reproductive health indicators developed

by the United Nation Population Fund (UNFPA). The list and
description of these indicators are given below.

1. Total fertility rate: Total number of children a

woman would have by the end of her reproductive
period, if she experienced the currently prevailing
age-specific fertility rates throughout her
childbearing life. TFR is one of the most widely
used fertility measures to assess the impact of family
planning programmes. The
 measure is not affected by the age structure of the
female population.

2. Contraceptive prevalence (any method):

Percentage of women of reproductive age who are
using (or whose partner is using) a contraceptive
method at a particular point in time.

3. Maternal mortality ratio: The number of maternal

deaths per 100 000 live births from causes associated
with pregnancy and child birth.

4. Antenatal care coverage: Percentage of women

attended, at least once during pregnancy, by skilled
health personnel for reasons relating to pregnancy.

5. Births attended by skilled health personnel:

Percentage of births attended by skilled health
personnel. This doesn’t include births attended by
traditional birth attendants.
6. Availability of basic essential obstetric care:
Number of facilities with functioning basic essential
obstetric care per 500 000 population. Essential
obstetric care includes, Parenteral antibiotics,
Parenteral oxytocic drugs, Parenteral sedatives for
eclampsia, Manual removal of placenta, Manual
removal of retained products, Assisted vaginal
delivery. These services can be given at a health
center level.

7. Availability of comprehensive essential

obstetric care: Number of facilities with
functioning comprehensive essential obstetric care per
500 000 population. It incorporates obstetric surgery,
anesthesia and blood transfusion facilities.

8. Perinatal mortality rate: Number of perinatal

deaths (deaths occurring during late pregnancy,
during childbirth and up to seven completed days of
life) per 1000 total births. Deaths which occur starting
from the stage of viability till completion of the first
week after birth (22 weeks of gestation up to end of
first week after birth, WHO). Total
 birth means live birth plus IUFD born after fetus
reached stage of viability.

9. Low birth weight prevalence: Percentage of live

births that weigh less than 2500 g.

10. 10. Positive syphilis serology prevalence in

pregnant women: Percentage of pregnant women
(15–24) attending antenatal clinics, whose blood has
been screened for syphilis, with positive serology for
syphilis.

11. Prevalence of anaemia in women: Percentage of

women of reproductive age (15–49) screened for
haemoglobin levels with levels below 110 g/l for
pregnant women and below 120 g/l for non- pregnant
women.

12. Percentage of obstetric and gynaecological

admissions owing to abortion: Percentage of all
cases admitted to service delivery points providing in-
patient obstetric and gynaecological services, which
are due to abortion (spontaneous and induced, but
excluding planned termination of pregnancy)
13. . Reported prevalence of women with FGM:
Percentage of women interviewed in a community
survey, reporting to have undergone FGM.

14. Prevalence of infertility in women: Percentage

of women of reproductive age (15–49) at risk of
pregnancy (not pregnant, sexually active, non-
contraception and non-lactating) who report trying
for a pregnancy for two years or more.

15. Reported incidence of urethritis in men:

Percentage of men (15–49) interviewed in a
community survey, reporting at least one episode of
urethritis in the last 12 months.

16. HIV prevalence in pregnant women: Percentage

of pregnant women (15–24) attending antenatal
clinics, whose blood has been screened for HIV, who
are sero-positive for HIV.

17. . Knowledge of HIV-related prevention

practices: The percentage of all respondents who
correctly identify all three major ways of
 preventing the sexual transmission of HIV and who
reject three major misconceptions about HIV
transmission or prevention.

3. Gender and Reproductive Health

Sex refers to biological and physiological attributes of that

identify a person as male or female

Gender refers to the economic, social and cultural attributes

and opportunities associated with being male or female in a
particular social setting at a particular point in time.

Gender equality means equal treatment of women and men

in laws and policies, and equal access to resources and
services within families, communities and society at large.

Gender equity means fairness and justice in the distribution

of benefits and responsibilities between women and men. It
often requires women-specific programmes and policies to
end existing inequalities.

Gender discrimination refers to any distinction, exclusion

or restriction made on the basis of socially
constructed gender roles and norms which prevents a person
from enjoying full human rights.

Gender stereotypes refer to beliefs that are so ingrained in

our consciousness that many of us think gender roles are
natural and we don’t question them.

Gender bias refers to gender based prejudice; assumptions

expressed without a reason and are generally unfavorable.

Gender mainstreaming: the incorporation of gender issues

into the analysis, formulation, implementation, monitoring of
strategies, programs, projects, policies and activities that can
address inequalities between women and men

Gender analysis is a research tool that helps policy makers

and program managers appreciate the importance of gender
issues in the design, implementation, and evaluation of their
projects.

The Social Construction of Gender

The people involved, Family members, peers, teachers and

people in educational and religious institutions are
usually the first to introduce a child to appropriate codes of
gendered behaviour.

Place

This often corresponds with the kinds of people involved.

The home or family for example, at play, in school or in
church for peers, teachers and adults in general.

Division of labour: the kind of household chores that girls

are expected to do compared to boys; girls work inside the
home and boys outside; girls work for others in the home,
for example cooking, washing dishes, cleaning the house and
washing clothes; boys are sent out on errands; girls do things
for boys like serving food, cleaning up after them and doing
their washing; boys in some cultures are asked to escort girls
in public.

Dress codes: across cultures, girls and boys are expected to

be dressed differently right from the moment they are born.
These differences may vary across cultures and societies.

Physical segregation of boys and girls: in many

cultures, especially in Asia, physical segregation starts
at an early age. Common experiences often include, being told
not to play with members of the opposite sex, or not to get
involved in any activity that will bring one into physical
contact with people of the opposite sex.

The kinds of games girls and boys play: girls are not
encouraged to play games like football, which involve
vigorous physical activity and physical contact with each
other; boys are often not allowed to play with dolls or play as
homemakers. Boys who do not engage in rough physical
games are thought to be “sissies”.

Emotional responses: girls and boys are expected to

respond differently to the same stimulus; while it is acceptable
for girls to cry, it is seen as a weakness in boys.

Intellectual responses: there is an expectation that girls

are not to talk back or express their opinions. This is often
mentioned in relation to school and how teachers pay more
attention to boys since they expect more from boys.

In one training program, a participant from Japan told the

story of how, when she obtained the highest marks in class,
her teacher called her and asked her to agree
that instead he would give the highest marks to the boy who
was really second. He explained that it would not be good
for the boy to come second and the boys would not treat the
girl well if she did better than them. Class, caste, ethnic and
other differences. Explore how differences across class, caste,
ethnicity and nationality affect how girls and boys are
expected to behave. For example, the physical segregation of
boys and girls may not be as strict in other parts.

Women’s Health Coalition, 1995.

The social construction of sexuality refers to the process by

which sexual thoughts, behaviours, and conditions (for
instance, virginity) are interpreted and given cultural meaning.
It incorporates collective and individual beliefs about the
nature of the body, about what is considered erotic or
offensive, and about what and with whom it is appropriate or
inappropriate for men and women (according to their age and
other characteristics) to do or to say about sexuality. In some
cultures, ideologies of sexuality stress female resistance, male
aggression, and mutual antagonism in the sex act; in others,
they stress reciprocity and mutual pleasure. The social
construction of sexuality recognizes that women’s and men’s
bodies
play a key role in their sexuality, but also looks carefully at
the specific historical and cultural contexts to gain an
understanding of how specific meanings and beliefs about
sexuality are generated, adopted and adapted.

3.1. Gender differences:

 Women give birth to babies, men do not. In many
societies child rearing is the sole responsibility of
women.

 According to United Nations statistics, women do

67 per cent of the world's work, yet their earnings for
it amount to only 10 per cent of the world's income.

 In one case, a child brought up as a girl learned that

when he was actually a boy, his school marks
improved dramatically.

 Sex is not as important for women as it is for men.

 In ancient Egypt, men stayed at home and did

weaving. Women handled family businesses.
  Women inherited property and men did not.

 Men's voices break at puberty, women's don't.

 In a study of 224 cultures, there were 5 in which men

did all the cooking and 36 in which women did all the
house building.

 Men are naturally prone to violent behaviour

 Women are more vulnerable to STDs than men.

For example, women may have access to health services, but

no control over what services are available and when. Another
common example is women having access to an income or
owning property, but having no control over how the income
is spent or how the property is used. There are many different
types of resources which women have less access to, and less
control over. These include:-
Power and decision-making

Having greater access to and control over resources

usually makes men more powerful than women in any social
group. This may be the power of physical force, of knowledge
and skills, of wealth and income, or the power to make
decisions because they are in a position of authority. Men
often have greater decision-making power over reproduction
and sexuality. Male power and control over resources and
decisions is institutionalized through the laws and policies of
the state, and through the rules and regulations of formal
social institutions. Laws in many countries of the world give
men greater control over wealth and greater rights in marriage
and over children. For centuries, religious institutions have
denied women the right to priesthood, and schools often insist
that it is the father of the child who is her or his legal
guardian, not the mother.
Figure 2: The Life Cycle approach in Women's and
Men's Health:

Pre-birth

Elderly Infancy

Life Cycle

Childhood
Reproductive age

Adolescence
 Figure 3: The reproductive life cycle

Newborn Infancy-Youth- Adult Middle Age- Death

Childhood AdolescenceElderly

Sexual Activity

Post-partum Pregnancy

Childbirth

A woman's reproductive years, which typically span

almost four decades, can be divided in stages

1. Menarche to intercourse
2. Intercourse to marriage
3. Marriage to first birth
4. First birth to attainment of desired family size
5. Attainment of desired family size to menopause
 4. REPRODUCTIVE HEALTH AND
DEFINING TARGET POPULATION
Rationale for Defining Target Population

 To set priority and deliver appropriate services to

high risk groups.
 To utilize resources efficiently,
 To determine the number of eligible for the
services,
 To plan the type of services to be provided,
 To focus the efforts towards the target group,
 To measure / evaluate changes,
 To address equity in delivery of the health services

The target population of a service includes for whom the

service is primarily or solely intended. These people may be
of a certain age or sex or may have other common
characteristics.

a. Women of child-bearing age (15 – 49 years old)

1. Women alone are at risk of complications from

pregnancy and childbirth
 2. Women face high risks in preventing unwanted
pregnancy; they bear the burden of using and
suffering potential side effects from most
contraceptive methods, and they suffer from the
consequences of unsafe abortion.

3. Women are more vulnerable to contracting and

suffering complications of many sexually transmitted
infections including HIV/AIDS.

4. From the equity point of view, this population group

constitutes about 24% of the population; which is a
significant proportion.

5. Deaths and illnesses from reproductive causes are

highest among poor women everywhere.

b. Adolescents (Both sexes)

1. Adolescents lack reliable reproductive health

information, and thus the basic knowledge to make
responsible choice regarding their reproductive
behavior.

2. In many countries around the world, leaders,

community members, and parents are reluctant
 to provide education on sexuality to young men and
women for fear of promiscuity.

3. Many adolescents are already sexually active, often at

a very young age.

4. The reproductive health status of young people, in

terms of sexual activity, contraceptive use, child
bearing, and STIs lays the foundation for the
country’s demographic feature.

5. During adolescence normal physical development

may be adversely affected by inadequate diet,
excessive physical stress, or pregnancy before
physiological maturity is attainted.

6. Adolescents are at high risk to acquire infertility

associated with STIs and unsafe abortion

7. Conditions of work are designed for adults rather than

adolescents and put them at greater risk of accidental
injury and death.
8. Current health services are generally not organized to
fulfill the reproductive need and demands of
adolescents.

C. Under Five Children

1. Children’s health is a base for healthy

adolescence and childbearing ages.
2. Proper health service for children serves to
increase the opportunities of women to have
contact with the health institution.

3. The health of children and women is inseparable

4. The morbidity and mortality of children in
Ethiopia is one of the highest in the world.
5. Bearing high number of children has adverse
consequences on health of the mother, the general
income distribution and health status of the
family.
Estimation of the Eligible Population Number
(Target Groups) for Reproductive Health

Knowing the number or estimate of the eligible for

reproductive health is important for the following purposes.

 To plan usage targets for services

 To plan for supplies
 To assign service providers
 To monitor utilization of services
 To monitor coverage of the service

1. The techniques to be utilized to estimate the eligible for

reproductive health should include:

- Deciding the catchments area for the health

institution providing reproductive health service.
- Identify all kebeles in the catchments area;
- Prepare a sketch map of the catchments area,
- Divide the catchments area in to zones for ease of
operation
- Divide the catchment area in to zones for ease of
operation
2. Determining the number of the eligible population from
the total population in the catchment area.

The methods for estimating the number of the eligible

could be;

- By conducting census of the population in the

catchment area
- By estimation of those eligible from the total
population using national, regional or district standard
figures.
 CHAPTER 2
MATERNAL HEALTH

Learning objectives:
 Describe the safe motherhood initiative and
services included under safe motherhood

 Understand important causes of maternal

mortality and morbidity

 Describe maternal health services

 Understand methods of maternal mortality

measures and their challenges

1. Introduction

Motherhood should be a time of expectation and joy for a

woman, her family, and her community. For women in
developing countries, however, the reality of motherhood is
often grim. For those women, motherhood is often marred by
unforeseen complications of pregnancy and childbirth. Some
die in the prime period of their lives and in great distress:
from
hemorrhage, convulsions, obstructed labor, or severe infection
after delivery or unsafe abortion.

Worldwide, it is estimated that 529,000 women die yearly

from complications of pregnancy and childbirth— about one
woman every minute. Some 99 percent of these deaths occur
in developing countries, where a woman's lifetime risk of
dying from pregnancy-related complications is 45 times
higher than that of her counterparts in developed countries.
The risk of dying from pregnancy-related complications is
highest in sub- Saharan Africa and in South-Central Asia,
where in some countries the maternal mortality ratios are
more than 1,000 deaths per 100,000 live births.

Sixty to eighty percent of maternal deaths are due to obstetric

hemorrhage, obstructed labor, obstetric sepsis, hypertensive
disorders of pregnancy, and complications of unsafe abortion.
These direct complications are unpredictable and most occur
within hours or days after delivery.
 2. The Safe Motherhood Initiative

In 1987 the World Bank, in collaboration with WHO and

UNFPA, sponsored a conference on safe motherhood in
Nairobi, Kenya to help raise global awareness about the
impact of maternal mortality and morbidity. The conference
launched the Safe Motherhood Initiative (SMI), which issued
an international call to action to reduce maternal mortality and
morbidity by one half by the year 2000. It also led to the
formation of an Inter- Agency Group (IAG) for Safe
Motherhood, which has since been joined by UNICEF,
UNDP, IPPF, and the Population Council.

The SMI's target has subsequently been adopted by most

developing countries. Under the Safe Motherhood Initiative,
countries have developed programs to reduce maternal
mortality and morbidity. The strategies adopted to make
motherhood safe vary among countries and include:

 Providing family planning services.

 Providing post abortion care.
 Promoting antenatal care.
 Ensuring skilled assistance during childbirth
  Improving essential obstetric care.
 Addressing the reproductive health needs of
adolescents.

As we can see from the following table, risk of death

from pregnancy is very high in developing countries, while
being very low in the developed world. This shows that the
difference is due to the quality of care provided to mothers.

2.1. Essential Services for Safe

Motherhood

Safe motherhood can be achieved by providing high- quality

maternal health services to all women. These services for safe
motherhood should be readily available through a network of
linked community health care providers, clinics and hospitals.
These services could be provided at different levels including
home and health institutions.
Essential Services include:

1. Community education on safe motherhood

2. Prenatal care and counseling, including the promotion

of maternal nutrition

3. Skilled assistance during childbirth

4. Care for obstetric complications, including

emergencies

5. Postpartum care

6. Post-abortion care and, where abortion is not against

the law, safe services for the termination of pregnancy

7. Family planning counseling, information and

services

8. Reproductive health education and services for

adolescents

Essential Obstetric Care

• Essential obstetric care is of two types basic essential

obstetric care and comprehensive essential obstetric
care. Ensuring access to
 essential obstetric care is important in reducing
maternal deaths.

• Basic essential obstetric care (also called basic

emergency obstetric care) at the health centre level
should include at least:

- Parentral antibiotics

- Parentral oxytoxic drugs

- Parentral sedatives for eclampsia

- Manual removal of placenta

- Removal of retained products

- Assisted vaginal delivery

Comprehensive essential obstetric services at district hospital

(first referral level) should include all of the above, plus:

– Obstetric Surgery

– Anesthesia

– Blood transfusion
• WHO recommends that there should be at least four
BEOC and one CEOC facilities for every 500,000
population.

• This practice was the main intervention to reduce

maternal mortality for about ten years until the
Colombo technical consultative meeting on safe
motherhood initiative in 1997 in Sri Lanka hosted by
the inter Agency group. The goal was to review key
lessons learned and articulate consensus on the most
effective strategies and ways to implement these
strategies at country level.

• Global experience showed maternal mortality and

morbidity could be prevented with the existing
knowledge and technology by:

• Recognizing that every pregnancy faces risk

• Increasing access to family planning services

• Improving quality of ANC and postpartum

care
 • Ensuring access to essential obstetric care
(including post-abortion care)

• Expanding access to midwifery care

• Training and deploying appropriate skilled

health personnel

• Ensuring a continuum of care, connected by

effective referral links, and supported by
adequate supplies, equipment, drugs, and
transportation

• Reforming laws to expand women’s access to

health services and to promote their health
interests

Key Lessons Learned after ten years of safe mother

hood strategy

 Strong political commitment at the national and/or

local level can help facilitate the implementation of
safe motherhood interventions and ensure their
integration into the health care system.

• Involving national and local leaders and other key

parties in the planning and implementation of
 safe motherhood activities helps facilitate the delivery
of maternal health services and ensure sustainability.

• Involving community members (particularly women

and their families, health care providers, and local
leaders) in efforts to improve maternal health helps
ensure program success.

• Training and deploying a range of health care

providers at appropriate service delivery levels help
increase access to maternal health services, especially
life-saving services.

• Effective communication between health care

providers at both the community level and the district
(first referral) level is essential for management of
obstetric emergencies and for ensuring continuity of
care.

• Community education about obstetric complications

and when and where to seek medical care is important
to ensure early recognition of complications and
prompt care- taking behavior.
 • The ten years review also recognized that there were
strategic missteps:

ANC with focus on risk assessment

Training of TBAs to improve delivery care at

community level

2.2. Causes of Maternal Mortality and

Morbidity

2.2.1. Definitions

 The Tenth Revision of the International Classification

of Diseases (ICD-10) defines a maternal death as the
death of a woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the
duration and site of the pregnancy, from any cause
related to or aggravated by the pregnancy or its
management, but not from accidental or incidental
causes.

 Maternal morbidity: Any deviation, subjective or

objective, from a state of physiological or
psychological well being of women.
  Women’s lifetime risk of Death: Is the risk of
an individual woman dying from pregnancy or
childbirth during her lifetime. Of the 171 countries
and territories, Niger has the highest lifetime risk of
maternal death (1 in 7 women die for reasons
associated with pregnancy and child birth)

Table 1: Women's Lifetime Risk of Death from

Pregnancy, 2000

Information adapted from AbouZahr C, Wardlaw, T. Maternal Mortality in 2000:

Estimates Developed by WHO, UNICEF and UNFPA. Geneva: WHO; 2000
Epidemiology

In many developing countries, including Ethiopia,

complications of pregnancy and childbirth are the leading
causes of death among women of reproductive age. More than
one-woman dies every minute from such causes. In 2005 more
than 636,000 women died each year worldwide. From that,
99% was accounted by developing countries. Of those, around
270,000 women died each year in Africa. Particularly being
one of the less developed countries in the world, 46,000
women died each year in Ethiopia. A total of 14 countries had
MMR greater than 1000 of which 13 were in sub- Saharan
Africa, with Sierra Leone being in the top with MMR of 2100
per 100,000 live births.

Around 50 million pregnant women worldwide had morbid

illness each year, of which 15% of them have disabilities like
fistula, infertility, etc. Over 300 million women in the
developing world currently suffer from short term and long
term illness related to pregnancy and childbirth. At least 2
million women in developing countries are living with
obstetric fistulas, and 50,000-
100,000 new cases occur each year. The prevalence of
obstetric fistula in Ethiopia is 1 %.

Maternal mortality and morbidity can be reduced or avoided

by providing and expanding resources and services that are
principally targeted in achieving maternal health and safe
motherhood.

More than one woman dies every minute from

complications of pregnancy and childbirth.

Maternal care is in the lowest level of use particularly in the

developing countries. Preventing maternal death is almost
equivalent with upgrading the socioeconomic status of the
country in particular. No body knows the exact number of
maternal deaths each year due to poor epidemiological studies
and poor recording of health care institution.

Women’s lifetime risk of death is 40 times higher in

developing countries compared to developed countries. In
general, women lifetime risk of death in developing countries
is 1 in 48 as opposed to 1:1800 in developed countries.
Maternal mortality ratio is by far the greatest disparity
between developed and developing countries.
More than seventy percent of maternal deaths are due to
hemorrhage, unsafe abortion, hypertensive diseases of
pregnancy, infection and obstructed labor, which are
preventable. Out of this, more than 60% of maternal deaths
occur following delivery, of which half occur in the first
day after delivery.

Causes of maternal Mortality

Direct obstetric deaths are those that result from obstetric

complications of the pregnancy state from interventions,
omissions, incorrect treatment or from chain of events.

Examples: Abortion, Ectopic pregnancy, pre-eclampsia,

Eclampsia, Obstructed labor, infection, etc.

Seventy percent of maternal deaths are usually preventable.

The commonest causes of maternal deaths include:

A. Hemorrhage: Includes antepartum, postpartum,

abortion, and ectopic pregnancy.

Hemorrhage accounts for 21% of maternal

deaths in Ethiopia.
B. Unsafe Abortion: It is claimed as the commonest
cause of maternal death in our country accounting
for 20 –40% of deaths.

C. Hypertensive disorders of pregnancy: This

includes pre-eclampsia, eclampsia, etc. Preclampsia
and eclampsia account for 10- 12% of maternal
deaths.

D. Obstructed Labor and uterine rupture: The

prevalence of obstructed labor is said to be 47
% in Ethiopia. It accounts for 9% of the total
maternal death.

E. Infection: The introduction and multiplication of

microbial agents in the pelvic organs and other
systems having an effect on the health of the
mother and newborn. It includes infection of the
uterus, tubes, urinary system and fetal infection. It
accounts for 10% of maternal deaths.
 Indirect Obstetric Death

Deaths resulting from previous existing diseases or

diseases that developed during pregnancy, which are
aggravated by the physiologic effects of pregnancy. This
includes:-

A. Anemia: This is the commonest indirect cause of

maternal death in our country, since malaria is
endemic and iron supplementation is low.
B. Other indirect causes include, heart disease, diabetes
mellitus, HIV/AIDS, TB, Malnutrition, etc. The
indirect obstetric death:

Incidental/Coincidental/ causes of maternal Death:

Deaths that are neither due to direct nor indirect obstetric

causes: E.g. Car accident, fire burn, bullet injury

2.2.2. Medical Causes of Maternal Death

Direct Causes Indirect causes

• Hemorrhage  HIV
• Hypertensive diseases  Malaria
• Infection and sepsis  Anemia
• Obstructed labor  Cardiovascular diseases
• Abortion  Others
• Others
– Embolism
– Anesthesia
–
2.2.3. Maternal Mortality in Context: The Three
D’s (Delays)

• Delays can kill mothers and newborns. There are three

phases during which delays can contribute to the
death of pregnant and postpartum women and their
newborns.

1. Delay in deciding to seek care

o Failure to recognize signs of complications

o Failure to perceive severity of illness

o Cost consideration

o Previous negative experience with the health

system

o Transportation
2. Delay in reaching care

o Lengthy distance to a facility

o Conditions of roads

o Lack of available transportation

3. Delay in receiving appropriate care

o Uncaring attitudes of providers

o Shortages of supplies and basic

equipment

o Non-availability of health personnel

o Poor skills of health providers

Life threatening delays can happen at home, on the way to

care, or at the place of care. Therefore, plans and actions that
can be implemented at each of these points are mandatory.

o Birth preparedness and complication

readiness to reduce delays

o Women-friendly care to enhance

acceptability
2.2.4. Causes of Maternal Morbidity

Maternal morbidity is difficult to measure due to

variation in the definition and criteria to diagnose. The
risk factors for maternal morbidity include prolonged
labor, hemorrhage, infection, preclampsia, etc. The
commonest long term complication of pregnancy and
child birth include:

A. Infection: There is high risk of infection of the

genital organs (cervix, uterus, tubes, ovaries and
peritoneum) after prolonged labor, when delivery
takes place in unclean settings, retained parts of
conception after unsafe abortion and delivery.

B. Fistula: are holes in the birth canal that allow

leakage from the urethra, bladder or rectum into the
vagina. They present with continuous leakage of
urine or feces or both. The commonest cause in our
country is obstructed labor as opposed to surgery
and cancer in the developed world.
 C. Incontinence: is leakage of urine upon straining
or standing.

D. Infertility: Unable to be pregnant for a year despite

unprotected sexual intercourse.

E. Uterine prolaps: the falling or sliding of the

uterus from its normal position into the vaginal
canal. Commonest predisposing factors include
prolonged labor, heavy exercise, multiple
childbirths, etc.

F. Nerve Damage: As a result of prolonged labor,

there may be compression or damage of the nerves
in the pelvis (Sciatic nerve).

G. Psychosocial problems: maternal blues

aggravated by other conditions

H. Others, Include, pain during intercourse, anemia,

etc.

2. 2.5. Risk factors for Maternal Health

Socio-cultural factors: Like early marriage, early

childbirth, harmful traditional practices including female
genital mutilation, etc.
Economy: Socio economic status affects the women’s
status by affecting their decision making roles in the
community, educational status, health coverage, level of
sexual abuse, etc.

Inadequate Health Service Coverage: Most mothers

do not get care during pregnancy and most deliveries are
unattended. This is due to lack of transportation, distance
from health facilities, small number of health facilities,
etc.

Psychological factors: For instance, after sexual

abuse women are at great risk of depression.

Health and nutrition services: The health status of

women who are not getting adequate amount of nutrients
and proper reproductive health services could be affected.

Interaction with providers: Some health care

providers are, unsympathetic and uncaring as they do not
respect women's cultural preferences. E.g. privacy, birth
position, or treatment by women providers.
 Gender Discrimination: E.g. lack of women
empowerment, giving more attention to a male child.

2.3 Maternal health services

2.3.1. Antenatal Care

Antenatal care refers to care given to pregnant women so that

they have safe pregnancy and healthy baby. Pregnancy is
a normal physiological process associated with certain risks to
health of the woman and the infant she bears. These risks can
be overcome through proper antenatal care. (Figure 1).

Most women have some antenatal care

Data for the late 1990s and for 2000-2001 show that just over
70% of women worldwide have at least one antenatal visit
with a skilled provider during pregnancy In the
industrialized countries, coverage is extremely high, with 98%
of women having at least one visit. In the developing world,
antenatal care use, is around 68% (data are not available for
China), but this indicates considerable success for
programmes aimed at making antenatal care available. The
region of the world with the lowest levels of use is South
Asia, where only 54% of pregnant women have at least
one antenatal care
visit. In the Middle East and North Africa, use of antenatal
care is some what higher at 65% of pregnant women. In sub-
Saharan Africa, generally the region with the lowest levels of
health care use, fully 68% of women report at least one
antenatal visit. The levels in the remaining regions of the
world range from 82% to 86%.

Ethiopia’s ANC coverage is very low compared to the rest of

sub Saharan Africa. The 2005 DHS showed 28% coverage of
ANC across the nation, while the rest of sub-Sahara has ANC
coverage of 46%.

Antenatal care (ANC) strategies target pregnant women in

order to screen and detect early signs of or risk factors for
disease, followed by timely intervention, originally with the
aspiration of reducing maternal and perinatal mortality and
morbidity. However, the contribution of antenatal care
specifically to maternal mortality reduction has been
challenged. The acknowledged benefits of antenatal care to
the baby in terms of growth, risk of infection, and survival,
however, remains. The justification of the benefits to the
mother has now shifted to emphasizing the promotion of
health and health-seeking behaviour, including birth
preparedness. Furthermore, since antenatal care is one
of the most widespread health services and coverage is often
high, it increasingly serves as a means of distribution for other
packages, for example, the roll-out of antimalarial drugs or of
antiretroviral therapy for maternal HIV/AIDS. As it is
mentioned above, ANC service faces a lot of criticism
recently for various reasons.

Criticisms of traditional ANC

 Ritualistic rather than rational: mostly the service is

given without precise goals.

 Emphasis of visits on frequency and numbers of

visits, rather than on essential goal-directed elements
of each visit.

 Communication is minimal, and focused on findings:

there is no much counseling on the changes the
woman going to face and the danger signs.

 Preparation/planning is not stressed: there should be

a birth plan and preparedness.

 Assessment of whether plan can be carried out is

not made (can she come for her delivery?):
 even though there is a plan to deliver in an institution
there are other variables that can affect the situation
during labor and delivery.

 Risk assessment based on predetermined parameters:

height, age, parity, past obstetric history, these
variables are usually the basis to classify whether the
pregnancy is at risk or not. But this has been found
out to be less helpful in identifying risk, Randomized
controlled trials have been conducted including in
less developed countries and the results have
consistently pointed to the need for a new strategy for
ANC.

Reducing antenatal care visits to 4-5 with proven effective

interventions (goal oriented visits) produces similar maternal
results. Based on the results of large- scale randomized
controlled trials, the WHO Technical Working Group
recommended a minimum level of care that is 4 visits per
pregnancy. It was found out that Antenatal care delivered by
midwife or general practitioner has similar clinical
effectiveness as that of obstetrician/ gynecologist led shared
care.
Antenatal care should be goal-oriented with interventions that
have of proven value. Examples include:

– Prevention, detection, and investigation of

anemia and treatment of iron-deficiency anemia

– Prevention of obstructed labor by external

cephalic version

– Immunization against tetanus and promotion of

clean delivery

The Risk Approach in Pregnancy

The risk approach is a managerial tool for health services to

identify people at risk as early as possible and intervene in
order to reduce the risk. It is the screening and classification
of the risk level of pregnancies based on maternal
characteristics. The “at risk pregnancy” is a pregnancy in
which there is a likelihood of an adverse outcome for the
mother and/or baby which is greater than that of the general
pregnant population.

The concept of the risk approach originates from the

assumption that vulnerability to death and disability is
not equally distributed among all pregnant women and their
children. If high risk factors as well as their effects are
identified, diseases and deaths can be prevented by providing
appropriate health care and services. The main objective of
the risk approach is the optimal use of existing resources for
the benefit of the majority. However, recently there have been
a lot of criticisms against routine screening procedures to
identify women at risk and take the necessary measures to
prevent morbidity and mortality. Risk screening has been
blamed to have low sensitivity and specificity.

Why Doesn’t Risk Assessment Work?

The broad characteristics used by most risk assessment

systems are not precise enough to predict an individual
woman’s risk. As a result, a large number of women are
identified as “high risk” even though they never develop any
complications.

E.g. A study in Zaire found that 90 % of women

identified as “at risk” for obstructed labor ended up in not
having any problem.
Most of the women who develop complications do not have
any risk factors, and are therefore, are classified as “low
risk”.

E.g. The same study found that 71 % of the women who

did develop obstructed labor did not have any history of
problems.

Even if a woman is correctly identified as being at

risk of complications, there is no guarantee that she
will get appropriate care:

• Many health systems cannot provide adequate

services

• Women themselves may be unable or unwilling to

seek medical care when they are told they are “high
risk.”

• Women may not receive life-saving care

• Personal cost and inconvenience is high

• Health systems are overburdened

Based on the above reasons, it is recommended that detection

of high risk pregnancies needs to be done
according to clear guidelines which have been shown to have
a high predictive value specific to the index
population. Since risk assessment cannot predict which
women will experience pregnancy complications, it is critical
that all women who are pregnant, in labor or recently had
a baby have access to high quality maternal health care and
every pregnancy should get due attention as a potential risk.
Based on these reasons as well, every pregnant woman must
be prepared to give birth in a place where she can find at least
basic services for delivery and new born care.

A. Focused antenatal care (New ANC approach)

Traditional antenatal care uses risk approach to classify which

women are more likely to develop complication and assumes
that more visits means better outcome for the mother and the
baby. However, many women who have risk factors do not
develop complications, while women without risk factors may
do so. Using a risk approach with its more frequent visits,
therefore, does not necessarily improve pregnancy out comes.
However, to achieve the full life-saving potential that ANC
promises for women and babies, four visits providing
essential evidence based interventions – a
package often called focused antenatal care – are required.
Essential interventions in ANC include identification and
management of obstetric complications such as preclampsia,
tetanus toxoid immunisation, intermittent preventive treatment
for malaria during pregnancy (IPTp), and identification and
management of infections including HIV, syphilis and other
sexually transmitted infections (STIs). ANC is also an
opportunity to promote the use of skilled attendance at birth
and healthy behaviours such as breastfeeding, early postnatal
care and planning for optimal pregnancy spacing.

Only 4-5 ANC visits were proven to be equally effective

interventions, with higher number of visits if provided
with goal oriented approach to the services. Services provided
by a Midwife or general practitioner have similar clinical
effectiveness with care given by obstetrician and gynecologist
shared care.

The main goals of the focused antenatal care are:

Goals of Focused ANC: The new approach to ANC

emphasizes the quality of care rather than the quantity. For
normal pregnancies, WHO recommends only four
antenatal visits. The major goal of focused antenatal care is to
help women maintain normal pregnancies through:

 Identification of pre-existing health conditions

 Early detection of complications arising during the
pregnancy
 Health promotion and disease prevention
 Birth preparedness and complication readiness
planning.

Identification of Pre-existing Health Conditions: As

part of the initial assessment, the provider talks with the
woman and examines her for signs of chronic conditions and
infectious diseases. Pre-existing health conditions such as
HIV, malaria, syphilis and other sexually transmitted diseases,
anemia, heart disease, diabetes, malnutrition, and tuberculosis
may affect the outcome of pregnancy, require immediate
treatment, and usually require a more intensive level of
monitoring and follow- up care over the course of pregnancy.

Early Detection of Complications: The provider talks

with and examines the woman to detect problems of
pregnancy that might need treatment and closer
monitoring. Conditions such as anemia, infection, vaginal
bleeding, hypertensive disorders of pregnancy, and abnormal
fetal growth or abnormal fetal position after 36 weeks may be
or become life-threatening if left untreated.

Health Promotion and Disease Prevention: Counseling

about important issues affecting a woman’s health and the
health of the newborn is a critical component of focused
ANC. Discussions should include:

 How to recognize danger signs, what to do, and

where to get help
 Good nutrition and the importance of rest
 Hygiene and infection prevention practices
 Risks of using tobacco, alcohol, local drugs, and
traditional remedies
 Breastfeeding
 Postpartum family planning and birth spacing.
All pregnant women should receive the following preventive
interventions:

 Immunization against tetanus

 Iron and folate supplementation.

In areas of high prevalence women should also receive:

 Presumptive treatment of hookworm

 Voluntary counseling and testing for HIV
 Protection against malaria through intermittent
preventive treatment and insecticide-treated bed nets
 Protection against vitamin A and iodine deficiencies.

Birth Preparedness and Complication Readiness:

Approximately 15 percent of women develop a life-
threatening complication, so every woman and her family
should have a plan for the following:

 A skilled attendant at birth

 The place of birth and how to get there including how
to obtain emergency transportation if needed
  Items needed for the birth
 Money saved to pay the skilled provider and for any
needed mediations and supplies
 Support during and after the birth (e.g., family,
friends)
 Potential blood donors in case of emergency.

The essential elements of a focused approach to

antenatal care can be summarized as:

 Identification and surveillance of the pregnant

woman and her expected child

 Recognition and management of pregnancy-

related complications, particularly pre- eclampsia

 Recognition and treatment of underlying or

concurrent illness

 Screening for conditions and diseases treatments

such as anemia, STIs (particularly syphilis), HIV
infection, mental health problems, and/or
symptoms of stress or domestic violence
 Preventive measures, including tetanus toxoid
immunization, de-worming, iron and folic acid
supplementation, intermittent preventive
treatment of malaria in pregnancy (IPTp),
insecticide treated bed nets (ITN) provision.

 Advice and support to the woman and her family

for developing healthy home behaviours and a
birth and emergency preparedness plan to:

 Increase awareness of maternal and newborn

health needs and self care during pregnancy and
the postnatal period, including the need for social
support during and after pregnancy

 Promote healthy behaviours in the home,

including healthy lifestyles and diet, safety and
injury prevention, and support and care in the
home, such as advice and adherence support for
preventive interventions like iron
supplementation, condom use, and use of ITN
  Support care seeking behaviour, including
recognition of danger signs for the woman and
the newborn as well as transport and funding
plans in case of emergencies

 Help the pregnant woman and her partner prepare

emotionally and physically for birth and care of
their baby, particularly preparing for early and
exclusive breastfeeding and essential newborn
care and considering the role of a supportive
companion at birth

 Promote postnatal family planning/birth spacing

Antenatal Care in Ethiopia

• ANC coverage according to EDHS 2005 is

27.6 %; little improvement from the 2000
finding.

• Large differences between urban (69 %) and rural

areas (24 %)

• Huge regional differences: ranges from 7.4 % in

Somali region to 88.3 % in Addis Ababa
 • Women with at least secondary education more
likely to receive ANC (81%) than women with
primary education (39 %) and those with no
education (22 %)

• Women in the highest wealth quintile are nearly

five times more likely to receive ANC than those
in the lowest quintile

• Only 12.2 % women make four or more antenatal

care visits during their entire pregnancy: urban
(55 %) and rural (8 %)

• Women start ANC at a late stage of pregnancy.

Median duration of pregnancy for the first ANC
visit is 5.6 months (6 months for rural women).
Only 6 % make their first ANC visit before the
4th month

2.3.2. Delivery Care

Normal birth is defined as Spontaneous in onset, low risk

at start of labour and remaining so throughout labour and
delivery. The infant is born spontaneously in the vertex
position between 37-42 completed weeks of pregnancies.
After birth, mother and baby (child) are in
good condition. Describes as the process by which the fetus,
placenta with its membrane is expelled through birth canal.

It is not always possible to anticipate which pregnancies end

up with complications. Therefore, it is essential to extend
delivery services to all pregnant women in order to provide
timely help for complications of labour and delivery.
Delivering women should be observed at least for 24 hours
after delivery as most of the deaths post partum occur at this
time.

Aims of delivery care are to achieve:

• A healthy mother and child with the least

possible level of intervention

• Early detection and management of

complications

• Timely referral of obstetric emergencies (if any) to

a level where it can be managed appropriately

More than three-quarters of all maternal deaths in developing

countries take place during or soon after childbirth. Based on
these aims, the single most critical intervention for safe
motherhood is to ensure that a
skilled attendant is present in every birth, and transportation is
available in case of an emergency referral.

Who is a skilled attendant?

In 1999, the WHO/UNFPA/UNICEF/World Bank statement

recognised skilled attendants as health professionals such as
midwives, doctors, or nurses with midwifery skills who have
been educated and trained to proficiency in the skills
necessary to manage normal pregnancies, childbirth and the
immediate postnatal period, and in the identification,
management, and referral of complications in women and
newborns.

Skilled care during childbirth is important because millions of

women and newborns develop hard-to- predict complications
during or immediately after delivery. Skilled attendants can
also recognize these complications, and either treat them or
refer women to health centers or hospitals immediately if
more advanced care is needed. Skilled attendance depends on
a partnership of skilled attendants, an enabling environment,
and access to emergency obstetric care services. This means
Skilled attendance can only be
provided when health professionals operate within a
functioning health system, or ‘enabling environment’, where
drugs, equipment, supplies, and transport are all available.

In 1996, skilled birth attendants were present at only 53

% of births in the developing world. In the developed world,
skilled birth attendance is almost universal. Countries where
skilled attendance at delivery is very low tend to have higher
rates of maternal death and disability. The maternal mortality
ratio and the proportion of deliveries with a skilled attendant
are used to monitor progress towards achieving the MDG goal
of improving maternal health.

The best person to care for women during delivery is a health

professional with midwifery skills who lives in or near to the
community he or she serves. However, most midwives work
in hospitals and urban areas. In parts of Asia and Africa, there
is only one midwife for every 15,000 births. Adequate
equipment, drugs and supplies are also essential to enable
skilled attendants to provide good quality care. In addition,
skilled attendants need to be supported by appropriate
supervision. When delivery is taking place at home or in a
local health facility, an
emergency transport system must be available to take women
to facilities that can be provide more advanced care.

In developing countries women commonly seek the help of

traditional birth attendants. These attendants may have some
training. However, without emergency back- up support
(including referral), training TBAs does not decrease a
woman’s risk of dying during childbirth. As countries try to
ensure that a qualified health professional is present at the
birth of every child, they face a number of significant
problems. Which are:-

 Existing health workers often lack the skills they need

to save the lives of women who suffer emergency
complications

 Curricula used to teach midwifery skills are often out

of date and do not reflect new techniques and
research

 In many places, especially in Africa and Asia, women

give birth with the help of a relative, or alone
  Refresher training in family planning and maternal
health care are often inadequate

 Many midwives and physicians have no training in

traditional belief systems, communication and
community organizing

Recommended ways to increase skilled birth

attendance

 Increase the number of professionals with midwifery

skills in underserved regions.

 Train, authorize and equip midwives, nurses and

community physicians to provide all feasible obstetric
services needed within communities, especially
emergency interventions and to prescribe medications.

 Upgrade, establish and expand comprehensive

midwifery training programmes that include life-
saving skills for dealing with obstetric emergencies.

 Create clearly defined protocols for routine care and

the management of complications.
  Establish systems for supervising and supporting
skilled attendants, and for emergency referral and Rx.

Because TBAs already exist in many developing country

communities, it has been suggested that they could perform
the role of the skilled attendant, where required with some
training. Research indicates that training of TBAs has not
contributed to reduction of maternal mortality. However, it is
recognized that for some women TBAs are the only source of
care available during pregnancy. And as experience from
some countries such as Malaysia has shown, TBAs can
become an important element in a country’s safe motherhood
strategy and can serve as key partners for increasing the
number of births at which a skilled attendant is present.

The impact of training TBAs on maternal mortality appears to

be limited and the greatest benefit may be improved referral
and linkages with the formal health system. Results from a
meta-analysis suggest that TBA training may increase
antenatal attendance rates. In Zambia, traditional birth
assistants serve as culturally knowledgeable social support
women during labor and
delivery, but have little accurate knowledge of appropriate
management of labor and delivery. It is now generally
accepted that one of the main reasons why many TBA-based
maternity care programmes of the past did not work, or were
unsustainable, was that the programmes failed to link TBAs to
a functioning health care system. In practical terms, TBAs can
help in the provision of skilled care to women and newborns
by serving as advocates for skilled attendants and maternal
and newborn health needs, disseminating health information
through the community and families.

In all countries, emphasis should be placed on training and

deploying an adequate number of professional, skilled
midwives to provide the majority of delivery care. Where
TBAs account for a significant portion of deliveries, safe
motherhood programs should include activities aimed at
providing adequate supervision and integrating them into the
health system.

 Appropriate training (skilled trainers and

appropriate teaching methodologies)

 Linkages to the health system that include proper

supervision and referral for complicated cases
  Ongoing assessment of the impact of TBA
programs

2.3.3. Postnatal Care

The postnatal period is the period when most maternal deaths

occur compared to the antepartum and intrapartum periods.
Post natal care is the care provided to the woman and her baby
during the six weeks period following delivery in order to
promote healthy behavior and early identification and
management of complications. It should include assessment,
health promotion and care provision. Care during the
immediate postpartum period (6-24 hours) needs to be viewed
as part of care during delivery. If no skilled attendant is
present at delivery, one should see the woman as early as
possible. WHO recommends a postpartum visit within 1-3
days, if possible through home visits by community health
workers. The main life- threatening complications of the
postnatal period include hemorrhage, anemia, genital trauma,
hypertension, sepsis, urinary tract infections and mastitis.
Delivery care in Ethiopia (EDHS 2005 report)

 Delivery in a health facility: 5.3 %

 Births attended by a health professional: 5.7 %, this

includes care given by doctors, nurses and midwifes

 Births attended by a TBA: 28.1 %

 The majority of births (60.5 %) are attended by a

relative or some other person

 Institutional delivery is generally low in most

regions. Highest in AA (79 %)

 Post natal care coverage is 6.3 %

 Only 4.6 % of mothers receive postnatal care within

the critical first two days after delivery

Children born in urban areas are 20 times more likely to be

delivered in a health facility than their rural counterparts.
Institutional delivery is 2 % among uneducated mothers
compared to 52 % among those with at least secondary
education. Births to women in the highest wealth quintile are
much more likely to be assisted by a trained health
professional (27 %) than to women in the lowest wealth
quintile (1 %).
Reasons for low utilization rates for maternal health
services

• No physical access
• High costs
• Poor information
• Cultural preferences
• Lack of decision-making power by women
• Poor quality of care
• Delays in referring women from community health
facilities to hospitals

2.3.4. Essential Newborn Care

Any intervention to prevent fetal deaths must focus on the

mother, since direct causes of neonatal deaths such as
asphyxia, respiratory distress syndrome and sepsis are related
to the health or care of the mother. The majority of neonatal
deaths (around 66%) occur in the first week of life.

You are expected to provide the following essential newborn

care during this period:

 Initiation of breathing and resuscitation when

needed
  Cleanliness
 Prevent heat loss, (Warming and drying of baby
and keeping the delivery room warm)
 Early breast-feeding
 Eye care
 Management of newborn illness
 Immunization
 Vitamin K administration.

Specific maternal health topics that have to be disseminated at

community level are summarized below.

1. Promote healthy behaviors to women, families and

communities

2. Promote appropriate use of maternal health care

3. Increase community awareness and organization.

4. Discourage practices which harm maternal health

2.3.5. Maternal Nutrition

Poor nutrition before and during delivery contributes in a

variety of ways to poor maternal health, obstetric problems
and poor pregnancy outcomes.
1. Stunting - exposes women to the risk of cephalo- pelvic
disproportion.
2. Anemia- the cause may be due to inadequate intake of
iron, parasitic infestation and malaria. Women with
severe anemia are therefore, more vulnerable to
infection and at increased risk of death due to obstetric
hemorrhage.
3. Severe vitamin A deficiency may make women more
vulnerable to obstetric complications, including infection
and associated maternal mortality.

A diet of pregnant and non-pregnant women should

contain daily allowance of Vitamin A of 800mg. It is
good to advice for women to have dark green, yellow
or orange fruits and vegetables, liver as a source of
vitamin A.

It is recommended to give supplemental vitamin A

to pregnant and lactating women 200,000IU during
pregnancy and 500,000IU during breast feeding. But
remember, high doses of vitamin A during pregnancy
causes teratogenic effect on fetus (consider doses
higher than 50,000 IU is toxic).
4. Iodine deficiency increases the risk of stillbirth and
spontaneous abortion in severely deficient areas in
country like Ethiopia. It also contributes to maternal death
through hypothyroidism. The daily allowance of iodine
is 150 mg and 175 mg for non-pregnant and pregnant
women respectively. Diets containing iodine such as
iodized salt and seafoods should be encouraged.

In summary the health care provider should encourage

women to take foods of varieties and able to
supplement available drugs during antenatal visits
(Iron, vitamin A, Iodine etc)

5.Folate Periconceptional folate supplementation has a

strong protective effect against neural tube defects.
Information about folate should be made more widely
available throughout the health and education systems.
Women whose fetuses or babies have neural tube defects
should be advised of the risk of recurrence in a subsequent
pregnancy and offered continuing folate supplementation.
The benefits and risks of fortifying basic food stuffs, such as
flour, with added folate remain unresolved.
2.3.6. Immunization

Prevention of Tetanus can be achieved by a combination of

two approaches: -

1. Improving maternity care with emphasis on increasing

the proportion of deliveries attended by trained
attendants.
2. Increasing the immunization coverage of women of
child bearing age, especially pregnant women with
tetanus toxoid (TT).

Important control measures include, licensing health care

providers providing professional supervision and health
education as to methods, equipment and techniques of asepsis
in childbirth; educating mothers, relatives and attendants in
the practice of strict asepsis of the umbilical cord of the
newborn. Any women of childbearing age visiting a health
facility should be screened and offered immunization, no
matter, what the reason for visit.
2.4. Estimation of maternal mortality

2.4.1. Definitions and measures of maternal

mortality

Definitions

The Tenth Revision of the International Classification of

Diseases (ICD-10) defines a maternal death as the death of
a woman while pregnant or within 42 days of termination
of pregnancy, irrespective of the duration and site of the
pregnancy, from any cause related to or aggravated by
the pregnancy or its managemen,t but not from
accidental or incidental causes.

The 42-day limit is somewhat arbitrary, and in recognition of

the fact that modern life-saving procedures and technologies
can prevent maternal death, ICD-10 introduced a new
category, namely the late maternal death, which is defined
as the death of a woman from direct or indirect obstetric
causes beyond
42 days, but less than one year after termination of
pregnancy.
According to ICD-10, maternal deaths should be divided into
two groups:

Direct obstetric deaths are those resulting from obstetric

complications of the pregnancy state (pregnancy, labour and
the puerperium), from interventions, omissions, incorrect
treatment, or from a chain of events resulting from any of the
above.

Indirect obstetric deaths are those resulting from

previous existing disease or disease that developed during
pregnancy and which was not due to direct obstetric causes,
but was aggravated by physiologic effects of pregnancy. The
drawback of this definition is that maternal deaths can escape
being so classified because the precise cause of death cannot
be given even though the fact of the woman having been
pregnant is known. Such under-registration is frequent in
both developing and developed countries. Deaths from
“accidental or incidental” causes have historically been
excluded from maternal mortality statistics. However, in
practice, the distinction between incidental and indirect causes
of death is difficult to make. To facilitate the identification of
maternal deaths in circumstances where cause of death
attribution is
inadequate, ICD-10 introduced a new category, that of
pregnancy-related death, which is defined as: the death of
a woman while pregnant or within 42 days of termination
of pregnancy, irrespective of the cause of death.

In practical terms then, there are two distinct approaches to

identify maternal deaths, one based on medical cause of
death following the ICD definition of maternal death, and
the other based on timing of death relative to
pregnancy that is, using the ICD definition of pregnancy-
related death. This has important implications for the
approaches to measurement described below.

Measures of maternal mortality

There are three distinct measures of maternal mortality in

widespread use: the maternal mortality ratio, the
maternal mortality rate and the lifetime risk of
maternal death. The most commonly used measure is the
maternal mortality ratio, that is the number of maternal deaths
during a given time period per 100,000 live births during the
same time period. This is a measure of the risk of death once
a woman has become
pregnant. The maternal mortality rate, that is, the number of
maternal deaths in a given period per 100,000 women of
reproductive age during the same time period, reflects the
frequency with which women are exposed to risk through
fertility. The lifetime risk of maternal death takes into account
both the probability of becoming pregnant and the probability
of dying as a result of that pregnancy cumulated across a
woman’s reproductive years. In theory, the lifetime risk is a
cohort measure, but it is usually calculated with period
measures for practical reasons. It can be approximated by
multiplying the maternal mortality rate by the length of the
reproductive period (around 35 years). Thus, the lifetime risk
is calculated as [1-(1-maternal mortality rate) 35].

2.4.2. Maternal mortality: The measurement

challenge

Why maternal mortality is difficult to measure

Maternal mortality is difficult to measure for both conceptual

and practical reasons. Maternal deaths are hard to identify
precisely because this requires information about deaths
among women of reproductive
age, pregnancy status at or near the time of death, and the
medical cause of death. All three components can be
difficult to measure accurately, particularly in settings where
deaths are not comprehensively reported through the vital
registration system and where there is no medical certification
of cause of death. Moreover, even where overall levels of
maternal mortality are high, maternal deaths are nonetheless
relatively rare events and thus, prone to measurement error.
As a result, all existing estimates of maternal mortality are
subject to greater or lesser degrees of uncertainty. Broadly
speaking, countries fall into one of four categories:

 Those with complete civil registration and good cause

of death attribution – though even here,
misclassification of maternal deaths can arise, for
example, if the pregnancy status of the woman was
not known or recorded, or the cause of death was
wrongly ascribed to a non-maternal cause.

 Those with relatively complete civil registration in

terms of numbers of births and deaths, but where
cause of death is not adequately classified; cause of
death is routinely reported for only 78
 countries or areas, covering approximately 35% of
the world’s population.

 Those with no reliable system of civil registration

where maternal deaths – like other vital events – go
unrecorded. Currently, this is the case for most
countries with high levels of maternal mortality.

Those with estimates of maternal mortality based on

household surveys, usually using the direct or indirect
sisterhood methods. These estimates are not only imprecise as
a result of sample size considerations, but they are also based
on a reference point some time in the past, at a minimum six
years prior to the survey and in some cases much longer than
this .

WHO, UNICEF and UNFPA have developed estimates of

maternal mortality primarily with the information needs of
countries with no or incomplete data on maternal mortality in
mind, but also as a way of adjusting for underreporting and
misclassification in data for other countries. A dual strategy is
used that adjusts existing country information to account for
problems of underreporting and misclassification and uses a
simple
statistical model to generate estimates for countries without
reliable data.

Approaches for measuring maternal mortality

Commonly used approaches for obtaining data on levels of

maternal mortality vary considerably in terms of
methodology, source of data and precision of results. The
main approaches are described briefly below. As a general
rule, maternal deaths are identified by medical certification in
the vital registration approach, but generally on the basis of
the time of death definition relative to pregnancy in household
surveys (including sisterhood surveys), censuses and in
Reproductive Age Mortality Studies (RAMOS).

Vital registration

In developed countries, information about maternal mortality

is derived from the system of vital registration of deaths by
cause. Even where coverage is complete and all deaths
medically certified, in the absence of active case-finding,
maternal deaths are frequently missed or misclassified. In
many countries, periodic confidential enquiries or surveillance
are used to assess the extent of misclassification and
underreporting. A
review of the evidence shows that registered maternal deaths
should be adjusted upward by a factor of 50% on average.
Few developing countries have a vital registration system of
sufficient coverage and quality to enable it to serve as the
basis for the assessment of levels and trends in cause-specific
mortality including maternal mortality.

Direct household survey methods

Where vital registration data are not appropriate for the

assessment of cause-specific mortality, the use of household
surveys provides an alternative. However, household surveys
using direct estimation are expensive and complex to
implement since large sample sizes are needed to provide a
statistically reliable estimate. The most frequently quoted
illustration of this problem is the household survey in Addis
Ababa, Ethiopia, where it was necessary to interview more
than 32,300 households to identify 45 deaths and produce an
estimated MMR of 480. At the 95% level of significance, this
gives a confidence interval of plus or minus about 30%, i.e.
the ratio could lie anywhere between 370 and 660. The
problem of wide confidence intervals is not simply that such
estimates are imprecise.
They may also lead to inappropriate interpretation of the
figures. For example, using point estimates for maternal
mortality may give the impression that the MMR is
significantly different in different settings or at different times
whereas, in fact, maternal mortality may be rather similar
since the confidence intervals overlap.

Indirect sisterhood method

The sisterhood method is a survey-based measurement

technique that in high-fertility populations substantially
reduces sample size requirements since it obtains information
by interviewing respondents about the survival of all their
adult sisters. Although sample size requirements may be
reduced, the problem of wide confidence intervals remains.
Furthermore, the method provides a retrospective rather than a
current estimate, averaging experience over a lengthy time
period (some 35 years, with a midpoint around 12 years
before the survey). For methodological reasons, the indirect
method is not appropriate for use in settings where fertility
levels are low [total fertility rate (TFR) <4] or where
there has been substantial migration, civil strife, war, or other
causes of social dislocation.
Direct sisterhood method

The Demographic and Health Surveys (DHS) use a variant of

the sisterhood approach, the “direct” sisterhood method. This
relies on fewer assumptions than the original method, but it
requires larger sample sizes and the information generated is
considerably more complex to collect and to analyze. The
direct method does not provide a current estimate of maternal
mortality, but the greater specificity of the information
permits the calculation of a ratio for a more recent period of
time. Results are typically calculated for a reference period of
seven years before the survey, approximating a point
estimate some three to four years before the survey. Because
of relatively wide confidence intervals, the direct sisterhood
method cannot be used to monitor short-term changes in
maternal mortality or to assess the impact of safe
motherhood programmes. The Demographic and Health
Surveys have published an in- depth review of the results of
the DHS sisterhood studies (direct and indirect methods) and
have advised against the duplication of surveys at short time-
intervals. WHO and UNICEF have issued guidance notes to
potential users of sisterhood methodologies, describing
the circumstances in which it is or is not appropriate to use the
methods and explaining how to interpret the results.

Reproductive Age Mortality Studies

The Reproductive Age Mortality Study – RAMOS – involves

identifying and investigating the causes of all deaths of
women of reproductive age. This method has been
successfully applied in countries with good vital registration
systems to calculate the extent of misclassification and in
countries without vital registration of deaths.

Successful studies in countries lacking complete vital

registration use multiple and varied sources of information to
identify deaths of women of reproductive age; no single
source identifies all the deaths. Subsequently, interviews with
household members and health-care providers and reviews of
facility records are used to classify the deaths as maternal or
otherwise. Properly conducted, the RAMOS approach is
considered to provide the most complete estimation of
maternal mortality, but can be complex and time- consuming
to undertake, particularly on a large scale.
Verbal autopsy

Where medical certification of cause of death is not available,

some studies assign cause of death using verbal autopsy
techniques. However, the reliability and validity of verbal
autopsy for assessing cause of death in general and identifying
maternal deaths in particular, has not been established. The
method may fail to correctly identify a proportion of maternal
deaths, particularly those occurring early in pregnancy
(ectopic, abortion-related), those in which the death occurs
some time after the termination of pregnancy (sepsis, organ
failure), and indirect causes of maternal death (malaria,
HIV/AIDS).

Census

There is growing interest in the use of decennial censuses for

the generation of data on maternal mortality. A high-
quality decennial census could include questions on deaths in
the household in a defined reference period (often one or two
years), followed by more detailed questions that would permit
the identification of maternal deaths on the basis of time of
death relative to pregnancy (verbal autopsy). The
weaknesses of the verbal autopsy method have already been
noted. Nonetheless, the advantages of such an approach are
that it would generate both national and sub-national figures
and that it would be possible to undertake analysis according
to the characteristics of the household.

Trend analysis would be possible because sampling errors

would be eliminated or greatly reduced. However, data
obtained from enquiries into recent deaths in the household in
a census require careful evaluation, and often adjustment. A
number of countries have used the census to generate maternal
mortality figures, and work is under way to assess the extent
to which such approaches may prove of value in measuring
maternal mortality.

2.4.3. Maternal mortality in Ethiopia

Since the launch of the Safe Motherhood Initiative in 1987,

attention to reproductive health has increased worldwide and
so has the need to provide reliable countrywide estimates of
maternal deaths. In response to this increased interest, DHS
surveys began collecting maternal mortality data through a
series of questions
designed to gather information and obtain a direct measure of
maternal mortality. These questions were included in the 2000
Ethiopian DHS and later in DHS 2005.

Maternal mortality estimates need a comprehensive and

accurate reporting of maternal deaths. Such estimates can be
obtained through vital registration, longitudinal studies of
pregnant women, or repeated household surveys. However,
there is no vital registration system in Ethiopia nor has there
been any national household survey carried out for the
purpose of estimating maternal mortality. The Ethiopian DHS
is the first population- based national survey to incorporate
questions on maternal mortality.

Direct estimates of maternal mortality use data on the age of

surviving sisters of survey respondents, the age at death of
sisters who have died, and the number of years since the death
of sisters. Interviewers in the Ethiopian DHS were asked to
list all the brothers and sisters born to the natural mother of
female respondents on chronological order starting with the
first. Information was then obtained on the survivorship of
each the siblings, the ages of surviving siblings, the year of
death
or years since death of deceased siblings, and the age at
death of deceased siblings. For each sister who died at age
12 or over, the respondents were asked additional
questions to determine whether the death was maternity
related ; that is, whether the sister was pregnant when she
died, and if so, whether the sister died during childbirth, and if
not, whether the sister died within two months of the
termination of a pregnancy or childbirth, listing all the siblings
in chronological order of their birth is believed to result in
better reporting of events than would be the case if only
information on sisters were sought. Moreover, the information
collected also allows the direct estimates of adult male and
female mortality.

Information on maternal mortality for the period 0-6 years

before the survey, as mentioned, this period was chosen to
reduce any possible heaping of reported years since death on
five-year intervals. Age-specific mortality rates are calculated
by dividing the number of maternal deaths by years of
exposure. Maternal deaths are defined as any death that
occurred during pregnancy, childbirth or within two months
after the birth or termination of pregnancy. This time-specific
definition
includes all deaths that occurred during the specified period
even if the death is due to non pregnancy-related causes.
However, this definition is unlikely to result in over reporting
of maternal deaths because most deaths to women in the
specified period are due to maternal causes, and maternal
deaths in general are more likely to be underreported than
over reported.

Maternal mortality rate in Ethiopia is high relative to

developed countries. There were 263 maternal deaths in the
seven years preceding the survey. The maternal mortality rate,
which is the annual number of maternal deaths per 1000
women age 15-49, for the period 1994- 2000 is 1.68. maternal
deaths accounted for 25 % of all deaths to women age 15-49;
in other words, one in four Ethiopian women who died in the
seven years preceding the survey died from pregnancy or
pregnancy-related causes.

The maternal mortality ratio, which is obtained by dividing

the age-standardized maternal mortality rate by the age-
standardized general fertility rate, is often considered a more
useful measure of maternal mortality since it measures the
obstetric risk associated with each live birth. The maternal
mortality ratio for Ethiopia for the
period 1994-2000 is 871 deaths per 100,000 live births (or
altnatively 9 deaths per 1,000 births).

Table 2: Direct estimates of maternal mortality for the

period 0-6 years prior to the survey, Ethiopia 2000.

Age Maternal Exposure Mortality Proportion of

deaths years rates 1 maternal deaths to
female deaths
15-19 32 34,277 0.919 18.8
20-24 63 34,082 1.843 30.6
25-29 56 28,641 1.957 31.8
30-34 61 23,757 2.585 31.6
35-39 34 17,445 1.940 22.9
40-44 12 10,968 1.102 13.3
5 7,164 0.690 8.6
Total 263 156,334 1.680 25.3
General Fertility Ratio (GFR) 0.190
Maternal Mortality Ratio (MMR)2 871

Expressed per 1,000 woman-years of exposure

Expressed per 100,000 live-birth; calculated as the maternal mortality rate
divided by the general ferility rate
Age-adjusted rate
 CHAPTER 3
ABORTION
Learning Objectives

At the end of the chapter, the student is expected to:

 Understand the magnitude of abortion

 Identify reasons behind unplanned pregnancy

 Define Unsafe abortion and know contributing factors

 Understand different components of post abortal care

 Know the revised Penal Code of Ethiopia on

Safe abortion

Abortion is the termination or initiation of termination of

pregnancy before reaching viability (before 20weeks or
<500grams according to WHO or before 28 weeks of
gestation or less than 1kg fetal weight in Ethiopia and UK). It
can be spontaneous where termination is not provoked
deliberately or induced when there is a deliberate interference
with the pregnancy for the sake
of terminating it. Clinical stages of spontaneous abortion are:
threatened, inevitable, incomplete, complete or missed
abortion. If any of the stages mentioned get infected it is
called septic abortion.

About Fifteen percent of all clinically recognizable

pregnancies end in spontaneous abortions. It is estimated that
30 to 50 million induced abortions are performed annually in
the world and about half of these are performed illegally. In
Ethiopia it is estimated that there are 3.27 million pregnancies
every year of which approximately 500,000 end in either
spontaneous or unsafely induced abortion

WHO characterizes unsafe abortion by the lack of skilled

providers, safe techniques, and/or sanitary facilities. Unsafe
abortion is the commonest cause of maternal mortality
accounting for up to 32% of all maternal deaths in Ethiopia.

Abortion is more than a medical issue, or an ethical issue, or a

legal issue. It is above all a human issue, involving women
and men as individuals, as couples and as a member of the
society.
3.1. Public Health Importance of Abortion

3.1.1. Abortion-related morbidities and

mortalities

Unsafe abortion is a global problem. Millions of women

around the world risk their lives and health to end an
unwanted pregnancy. Every day, 55, 000 unsafe abortions
take place–95 % of them in developing countries-and lead to
the deaths of more than 200 women daily. Globally, one
unsafe abortion takes place for every seven births.

Every year, 68,000 deaths and about 5 million disabilities

occur globally due to unsafe abortion. One out of every
eight maternal deaths is due to abortion related complications.
In some settings a quarter or more of all maternal deaths are
abortion-related.

Many women fail to seek treatment for abortion-related

complications, leading to countless-and uncounted- deaths
outside of health care systems. Unsafe abortion is, however,
one of the most easily preventable and treatable causes of
maternal death and disability.
Between 20 and 50 % of all women who undergo unsafe
abortions need hospitalization for complications.

Acute Complications

• Incomplete abortion

• Sepsis

• Hemorrhage

• Uterine Perforation

• Bowel injury

Long-term Complications

• Chronic pelvic pain

• Pelvic inflammatory disease

• Tubal blockage and secondary infertility

• Ectopic pregnancy

• Increased risk of spontaneous abortion or

premature delivery in subsequent pregnancies.

These complications can limit women’s productivity inside

and outside the home, constrain their ability to care for
children and adversely affect sexual life.
3.1.2 Impact on the public health system

Treatment of abortion-related complications:

 Often require several days of hospitalization and staff

time, as well as

 Blood transfusions, antibiotics, pain control

medications and other drugs.

Providing this care depletes funds and medical supplies

needed for other types of treatment. As much as 50 % of
some hospital budgets in developing countries are used to
treat complications of unsafe abortion. For example, a recent
study in Tanzania showed that 34 to 57 % of all admissions to
the gynecological ward of a hospital in Dares Salaam were
women suffering from complications of abortion, costing the
hospital $7.5 per day to treat each woman. The national health
budget allocates only $1 per person per year for health care.

Magnitude of Abortion in Ethiopia

Accurate estimates are difficult to get, but it is clear that

abortion is widespread and generally performed by untrained
persons. It is the leading cause of maternal mortality. In a
community-based study, abortion
accounted for 54.2 % of the direct causes of maternal deaths.
It is one of the top ten causes of admissions among women.
Unsafe abortion accounts for nearly 60
% of all gynecologic admissions and almost 30 % of all
obstetric and gynecologic admissions. In a study done in
Addis Ababa; abortion hospital occupancy rate among
mothers was 32. 2 %.

3.2. Why Women Find Themselves with

Unwanted Pregnancy?

3.2.1 Non-use of contraception

The majority of unwanted pregnancies occur in Non- users of

contraceptive methods.

Despite the fact that family planning services are more

effective and available than ever before, estimates suggest that
,worldwide:

• 350 million couples lack access to information about

contraceptives and a full range of modern family
planning methods

• 105 million married women have unmet need for

family planning
 • 12 to 15 million women may also lack access to
services that will enable them to achieve their
reproductive intentions.

• Even after treatment for complications of unsafe

abortion, many women leave hospitals without any
counseling on how to prevent future pregnancies, and
without a contraceptive method.

In Zambia, for example, 78 % of women treated for

abortion complications indicated that they would like to
receive information about family planning, and 44
% indicated they would have liked to receive a method.
However, Family planning was discussed with only 33 %
of the women, and none was offered a method to take
home.

3.2.2 Contraceptive failure

Contraceptive failure results in 8-30 million pregnancies each

year either from inconsistent or incorrect use of family
planning methods or method-related failure.
3.2.3 Sexual coercion or rape

Twenty to fifty percent of women and girls report sexual

abuse, rape or sexual coercion which carries about 5% risk of
pregnancy in those in reproductive age unless emergency
contraceptives given.

3.2.4 Other factors include:

• Lack of control over contraception;

• Young age or single marital status;

• Abandonment or unstable relationship;

• Mental or physical health problems;

• Severe malformation of the fetus; and

• Financial constraints.

3.3 Why does induced Abortion Occur?

Each year women around the world experience 80 million
unwanted pregnancies. Out of these mothers, nearly 42
million decide to have an abortion and about 20 million of
them undergo unsafe abortion.
A woman's decision to get an abortion is not made in a
vacuum, but is bound up in society's feelings about abortion
as well as her feelings about the pregnancy:

 Several social factors influence the emotional

decision of obtaining abortion

 The cultural attitudes toward family size also

influence woman’s perception of abortion. When
large families are the norm, she is viewed as, at best,
odd. However, as norms change and children become
more of an economic burden, this should remove
another source of external pressure.

 Religious attitudes strongly affect the decision

 Personal and interpersonal reasons for continuing the

pregnancy can be a great source of conflict. Often,
pregnancy is the unwanted by- product of wanted
sexual relations, while a pregnancy that is desired to
prove her ability as a woman may have little
relationship to desire for the actual child.
  Age and martial status are important factors in the
decision along with number of other children already
born.

In some instances abortion is the first responsible decision the

woman has made, and often the effect is beneficial to other
children in a large family or to the woman planning an unwise
marriage. Counseling helps the outcome. A large benefit of
legalized abortion is the opportunity to talk with a trained
counselor.

Unsafe abortion is a public health problem, particularly

among young women since:

• Poor access to family planning information and

services →unplanned pregnancy

• They are less likely than older women to have the

social contacts and financial means to obtain a safe
abortion

• Young women are more likely to delay seeking help

and hence seek terminations at more advanced stages
of gestation when the risks of morbidity and mortality
are higher.
In many African countries, up to 70 % of all women
hospitalized for abortion complications are younger than 20.

3.4 Legislation and policies

National laws and policies on abortion vary widely. In 98
% of the world’s countries; danger to the woman’s life is
recognized as a legal basis for terminating a pregnancy. Only
in a few countries- Chile, the Holy See, El Salvador,
Nicaragua, and Malta-is abortion illegal in all circumstances.

When abortion is illegal,

 It is most difficult for a woman to obtain it,

 Society is generally against abortion, and

 The psychological trauma is generally great.

Evidence shows that restrictive legislation is associated with

higher rates of unsafe abortion and correspondingly high
mortality.

Once abortion is legalized, a supportive relationship can be

established and the decrease in external stress will be
accompanied by a similar decrease in negative feelings.
 • Up to 23 unsafe abortion/1000 women restrictive laws
compared to 2/1000 in permissive laws

• Mortality 34/1000 live births in restrictive countries

compared to 1 or less per 1000 live birth in liberal
laws

In Romania, for example, abortion-related deaths increased

sharply when the law became very restrictive in 1966 (to
148/100,000), and fell after 1990 with a return to less
restrictive legislation (9/100,000) in 2002.

3.5 Inadequate services

In many developing countries, safe abortion services are not
available to the full extent permitted by law. Many health
workers lack vital information about the legal status of
abortion, and do not know how to perform abortions. When
women experience complications due to unsafe abortion,
appropriate medical care is often unavailable or inaccessible.

Lack of protocols for post-abortion care, misdiagnosis,

negative attitudes on the part of health care providers and
case overload result in life-threatening. These
factors also costly, delay services for women seeking
treatment from the health system.

3.6 What can be done about unwanted

pregnancies and unsafe abortions?
• Ensure universal access to family planning

• Increase the availability of safe abortion services to

the extent allowed by law

• Improve the quality and accessibility of post-

abortion care

• Educate communities about reproductive health and

unsafe abortion; and

• Work for changes in policies to safeguard women’s

reproductive health.

I. Contraceptive services and information

Prevent unwanted pregnancies through comprehensive, client-

oriented reproductive health services especially family
planning.

 During service provision one must be non-

judgmental in attitudes,
  Confidential counseling and quality family planning
information and services, including emergency
contraception, should be universally accessible to all
women,

 Special attention should be given to the needs of

young people, marginalized women, women living in
situations of conflict, and women at risk of sexual
abuse, rape and violence.

II. Providing high quality appropriate services

In more than 131 developing countries, induced abortion is

permitted in certain circumstances. In countries where
abortion is legal:

• Services should be safe and available

• Service providers must be carefully trained to offer

high quality services and compassionate counseling.

• Providers must be well-informed about the legal status

of abortion and protocols for providing services, so
that women who are eligible can access services
quickly and without unnecessary delays or
bureaucratic procedures.
Available services should also be publicized within the
community and links should be strengthened with women’s
groups, health centers and related organizations to ensure that
women who need services are informed about where and
when to seek care. Appropriate technologies such as vacuum
aspiration should be available. New technologies, such as non-
surgical abortion, should be made available, where
appropriate and feasible.

III. Offering post-abortion care

Whatever the legal status of abortion, high quality services for

treating and managing complications of abortions should be
accessible to all women to reduce related maternal death. The
recently promoted abortion care approach is women-centered
approach of provision of the services. In the woman –centered
approach, the provider asks for and focuses on woman’s
concerns and interests and takes a comprehensive approach to
meeting every woman’s medical and psychological needs at
the time of treatment.
Key elements of post abortion care include:

1. Treatment of incomplete and unsafe abortion;

2. Counseling;

3. Family planning services;

4. Links to comprehensive reproductive health services; and

5. Community and service provider partnerships.

IV. Educating communities

Education is critical for reducing the public health problem of

unsafe abortion. Health education messages should be based
on the incidence and impact of unsafe abortion within
communities, and be sensitive to people’s beliefs, attitudes
and practices. They should offer information on: the legal
status of abortion; preventing unwanted pregnancy; avoiding
unsafe abortion; and recognizing and seeking appropriate
treatment for abortion complications.

V. Supportive laws and policies

When laws are modified to allow greater access to abortion-

related services, such as legal changes, must
be accompanied by changes in the health service structure.

• Development of appropriate service delivery

standards; protocols, guidelines and administrative
procedures;

• Restructuring of the health system to ensure that high

quality, safe services are available at the lowest levels
compatible with good quality care.

• Staff must be trained and willing to provide services;

and

• Supplies of necessary equipment and drugs must be

available

• Requisite funds must be allocated for all these

activities.

Policies and laws can contribute to unsafe abortion by

impeding women’s ability to protect their sexual and
reproductive health.

Examples

– Prohibitions on contraceptive delivery to

unmarried women and adolescents
 – Requirements for spousal consent for the use of
family planning services

Such policies and laws should be reviewed and revised, taking

into account the cultural, religious and moral values of the
communities concerned.

3.7 Grounds on Which Abortion is

Permitted, revised abortion law of
Ethiopia, (House of Parliament,
2005)
• When the pregnancy puts the woman’s life at risk
• Fetal impairment or deformity
• When pregnancy follows Rape or incest (based on
the woman’s complaint only)
• When pregnancy occurs in minors (stated
maternal age <18 years)
• The woman is physically and mentally unable to
care for the would-be born child
References for Further Reading
• WHO. Unsafe abortion. Fifth edition, 2007
• The Lancet Series on SRH. Unsafe abortion, 2006
• UN. World Abortion Policies, 2007
• MOH abortion protocol
 CHAPTER 4
FAMILY PLANNING

Learning objectives
At the end of the chapter, the student is expected to:
o Understand the rationale for FP
Programs in developing countries
o Understand steps in counseling
o Understand the reasons behind non-use of
contraceptive methods

o Know different FP delivery systems

Introduction
Family Planning Refers to the use of various methods of
fertility control that will help individuals (men and women)
or couples to have the number of children they want and when
they want them in order to assure the well being of children
and the parents. Family planning simply means preventing
unwanted pregnancies by safe methods of prevention. This is
considered to be part of the basic human rights of all
individuals or couples as it
was endorsed by the International Conference on
Population and Development in Cairo in 1994.

Family planning programs provide services that help

people achieve:

• The number of children they desire

• Reduce the number of unwanted pregnancies
• Reduce the risk of sexually transmitted infection
(especially condom), and
• Improve the health of women and children by
spacing birth.
To achieve the above objectives, the service should offer:
 A wide range of contraceptives and counseling for well
informed choice
 Screening and follow up
 Integrated services like prevention and treatment of STIs
4.1. Origins and Rationale for Family
Planning Programs in Developing
Countries

4.1.1. Demographic Rationale

Reducing high fertility and slowing population growth

provided the dominant rationale for FP programs in the 1960s
and 1970s. The rationale was based on concerns over the
potentially negative effects of rapid population growth and
high fertility on living standards and human welfare,
economic productivity, natural resources, and the environment
in the developing world, but still surveys showed substantial
unmet need for family planning.

4.1.2. Health Rationale

During the 1980s, the public health consequences of high

fertility for mothers and children are set of concerns for
international community especially for developing countries.
High rates of infant, child, and maternal mortality as well as
abortion and its health consequences, were pressing health
problems in many
developing nations and had also become of greater concern
for international development agencies.

4.1.2. 1. Benefits to women’s health

Simply by providing contraceptives to women who desire to

use it, we can reduce maternal deaths by as much as one-third
because:

 Avoiding pregnancy at the extremes of maternal

age

 Decreasing risks by decreasing parity: If all women

had five births or fewer, the number of maternal
deaths could drop by 26 % worldwide.

 Preventing high-risk pregnancies: decrease maternal

deaths by quarter

 Prevention of unwanted pregnancy: reduces

unnecessary risks of pregnancy, childbirth and risks
of induced abortion

 Improving health through non-contraceptive benefits

including prevention of STIs and reproductive
cancers
4.1.2.2. Family planning benefits children’s
health

Family planning indirectly contributes to children’s health,

development and survival by reducing the risk of maternal
mortality and morbidity.

Spacing births at least 2 years apart has to do with their

survival:

• On average, babies born less than two years after the

previous birth in the family are about twice as likely
to die in the first year as babies born after at least a 2-
year interval.

• Even older children who are spaced too closely face

an increased risk of death during the toddler and
childhood years.

Planning births during the mother’s optimal age-not too old or

too young: women who are very young or very old are more
likely to have an infant or child death. Family planning
prevents further pregnancies in a mother who has had
numerous pregnancies already and avoids close birth spacing
and sharing limited resources such as food.
4.1.2.3. Family planning benefits women and
their societies

Family planning reduces the health risks of women and gives

them more control over their reproductive lives. With better
health and greater control over their lives, women can take
advantage of education, employment, and civic opportunities.
If couples have fewer children in the future, the rate of
population growth would decrease. As a result, future
demands on natural resources such as water and fertile soil
will be less. Everyone will have a better opportunity for a
better quality of life.

4.1.3. Human Rights Rationale

This rationale became preeminent in the 1990s, in part

because of the excesses reactions to the demographic
rationale. It rests on the belief that individuals and couples
have a fundamental right to control reproductive decisions,
including family size and the timing of births. This rationale
found its strongest articulation at the ICPD, held in Cairo, in
1994.
 4.2. Family Planning methods
The commonly used family planning methods are:

1 Natural Method

 Breast feeding

 Abstinence

 Withdrawal (Coitus interrupts)

 Calendar methods

 Cervical mucus (Billing’s Method)

 Sympathothermal

2 Artificial methods

 Barrier methods

- Diaphragm

- Condom

 Intra-uterine device (IUD)

 Hormonal

- Pills

- Implants

- Injectable
  Surgical methods (Permanent)

- Tubal ligation (ligating the oviduct).

- Vasectomy (ligating the sperm duct).

Emergency contraception

 IUD

 Levonorgestrel-only or combined estrogen-

progesterone

 RU486

Even though various methods are available and accessible,

clients do not get the opportunity to discuss with health care
providers how/when to use and where to go. Therefore, it is
important to ensure provision of information and counseling
in family planning services.

The major activities to be carried out are:

1. Review of all available methods in a simple and

understandable manner.

2. Understanding and respecting the clients’ right.

3. Follow the acronym GATHER- greet, ask, tell, help,

explain, and return
4.3. Fertility Trends and Contraceptive
Use

Contraceptive use and fertility rates vary substantially among

developing countries. In a few countries of Asia and Latin
America, at least three-fourths of married women use a
contraceptive method—levels equal to those in developed
countries. In contrast, in some sub- Saharan African countries
fewer than 10% of married women use contraception. An
estimated 105 million married women, about 1 in every 5,
have an unmet need for family planning—that is, they are
sexually active and want to avoid pregnancy, but are not using
contraception. The percentage of women with unmet need fell
since 1990, but still large number of women have no access to
family planning services. Sub- Saharan Africa stands out as
the region having the highest unmet need for contraception
in the world (24
%). Among the 60 developing countries surveyed since 1990,
the TFR varies from 2.3 children per woman in Vietnam to 7.2
in Niger. The average is 4.5 children per woman for those 60
countries as a whole.
The fertility decline in developing countries that began in the
1960s and 1970s continued through the 1990s. Among 38
developing countries with more than one survey since 1990,
the total fertility rate (TFR) fell in almost all. Among
developing countries surveyed since 1990, fertility is highest
in sub-Saharan Africa, at an average of 5.3 children per
woman, but subsequent surveys suggest that parts of Africa
have started down the path already taken in other regions.
Behind fertility declines, there is continued increase in
contraceptive use, particularly use of modern methods.
Population Reports estimate that in 2000 about 55% of
married women of reproductive age in developing countries
were using a contraceptive method. This level of
contraceptive use is well below the level in the developed
world of 75 % to 84 % of married women which is the level of
contraceptive use generally considered necessary to achieve
replacement-level fertility (each couple having an average
number of two children with contraceptive prevalence rate of
75% to 84%).
Replacement-level fertility is the fertility rate at which
each generation has only enough children to replace itself. In
industrialized countries, where mortality is lower than in most
developing countries, the replacement fertility level is a TFR
of about 2.1. In developing countries with higher mortality
levels, particularly among children, can push replacement-
level fertility higher—to as high as a TFR of 3.5 or 4.0.
Compared with earlier demographic transitions elsewhere, the
transition in sub- Saharan Africa is much slower. Many
factors—cultural, economic, political, and demographic—help
explain the difference. Some researchers point to continued
strong cultural preference for large families, to large rural
populations relying on subsistence farming, and to low levels
of economic development. In addition, continued high rates
of infant and child mortality have contributed to high fertility
levels, because many couples may have “extra” children to
make up for those who die young.

In the past, lack of government commitment to family

planning programs in some countries limited access to the
range of contraceptive methods and services needed to meet
people’s needs. Moreover, some sub- Saharan countries have
faced internal conflicts that
have made it difficult to provide family planning.
Nevertheless, if recent fertility trends in sub-Saharan Africa
are any indication, fertility rates in the region will fall in the
future as they already have elsewhere. Reflecting such an
expectation, the latest medium variant UN projection shows a
TFR in Africa of 2.4 children per woman by 2045-2050.

4.4. Men’s Attitude towards FP

Men’s attitude towards contraceptive use exerts an important
influence on their partner’s attitude and eventual adoption of a
method. Since 1990, 46 countries, most in sub-Saharan
Africa, have taken nationally representative surveys of men’s
family planning attitudes and behavior. In nearly all surveyed
countries, most men know and approve of contraception.
Most married men say that they want to have more children,
however, and on average, they want more children than
married women do.

4.5. Fertility among Different Groups

Fertility levels vary according to women’s educational
attainment, residence, and other social and economic
characteristics. Such differences often are substantial.
In most surveyed countries, the more years of school that
women have completed, the lower their fertility. Women’s
educational attainment has a stronger effect on fertility than
does men’s education or other characteristics of households,
such as wealth for example in Malawi, among women with
no education the TFR is 7.3, while among women who have
completed secondary education, it is only 3.0. Education
affects fertility through a number of interrelated factors,
including women’s social and economic status, status within
the household, age at marriage, family size desires, access to
family planning information and services, and use of
contraception. In all countries surveyed, the TFR is lower in
urban than rural areas.

4.6. Counseling in Family Planning

4.6.1. Goal of Family Planning Counseling

The main goal of family planning is to improve the quality of

life and reproductive health by empowering individuals and
couples to exercise their right to safe sexuality, and to decide
whether and when to have children and how many to have.
This goal is to provide opportunities for people to discuss
their circumstances,
needs and options to help clients make informed decisions
about contraception, fertility and sexual health.

The counselor should be trained with regards to FP. He/she

should also have some personal qualities. The following
points can be seen in this context.

a) Bridge Knowledge Gap

 Brief anatomy and physiology of reproductive health
to clients.
 Explain about the contraceptive technology - the
benefits, risks, effectiveness and mode of action for
all available family planning methods.
 Myths and belief should be told.

b) Help Clients Make Informed Choice

 Consider that women may be unprepared to make
their own choice.
 Encourage clients to take responsibility for decision-
making.
 Give complete information about the method chosen
by the client.

C) Provide Services
 Record should be kept for a client.
  Give family planning services.
 Should schedule follow - up visits.

4.6.2. Steps in Family Planning Counselling

Counseling new clients about family planning needs a step-

by-step process. The process includes learning, making
choices, making decisions and carrying them out. It consists
of six steps which can be remembered with the acronyms
GATHER. Not every new client needs all the steps; some
clients need more attention to one step than another.

The GATHER Steps

G -Greet clients in an open, respectful manner. Assure the

client of confidentiality. Give as much time listening as
talking.

A -Ask clients about themselves. Help client talk about their

family planning practices, intentions, concerns, and
wishes.

T -Tell clients about choices. Depending on the clients need,

tell the client what reproductive health choices she/he
might take. Focus on methods that interest
 the client. Also explain other services that the client may
want.

H -Help clients make an informed choice. Help the client

think about the options. Encourage the client to express
opinions and ask questions. Consider medical eligibility
criteria for the family planning method that interest the
client. In the end, make sure that the client has made clear
decision.

E -Explain fully how to use the chosen method: after a client

chooses a family planning method, give her or him the
supplies if appropriate. Encourage questions, and answer
them openly and fully. Give condoms to any one at risk
for sexually transmitted diseases (STD's) and encourage
using condoms along with any other family planning
method. Check that the clients understand how to use their
method.

R -Return visits should be welcomed: Discuss and agree

when the client will return for follow-up or more supplies
if needed. Always invite the client to return any time for
any reason.
Counseling is crucial to help clients make and carry out their
own choices about reproductive health and family planning,
makes clients more satisfied and helps clients use family
planning longer and more successfully.

Counseling should be tailored to each client. At the same

time, most counseling about method choice covers six topics.

 Effectiveness
 Advantages and disadvantages
 Side effects and complications
 How to use
 STI prevention
 When to return

4.6.3. Adolescent Counseling on Family

Planning

Most of the fertility related problems affecting adolescents

come about because of family life, education both at home
and school. Therefore, giving family life education and
counseling are important to adolescents in order to tackle the
problems.
Adolescence, married or unmarried, face several potential
problems in relation to their sexual and Reproductive
Health. These includes:-

 Consequences of unwanted pregnancy which may

result in unsafe abortion.

 High risks of early child bearing for the mother, infant

and child.

 Diminished opportunities for education and education

especially for females.

 Unprotected sexual intercourse exposes adolescents to

a high risk of STD's. Consistent and correct use of
condom is highly effective in preventing pregnancy
and STI (dual protection).

4.7. Trends in Contraceptive Use in

Ethiopia
According to EDHS, majority (79.5 %) of current
contraceptive users obtain methods from the public sector.
Thirty-four percent of currently married women have unmet
need for family planning. Men desire larger family size than
women:
 – Mean ideal number of children is 4.5 for all women
and 5.1 for currently married women

– Mean ideal number of children is 5.2 among all men

and 6.4 for currently married men

The TFR in the rural areas is 6.0, two and half times higher
than the TFR in the urban areas (2.4). There are also
substantial differences in fertility among regions. The level
of fertility is inversely related to women’s educational
attainment, decreasing rapidly from 6.1 children among
women with no education to 2.0 children among women who
have at least some secondary education, which is similar to
reports from other regions.

4.8. Family Planning Delivery

Strategies
Service delivery strategies need to be tailored to reach
populations in different locations- urban areas, rural towns,
villages, and remote areas. The most common service delivery
sites include clinics, community-based distribution programs,
commercial retail sales, workplace programs, postpartum
programs, and private physicians.
1. Clinic-based services

A clinic-based approach is reasonable in areas where clients

do not live far from the clinic. Clinics often have the
advantage of being able to provide methods that are more
medically complex, such as IUDs, implants, Injectable and
sterilization. In urban areas and rural towns, FP is most often
provided by clinics that integrate it with other health services
for women and children or offer it only on certain days of the
week.

2. Community-Based Distribution (CBD)

In areas that do not have clinics nearby, family planning

services may be made available through CBD programs. In
this approach, CBD workers, usually village women are
trained to educate their neighbors about family planning and
to distribute certain contraceptives. In some programs, CBD
workers also provide some primary health care services. In
some programs, the workers receive some kind of payment;
in others they are strictly volunteers. A midwife, family
planning nurse, program coordinator, or other staff member is
usually responsible for supervising the CBD workers’
activities and managing any problems that occur. FP
administrators may find that CBD services are most
effective when a program is fairly new and people are not
familiar with contraceptives. Adding CBD services to existing
clinic services has been shown to make family planning more
acceptable to a community and to increase a program’s
impact. In Ethiopia, CBD workers provide FP to 1.7 % of
current users from the public sector and 1.4 % of the private
sector.

To establish CBD

– Selection of CBD workers

– Training (initial/in-service)

– Supervision

– Integrating into a functional referral

system

– Incentives to CBD workers

3. Commercial Retail Sales

If people are willing to obtain contraceptives from sources

outside the health care system, commercial retail sales can
make contraceptive methods very accessible. In this approach,
contraceptives such as OCPs and condoms are sold at
reduced, subsidized prices in pharmacies, stores, shops, bars,
beauty salons
and barber shops and are advertised on the mass media. When
this approach is used, retailers should be given training in
basic information about the products and how to refer
people who have problems with a contraceptive.

4.9. Reasons for Not Using

Contraceptives
An understanding of the reasons why people do not use family
planning methods is critical in designing programmes that are
effective in reaching women with unmet need and to improve
the quality of family planning services.

Main Reasons for Not Intending to Use are:

• Outside sub-Saharan Africa: At little risk of

becoming pregnant.

• Sub- Saharan Africa: Currently pregnant or want to

have more children.

Other reasons for not intending to use:

• Concerns with contraceptive side effects

• Religious or other opposition to family planning.

Major Reasons in Ethiopia (EDHS)

• Fertility-related reasons (40 %) mainly desire for

more children

• Opposition to use (23.6 %)

• Lack of knowledge (11.2%),

• Method-related reasons (13.6%)

The proportion of women who cited a desire for more children

has dropped markedly from 42 percent in 2000 to 18 percent
in 2005, suggesting that women are realizing the
disadvantages of large family sizes.
References for Further Reading

• Lancet Series on SRH. Family planning: an

unfinished agenda

• CSA, EDHS 2005. Ethiopian Demographic and

Health Survey

• Men’s surveys. New findings. Population Reports

2004, Series M, Number 18

• The Reproductive Revolution Continues. Population

Reports 2003, Series M, Number 17

• Jane T. Bertrand, Robert J. Magnani, Naomi

Rutenberg. Handbook of indicators for FP program
evaluation. December 1994

• Judith Bruce. Fundamental elements of the quality

of care: a simple framework. Studies in FP. 1990,
Vol. 21, No.2. pp 61-91

• Saumya RamaRao and Raji Mohanam. The Quality of

Family Planning Programs: Concepts, Measurements,
Interventions, and Effects. Studies in Family
Planning. 2003; 34[4]: 227–248
 CHAPTER 5

SEXUALLY TRANSMITTED
INFECTIONS
Learning Objectives
At the end of the chapter, the student is expected to:

 Describe the Classification of STIS

 Outline the public health significance of STIS
 Understand STI Control strategies and obstacles
 Understand advantages and limitations of
syndromic approach

5.1 Introduction
Reproductive tract infections (RTIs) are infections of the
genital tract of women and men. There are three types of
RTIs:
1. Sexually transmitted infections (STIs)

 Infections caused by organisms that are passed

through sexual activity with an infected partner.

More than 40 have been identified, including Chlamydia,

gonorrhea, hepatitis B and C, herpes, HPV, syphilis,
trichomoniasis, and HIV.

2. Endogenous infections

– Infections that result from an overgrowth of

organisms normally present in the vagina.

– These infections are not usually sexually transmitted,

and include bacterial vaginosis and candidiasis.

3. Iatrogenic infections

– Infections introduced into the reproductive tract by a

medical procedure such as menstrual regulation,
induced abortion, IUD insertion, or childbirth.

– This can happen if surgical instruments used in the

procedure are not properly sterilized, or if an infection
already present in the lower
 reproductive tract is pushed through the cervix into
the upper reproductive tract.

These three types of RTIs overlap and should be considered

together. For example, some STIs, like gonorrhea or
Chlamydia, can be spread in the reproductive tract if not
treated prior to a procedure. In addition, some non-sexual
infections, such as candidiasis, can be passed on through
sexual activity. Not all STIs are RTIs; and not all RTIs are
sexually transmitted; STI refers to the way of transmission
whereas RTI refers to the site where the infections develop.

5.1.1. Main STI Pathogens

More than 30 pathogens are transmissible through sexual

intercourse-oral, anal, or vaginal. The main sexually
transmitted bacteria are:

Neisseria gonorrhoeae (causes gonorrhoea)

Chlamydia trachomatis (chlamydial infections)

Treponema pallidum (causes syphilis)

Haemophilus ducreyi (causes chancroid)

The main sexually transmitted viruses are:

– Human immunodeficiency virus (causes

AIDS)

– Herpes simplex virus (causes genital herpes)

– Human papilloma virus (causes genital

warts)

– Hepatitis B virus

– Cytomegalovirus

• The main parasitic organisms are:

– Trichomonas vaginalis (causes vaginal

trichomoniasis)

5.1.2. Public Health Significance of STIs

Over 340 million curable, and many more incurable, STIs

occur each year. Among women, non-sexually- transmitted
RTIs are usually even more common. In developing countries,
STIs and their complications rank in the top five disease
categories for which adults seek health care. In women (15-49
years), STIs, even excluding HIV, are second only to maternal
factors as causes of disease, death and healthy life lost. Self-
reported prevalence of STIs in Ethiopia is 2 % in women and
1.5 % in men.

The links between STIs and HIV is one of the reasons that
force the world to give attention to almost neglected sexually
transmitted infections, because:

• The presence of an untreated STI enhances both

acquisition and transmission of HIV. HSV-2 plays an
important role in the transmission of HIV infection.

• STI treatment is an important HIV prevention strategy

in a general population

• Integration of HIV/AIDS programs with STIs

prevention and care programs is economically
advantageous (similar interventions and target
audiences)

• Clinical services offering STI care are important for

providing information and education about STIs
including HIV in order to promote lower risk
behavior.

Another reason to consider STIs as public health problems is

because STIs can lead to the development of serious
complications like:
 • Women: cervical cancer, pelvic inflammatory disease,
chronic pelvic pain, ectopic pregnancy and infertility.

• Men: sub-fertility

• Newborn: blindness and lung damage

• Syphilis can result in congenital syphilis for the baby

and fatal cardiac, neurological and other
complications in adults

• Genital warts can lead to ano-genital cancers

Untreated gonococcal and chlamydial infections in women

will result in pelvic inflammatory disease in up to 40% of
cases. One in four of these will result in infertility. In
pregnancy, untreated early syphilis will result in a stillbirth
rate of 25% and be responsible for 14% of neonatal deaths –
an overall perinatal mortality of about 40%. Syphilis
prevalence in pregnant women in Africa, for example, ranges
from 4% to 15%. Human papillomavirus (HPV) causes about
500 000 cases of cervical cancer annually with 240,000
deaths, mainly in resource poor countries. Worldwide, up to
4000 newborn babies become blind every year because of
eye infections attributable to untreated maternal gonococcal
and chlamydial infections.

STIs constitute a huge health and economic burden, especially

for developing countries, where they account for 17 % of
economic losses due to ill-health. Herpes simplex virus type 2
(HSV-2) infections is the leading cause of genital ulcer
disease (GUD) in developing countries. Data from sub-
Saharan Africa show that 30%–80% of women and 10%–50%
of men are infected. Throughout the world, HSV-2
seropositivity is uniformly higher in women than in men and
increases with age. HSV-2 plays an important role in the
transmission of HIV infection. A study in Mwanza, the United
Republic of Tanzania, showed that 74% of HIV infections in
men and 22% in women could be attributable to HSV-2
ulcers. Hepatitis B virus (HBV), which may be transmitted
sexually results in an estimated 350 million cases of chronic
hepatitis and at least one million deaths each year from liver
cirrhosis and liver cancer. A vaccine to prevent hepatitis B
infection, and thereby reduce the incidence of liver cancer,
exists.
The socioeconomic costs of STIs and their complications are
substantial:

• Ranks among the top 10 reasons for health-care visits

in most developing countries, and substantially drain
both national health budgets and household income.

• Care for the sequel of STIs accounts for a large

proportion of tertiary health-care costs

• The social costs of STIs include conflict between

sexual partners and domestic violence.

These are the main reasons to consider STIs as public health

problems and to design and implement appropriate
intervention both preventive and curative.

5.2 Classification of STIs

1. Diseases characterized by genital ulcer

 Chancroid, Genital herpes simplex virus,

Granuloma inguinale (Donovanosis),
Lymphogranuloma Venarum, Syphilis

2. Diseases characterized by urethritis and cervicitis

 Chlamydial infection, Gonorrhea

3. Diseases characterized by vaginal discharge

 Bacterial vaginosis, trichomoniasis, Vulvo-

vaginal candidiasis

4. Pelvic Inflammatory Disease (PID)

5. Epididymitis

6. Human papilomavirus infection (Genital wart)

7. Vaccine preventable STDs

 Hepatitis A, Hepatitis B

8. Proctitis, Proctocolitis and enteritis

9. Ectoparasitic Infections

 Pediculosis Pubis, Scabies

Prognostic classification of STDs

Curable (mostly bacterial)

Gonorrhea Syphilis

Chlamydia Trichomoniasis

Incurable (virus)

 HIV/AIDS

 Hepatitis
  Herpes

 Human papilloma virus

5.3 Traditional Approaches to STI

Diagnosis
1. Etiologic diagnosis: using laboratory tests to
identify the causative agent

2. Clinical diagnosis: using clinical experience to

identify the symptoms typical for a specific STI.

• Even in a well-structured health system,

etiological and clinical diagnoses are problematic
because they are low in sensitivity.

• Etiological diagnosis is expensive and time-

consuming; it requires special resources and
delays treatment.

• With clinical diagnosis, it is easy to diagnose

some STIs incorrectly and also to miss mixed
infections.
 5.4 The STI Syndromes and the
Syndromic Approach to Case
Management
Many different agents cause STIs, however, some of these
agents give rise to similar or overlapping clinical
manifestations.

Aim of Syndromic management of STIs:

 Prompt and effective detection and treatment of

STDs

 Decrease STD incidence and prevalence by reducing

period of infectiousness

The main STI syndromes are:

o Urethral discharge

o Genital ulcer
o Inguinal bubo
o Scrotal swelling
o Vaginal discharge
o Lower abdominal pain
o Neonatal conjunctivitis
 NB. Some of the flow charts are annexed at the end
of the book.

Main Features of Syndromic Management

• Periodic laboratory-based classification of the main

causal pathogens by the clinical syndromes they
produce
• Use of flow charts derived from this classification to
manage a particular syndrome
• Treatment for all important causes of the syndrome
• Education and counseling of the patient on how to
prevent re-infection
• Notification and treatment of self

Principles in the Syndromic management

• Many STIs can be identified and treated on the basis

symptoms and signs.

• Treatment covers several possible infections

responsible for the syndrome

• Syndromic management will reduce the cost of

laboratory work up and extra visits to the clinic and
treatment delay.
Advantages and Limitations of Syndromic
Management

Advantages of Syndromic management:

 Immediate treatment: Clients receive diagnosis

and treatment within a single visit.

 Effectiveness: Clients are treated for a potential

mixed infection. The use of flowcharts with
appropriate treatment recommendations reduces the
chance of ineffective treatment. This approach helps
to prevent incorrect diagnoses in settings where
clinical diagnosis is common.

 Ease of use: It is easy to teach and learn. So, all

levels of health care providers and facilities can use it.
It requires good training, but not specialized
knowledge about STIs/RTIs.

 Low costs: There are cost savings since expensive

lab tests are not used.

Limitations and concerns:

 Limitations in diagnosing vaginal discharge:

Vaginal discharge poses a particular challenge since
the syndrome might not be related to an
 STI. Because of the potential for negative reactions
from clients and partners when the infection may not
even be caused by an STI, it is important to consider
each case on an individual basis. Women who do not
have STIs, but who have non-sexually transmitted
RTIs that cause vaginal discharge may be told that
they should have their partners come for treatment;
this can lead to relationship problems, including
violence.

 Potential for over treatment: Clients are treated

for multiple infections, although some will have no
infection or only one. This is costly in terms of
unnecessary drug use, waste of drugs that could be
used to treat other clients, and the potential for
microorganisms to develop resistance to antimicrobial
drugs.

 Ineffectiveness against asymptomatic

infections: This approach cannot be used with
clients who are infected, but show no signs and
symptoms.

 Need for data: Algorithms, risk assessment tools,

and treatment protocols should be based on
information that is difficult to collect in many
 settings, including: disease surveillance data, studies
of risk factors, and microbial resistance tracking in the
geographic location where the Syndromic approach is
being used.

5.5 Why Invest in STI Prevention and

Control Now?
To reduce STI-related morbidity and mortality

• To prevent HIV infection because:

– Genital ulcer diseases have been estimated to

increase the risk of transmission of HIV 50–300-
fold per episode of unprotected sexual intercourse

– Improved syndromic management of STIs

reduced HIV incidence by 38% in a community
intervention trial in Mwanza, Tanzania

– Thailand also reduced HIV prevalence by

effectively controlling STIs

• To prevent serious complication in women

– STIs are main preventable cause of

infertility
 – PID, ectopic pregnancy and cervical
cancer

• To prevent adverse pregnancy outcome

– Perinatal deaths

– Spontaneous abortions

– Preterm deliveries

– Ophthalmia neonatorum

Universal institution of an effective intervention to prevent

congenital syphilis should prevent an estimated 492 000
stillbirths and perinatal deaths per year in Africa alone.

5.5. STI Control Strategies

1. Prevention by promoting safer sexual behaviors;

What is safer sex? It is any sexual activity that reduces the risk
of passing STI and HIV from one person to another.
Some safer sex practices:

 Consistent use of condom every time individual is

having sex

 Reducing the number of sex partners-sex with

uninfected monogamous is safe

 Massaging, rubbing touching, dry kissing,

hugging or masturbation instead of intercourse

 To be away from unsafe sexual practices, like

“dry sex”

 Not to have intercourse with partner having genital

sore or discharge

2. General access to quality condoms at affordable prices;

3. Promotion of early recourse to health services by

people suffering from STIs and by their partners;

4. Inclusion of STI treatment in basic health services;

5. Specific services for populations with frequent or

unplanned high-risk sexual behaviors
6. Proper treatment of STIs, i.e. use of correct and effective
medicines; treatment of sexual partners; education and
advice; reliable supply of condoms;

7. Screening of clinically asymptomatic patients;

8. Provision for counseling and voluntary testing for HIV

infection;

9. Prevention and care of congenital syphilis and neonatal

conjunctivitis;

10. Involvement of all relevant stakeholders, including the

private sector and the community, in prevention of STIs
and prompt contact with health services for those
requiring care.

Many people with an STI/RTI do not seek treatment since

they are asymptomatic or have mild symptoms and do not
realize that anything is wrong. Others who have symptoms
may prefer to treat themselves or seek treatment at pharmacies
or from traditional healers. Even those who come to a clinic
may not be properly diagnosed and treated. In the end, only a
small proportion of people with an STI/RTI may be cured and
avoid re-infection.
In order to address these challenges,
health providers should:

• Raise awareness in the community about

STIs/RTIs and how they can be prevented

• Promote early use of clinic services.

• Promote safer sexual practices when counseling

clients.

• Detect infections that are not obvious.

• Prevent iatrogenic infection

• Manage symptomatic STI/RTI effectively

• Counsel patients on staying uninfected after

treatment.

5.6 Obstacles to Provision of Services

for STI Control
 Decline in interest and resources for STIs prevention and
control globally in favor of ART and VCT

 Lack of integration of prevention and care activities for

STIs (including HIV) into sexual and reproductive health
services
 Problem with Syndromic management of women with
vaginal discharge, especially in low prevalence areas

 Intervention efforts to prevent STIs have failed to take

into consideration the full range of the underlying
determinants

 Inability to ensure consistent supplies of STI medicines

and condoms

 Counseling on risk reduction is also usually lacking

 Inadequate participation of partners, especially

communities

 Diagnostic problem: either asymptomatic or do not seek

care
Barriers to STI control-finding people with STI

People with STI

Symptomatic asymptomatic

Seek care Do not seek care

Accurate diagnosis

Correct treatment

Completed
treatment

Cure

Source: WHO integrating STI/RTI care for reproductive

health, a guide to essential practice, 2005
References

• RTIs. RHO (www.rho.org)

• STI Fact Sheet 2004

• Lancet SRH series 5: Global control of STIs, 2006

• WHO. Prevention and Control of STIs: draft global

strategy. May 2006

• WHO. Sexually transmitted and other

reproductive tract infections. 2005

• WHO. Training modules for the syndromic

management of STIs. 2nd edition
 CHAPTER 6

HIV/AIDS AND REPRODUCTIVE

HEALTH
Learning objective
• To know the HIV/AIDS Global, regional and
national status

• To understand main modes of transmission of

HIV

• To know the main preventive strategies

6.1. Introduction
AIDS (acquired immune deficiency syndrome) is a human
tragedy. Since the epidemic began in the early 1980s, AIDS
has caused more than 30 million deaths and orphaned more
than 14 million children worldwide. With no cure in sight, the
AIDS-causing virus, human immunodeficiency virus (HIV),
continues to spread around the world, causing more than
13,000 new infections each day.
By the end of 2007, 33.2 million people were living with HIV,
including 2.5 million children under 15 years old. Over 95
percent of these HIV cases occurred in the developing
countries of sub-Saharan

Africa and South and Southeast Asia.

In 2007, approximately 2.5 million new adult HIV infections

with 420,000 newly infected under 15 years children and 2.1
million AIDS-related adult deaths occurred worldwide with
330,000 deaths of children under 15 years. Women accounted
for approximately more than half of the new infections and
2.1 million AIDS deaths.

HIV/AIDS exacts a heavy toll on its victims. People living

with HIV/AIDS face tremendous health risks from
opportunistic illnesses (such as tuberculosis) that compromise
their way of life and dramatically increase their risk of death.
In sub-Saharan Africa, average life expectancy has dropped to
47 years, 15 years less than it would have been without AIDS.
In addition to health risks, people living with HIV/AIDS face
social and cultural barriers, including stigmatization,
discrimination, and rejection from health-service providers,
friends, and relatives. These barriers, often worsened by the
concurrence of the HIV and tuberculosis epidemics, can affect
their access to health and medical services, the quality of
services they receive, and their daily livelihoods.

The consequences of HIV/AIDS extend beyond its immediate

victims, also affecting surviving family members,
communities, and societies. It is estimated that for each
woman who dies of AIDS in Africa, two children will be
orphaned. More than 90 percent of children orphaned by
AIDS live in sub-Saharan Africa, and the numbers are
increasing daily. In the next decade, the number of orphans is
also expected to increase in Asia, the Americas, Central and
Eastern Europe, and the countries of the Newly Independent
States (NIS). In developing countries, AIDS orphans face
extreme economic uncertainty and are at higher risk of
malnutrition, illness, abuse and sexual exploitation than
children orphaned by other causes. In addition, these surviving
children face the stigma and discrimination that accompany
HIV/AIDS, leaving them socially isolated and often deprived
of basic social services such as education.
Because HIV/AIDS affects people during their most
productive years, when they are responsible for the support
and care of others, it carries profound social and economic
repercussions for communities and societies. HIV/AIDS is the
primary cause of disease burden in developing countries and
accounts for about 2.8 percent of the global burden of disease
worldwide. It is now the leading overall cause of death in
Africa, accounting for more than 6 percent of the disease
burden in some cities, and is the fourth greatest cause of
death worldwide.
 Table 3: Global Summary of the HIV/AIDS Epidemic,
December 2007

Number of Total 33.2 million (30.6-

people living with 36.1 million)
HIV/AIDS Adults 30.8 million [28.2–
33.6 million]
Women
Children under 15.4 million
15 years 2.5 million
People newly Total 2.5 million
infected with HIV Children under 420,000
in 2003 15 years
AIDS deaths in Total 2.1 million (2.1 - 2.9
2007 Children under million)
15 years 330,000

AIDS epidemic in sub Saharan Africa (2007 AIDS

epidemic update)
Sub Saharan Africa continues to be the most affected region
by HIV/AIDS with:

 More than 68% of adults infected with HIV (

>22.5 million)

 90% of infected children with HIV

 70% of AIDS deaths in 2007

 1.7 million people newly infected

 Majority of people living with HIV/AIDS are

women.

UNAIDS/WHO classification of HIV epidemic states

Low level: HIV prevalence has not consistently exceeded

five percent in any defined sub- population

Concentrated: HIV prevalence is consistently over

5 percent in at least one defined sub-pulation, but below one
percent in pregnant women in urban areas.

Generalized: HIV prevalence is consistently over one

percent on pregnant women nation-wide.
 6.2. Modes of Transmission of HIV
Several large studies have confirmed that there is no risk
of transmission through casual contacts with household
members, such as sharing meals, sleeping together (without
sexual contact), handshaking, hugging, or holding a baby.
There have been no reports of transmission in out-of-home
childcare settings or in schools.

The primary modes of transmission of HIV are: sexual

transmission, transfusion, or exposure to, infected blood
products, or exposure to contaminated needles and other
equipment; and MTCT. Each mode of transmission is
associated with a different risk of acquiring HIV infection.
The greatest risk of transmission of HIV infection follows an
HIV-contaminated blood transfusion. Ninety percent of
individuals who receive a transfusion of HIV-contaminated
blood acquire infection. In many developing countries,
screening of blood products before transfusion is inadequate
or nonexistent.
Contaminated blood products continue to be a significant
source of new HIV infections. Re-use of needles or syringes
in the health care setting has led to many infections in infants
and children. If equipment must be re-used, strict adherence to
proper decontamination and sterilization procedures is
essential. Intravenous drug abuse carries a risk of
approximately 0.5 to 1% per exposure if needles or injection
equipment used by an HIV-infected person are shared.

When visible blood or other body fluids are present, (for

example, on bandages) there may be a small risk of HIV
transmission through an intact skin. Therefore, in such
situations, gloves should be worn. Hands should be washed
immediately with soap and water, if contact with blood or
other bodily fluids occurs.

6.2.1. Sexual Transmission of HIV

Heterosexual transmission is the primary mode of acquiring

HIV in developing countries. Women, especially young girls,
are more likely than men to become infected following
heterosexual intercourse. Cases of HIV infection resulting
from sexual abuse of
children, and even infants, have been reported. Adolescents
are increasingly at risk from unprotected sexual intercourse or
the use of contaminated needles.

Disturbing gender differences in rates of HIV infection have

been reported in developing countries, especially in sub-
Saharan Africa, where several countries report that the
number of teenage girls infected with HIV is up to six times
greater than the number of teenage boys who are infected.
Studies suggest that girls are more susceptible than mature
women to HIV infection per sexual act.

Many girls are exposed to older HIV-infected men who seek

sexual partners less likely to be HIV infected, or to men who
request sexual favors in exchange for economic support.
Worldwide, sexual abuse and trafficking of children increases
the risk of HIV infection in very young children. Some
studies place the number of children in forced prostitution as
high as 10 million. The fairly widespread (and false) myth that
having sex with a virgin can cure HIV infection has resulted
in HIV infected men seeking younger sexual partners. Young
girls, who are viewed as less likely to be HIV infected,
may command a premium as prostitutes, placing them at
high risk for acquiring HIV.

6.2.2. MTCT of HIV

Children can become infected with HIV through the same

modes as those by which adults are infected (exposure to
contaminated blood or other body fluids, eg, through
transfusions of infected blood products, through contact with
needles or other instruments contaminated with infected blood
or other body fluids, and through sexual abuse), and also
through MTCT.

Perinatal transmission encompasses MTCT before delivery

(antepartum), during delivery (intrapartum), or following
delivery through breast-feeding in the first few days of life
(postnatal). In medical literature, the term "perinatal" is used
synonymously with "vertical" to describe MTCT, but
generally does not include transmission by breast-feeding
after the first few days of life. In resource-rich countries,
where safe alternatives to breast-feeding are available
perinatal (intrauterine and intrapartal), HIV transmission
accounts for virtually all new cases of HIV infection in
children. A small
proportion of children may be infected as the result of sexual
abuse.

Rates of MTCT

The majority of children born to HIV-infected mothers are

uninfected. Without interventions to prevent MTCT of HIV,
rates of MTCT range from 13% in Europe to approximately
40% in Africa. Although there are many possible explanations
for this difference, the distinct difference in the prevalence of
breast-feeding among HIV-infected mothers in resource-rich
versus resource- poor settings is likely implicated.

Timing of MTCT

MTCT of HIV occurs during three different time periods:

antepartum, intrapartum, and postnatally through breast-
feeding. With the advent of highly sensitive techniques for
detecting virus in the peripheral circulation of the infant, it is
possible to estimate the timing of MTCT more accurately. In
the absence of breast-feeding, an estimated 50 to 70% of
transmissions occur around the time of delivery, with the
remainder occurring in utero. Therefore, without breast-
feeding, most MTCT is presumed to be a result of exposure
to HIV during late
 pregnancy, during parturition via the placenta, or during
passage of the infant through the vagina. Intrapartum
transmission is presumed to occur across the infant's mucous
membranes, principally in the oropharynx and possibly in the
esophagus and stomach.

Table 4: Describes the rate of Mother-to-child

Transmission in the absence of intervention.

Estimated Risk of MTCT

Timing Transmission rate without

intervention
During pregnancy 5-10%
During labour and delivery 10-15%
During breastfeeding 5-20%
Overall without breastfeeding 15-25%
Overall with breastfeeding to six months 20-35%
Overall with breastfeeding to 18-24 months 30-45%
Note: Rates vary because of differences in population characteristics such as
maternal CD4+ cell counts, RNA viral load and duration of breastfeeding.
“HIV transmission through breastfeeding: A review of available evidence.” Marie
Louise Newell; endorsed by UNICEF, UNFPA, WHO, UNAIDS. 2004 (adapted from
De Cock KM et
al., 2000.).

Source; FMOH, PMTCT guideline, July 2007

Risk Factors for MTCT

Several factors put a woman at a higher risk of

transmitting HIV to her child.

Maternal Factors

 High maternal viral load

 Low CD4 count

 Advanced maternal disease

 Viral or parasitic placental infections during

pregnancy, labour and childbirth

 Maternal malnutrition ( including iron and folate,

vitamin A, and zinc deficiencies)

 Nipple fissures, cracks, mastitis and breast abscess

Infant factors

 First infant in multiple birth

 Preterm low birth weight

 Duration of breastfeeding

 Mixed feeding

 Oral diseases in child

Obstetric and Delivery Practices

 Rupture of membrane for more than four hours

 Injuries to birth canal during child birth (vaginal

and cervical tears)

 Ante partum procedures e.g. amniocentesis,

external cephalic version

 Invasive childbirth procedures (e.g. episiotomy,

fetal scalp monitoring)

 Vaginal delivery

 Delayed infant cleaning and eye care

 Routine infant airway suctioning

6.2.3. Breast-Feeding Transmission

Breast-feeding is associated with increased transmission

overall. A randomized clinical trial comparing breast-feeding
with formula feeding demonstrated the efficacy of complete
avoidance of breast-feeding for the prevention of MTCT.

In resource-poor settings, breast-feeding offers the best

opportunity for inexpensive, readily available, and safe infant
nutrition. In most communities, breast-feeding is
naturally viewed as a caring and nurturing response of a
mother toward her infant. There are many studies that
document the beneficial aspects of breast-feeding in
protecting against many kinds of infection. Unfortunately,
HIV is one particularly serious infection that can be
transmitted by means of breast-feeding. This presents a
dilemma for the HIV-infected mother when alternative means
of safely feeding her infant are difficult to obtain. There were
many recommendations for this problem, but the current
recommendation for mothers who are living in developing
countries is exclusive breast feeding for six months and
abrupt weaning with no mixing of breast milk with weaning
food.

HIV/AIDS prevention and control

The steady growth of HIV prevalence throughout the

world stems not from the deficiencies of available prevention
strategies and tools, but rather from the failure to use them. At
present, there are more HIV infections every year than AIDS-
related deaths. The trends in increasing infections pose a
major threat to the global response to AIDS.
Effective HIV prevention programming focuses on the critical
relationships between the epidemiology of HIV infection, the
risk behaviours that transmit HIV, and the cultural,
institutional and structural factors that drive risk behaviours.
Risk behaviours are enmeshed in complex webs of economic,
legal, political, cultural and psychosocial determinants that
must be analyzed and addressed by policies that are also
effectively implemented and through scaled-up programming.

Prevention and treatment must be scaled up in a balanced

way, to capitalize fully on synergies between the two.
Comprehensive HIV prevention requires a combination of
programmatic interventions and policy actions that promote
safer behaviours, reduce biological and social vulnerability to
transmission, encourage use of key prevention technologies,
and promote social norms that favour risk reduction.

Essential Policy Actions for HIV Prevention

1. Ensure that human rights are promoted, protected and

respected and that measures are taken to eliminate
discrimination and combat stigma.
2. Build and maintain leadership from all sections of society,
including governments, affected communities,
nongovernmental organizations, faith- based
organizations, the education sector, media, the private
sector and trade unions.

3. Involve people living with HIV, in the design,

implementation and evaluation of prevention strategies,
addressing the distinct prevention needs.

4. Address cultural norms and beliefs, recognizing both the

key role they may play in supporting prevention efforts
and the potential they have to fuel HIV transmission.

5. Promote gender equality and address gender norms and

relations to reduce the vulnerability of women and girls,
involving men and boys in this effort.

6. Promote widespread knowledge and awareness of how

HIV is transmitted and how infection can be averted.

7. Promote the links between HIV prevention and sexual and

reproductive health.
8. Support the mobilization of community-based responses
throughout the continuum of prevention, care and
treatment.

9. Promote programmes targeted at HIV prevention needs of

key affected groups and populations.

10. Mobilizing and strengthening financial, and human and

institutional capacity across all sectors, particularly in
health and education.

11. Review and reform legal frameworks to remove barriers

to effective, evidence based HIV prevention, combat
stigma and discrimination and protect the rights of people
living with HIV or vulnerable or at risk to HIV.

12. Ensure that sufficient investments are made in the

research and development of, and advocacy for, new
prevention technologies.

HIV prevention strategies

The main strategies proposed by the United Nations AIDS

programme are:-

1. Condom use
2. Education
 3. HIV prevention for key population
4. HIV post exposure prophylaxis
5. Male circumcision
6. New HIV prevention technologies
7. Prevention of mother to child transmission
8. Social and behavior change

Condom use

Conclusive evidence from extensive research shows that

correct and consistent condom use significantly reduces the
risk of HIV transmission.

The male latex condom is the single, most efficient, available

technology to reduce the sexual transmission of HIV and
other sexually transmitted infections. Along with the female
condom, it is a main component of comprehensive strategies
to reduce risks of sexual exposure to HIV.

Condom promotion must be incorporated into a

comprehensive prevention strategy that involves leadership
from all sections of society, addresses cultural norms and
beliefs, promotes gender equality, and promotes widespread
knowledge and awareness of
how HIV is transmitted and how condoms can avert infection.

Prevention programmes need to ensure that high-quality male

and female condoms are readily and consistently available to
all those who need them, when they need them, and that
people have the knowledge and skills to use them correctly.
Condoms must be promoted in ways that help overcome
sexual and personal obstacles to their use. Complex gender
and cultural factors can be a challenge for HIV prevention
education and condom promotion.

Education

The education sector is critical to HIV prevention for

young people and can also play a vital role in support for
orphans and vulnerable children affected by HIV.

Education in school settings

Simply ensuring young people’s access to school or other

educational opportunities is an important aspect of HIV
prevention. Not only are higher levels of education associated
with safer sexual behaviours and delayed
sexual debut, but school attendance provides students the
benefits of school-based sexuality education and HIV
prevention programming.

Young people in many parts of the world are denied sex and
health education in schools because parents and other
authorities fear that it encourages early sexual activity.

But there is compelling evidence from studies conducted

around the world and in many different cultures that, in fact,
sex education encourages responsibility. Knowledgeable
young people tend to postpone intercourse or, if they do have
sex, to use condoms.

Experience shows, however, that information is not enough.

Young people also need life skills such as decision-making,
communication and negotiation. They need to understand the
concepts of risk behaviour, such as unprotected sex and the
use of alcohol and drugs, the possible consequences of such
behaviour and how to avoid them. And they need to know
where to go for services and help. AIDS education should
cover all these aspects.
Among the most effective approaches to sex and health
education in schools are the use of role play to personalize
issues, and peer education, in which young people are trained
to spread messages and promote responsible behaviour among
their friends and colleagues.

Education outside school settings

Out-of-school youth are a diverse group that includes young

people who have dropped out of school or college, children
kept out of school by families who cannot afford to send them
or who need their labour at home, and children living on the
streets. Such youngsters are often especially vulnerable to
HIV. Bored, alienated and sometimes hopeless at finding
them selves excluded from the mainstream, they may seek
escape and thrills in drugs, alcohol or sex. Providing them
with the information and skills they need to protect
themselves from HIV is a special challenge. The fact that they
are not part of an institution such as a school or workplace
makes them difficult to reach. Moreover, their levels of
literacy vary.
Experience shows that peer education, which involves training
representatives among out-of-school youth to convey
information, is one of the most effective strategies. Peer
educators understand the lives and concerns of others out of
school and are therefore more trusted.

Another effective strategy is to use entertainment such as

street theatre, music and puppetry, which draws people in and
provides a focus as well as an alternative pastime to risky
activities.

HIV prevention among key populations

Although comprehensive HIV prevention programmes must

be made available to all, actions must be taken to ensure that
specialized and focused HIV prevention programmes are
developed and available for people most at risk.

UNAIDS encourages countries to “know their epidemic and

their current response”. Knowing their epidemic and response
enables countries to “match and prioritize the response” by
identifying, selecting and funding those HIV prevention
measures that are most appropriate and
effective for the country in relation to its specific epidemic
scenario(s) and settings. Matching and prioritizing the
response entails identifying those populations most-at-risk and
vulnerable, gauging the extent to which new HIV infections
are occurring within these populations and the extent to which
they are consulted and engaged in tailoring the response for
their communities.

Engaging these key populations within HIV prevention

activities is critical to an effective response, so too is ongoing
analysis of what works, the costs and benefits of the
different HIV prevention measures and their feasibility given
the available human and financial resources.

Key populations include:

Children and orphans

Indigenous people

Injecting drug users

Men who have sex with men

Migrants and mobile workers

Peacekeepers
 People in the education sector

People in the health sector People

living with HIV Prisoners

Refugees and internally displaced people

Rural communities

Sex workers and their clients

Women and girls

Workplace populations

Young people

HIV post-exposure prophylaxis

The immediate use of antiretroviral drugs to prevent HIV sero

conversion after exposure to potentially HIV- infected blood
or body fluids is called Post-exposure prophylaxis for HIV
infection (HIV-PEP).

The efficacy of HIV-PEP has been shown in occupational

settings but, the evidence is indirect. Studies suggest that
when initiated within 12, 24, or 36 hours after exposure,
HIV-PEP is more effective than
initiation within 48 to 72 hours, and that HIV-PEP is not
effective when given more than 72 hours following the
exposure. Furthermore, a 28-day course of drug therapy
appears to be more effective than courses lasting 3 or 10 days.

Since HIV-PEP is not 100% effective, the importance of

primary prevention must be reinforced. The use of HIV- PEP
following possible occupational exposure in settings such as
hospitals has become a routine component of occupational
safety policy in most of North America and Europe.

Non-occupational use of HIV-PEP has been introduced and is

being studied in settings supporting sexual assault survivors,
rape survivors in refugee camps, and persons in communities
at high risk of HIV, such as sex workers, people who use
injection drugs, men who have sex with men, and people in
prisons. Risk behaviour has not been shown to increase
substantially among HIV-PEP users and in communities
where HIV-PEP is available.
A key consensus at the 2005 Joint International Labor
Organization/World Health Organization Technical Meeting
for the Development of Policy and Guidelines regarding
occupational and non-occupational HIV-PEP was that HIV-
PEP must be part of comprehensive HIV prevention,
occupational health, and post-rape care service policies.
Services must be provided as part of a comprehensive
prevention package that emphasizes primary prevention.

Male circumcision

Male circumcision is one of the oldest and most common

surgical procedures known. It is undertaken for cultural,
religious, social as well as medical reasons.

The evidence that adult male circumcision is efficacious in

reducing sexual transmission of HIV from women to men is
compelling. The partial protective effect of male circumcision
(approximately 60% reduction in risk of heterosexually
acquired HIV infection) is remarkably consistent across the
observational studies (ecological, cross-sectional and cohort)
and the three randomized controlled trials conducted in
diverse settings.
In response to the urgent need to reduce the number of new
HIV infections globally, the World Health Organization
(WHO) and the UNAIDS Secretariat convened an
international expert consultation in March 2007 to determine
whether male circumcision should be recommended as an
HIV prevention measure. Based on the existing evidence,
experts attending the consultation recommended that male
circumcision now be recognized as an additional important
intervention to reduce the risk of heterosexually acquired HIV
infection in men.

Male circumcision should always be considered as part of a

comprehensive HIV prevention package. Moreover, wherever
male circumcision services are offered, training and
certification of providers, as well as careful monitoring and
evaluation of programmes, will be necessary to ensure that
these meet their objectives and that quality services are
provided safely, with adequate equipment and with
appropriate counselling and other services.

The communication strategies around male circumcision will

be critical, since men should not develop a false
sense of security and engaging in high-risk behaviours that
could undermine the partial protection provided by male
circumcision. Additional research is still required in a number
of areas to inform the further development of male
circumcision programmes such as the impact of male
circumcision on sexual transmission from HIV- infected men
to women, the protective benefit of male circumcision in the
case of insertive partners engaging in anal intercourse, and
research into the resources needed for, and most effective
ways, to expand quality male circumcision services.

Prevention of mother-to-child transmission of HIV

Each day, approximately 1,800 children become infected

with HIV, the vast majority of whom are newborns. A
pregnant woman who is HIV-positive can pass the virus on to
her baby in the womb or during childbirth, or postnatal,
through breastfeeding.

In the absence of any intervention, the risk of mother-to-

child-transmission (MTCT) of HIV is around 15-30%, if the
mother does not breastfeed the child. But it can rise as high as
30-45% with prolonged breastfeeding.
The risk of transmission can be reduced by up to 50% with the
administration of a short course of antiretroviral drugs to
mother and baby around the time of delivery, in conjunction
with replacement feeding.

However, less than 8% of pregnant women worldwide are

currently offered services to prevent mother-to-child
transmission (MTCT) of HIV.

Prevention of perinatal HIV transmission requires a

comprehensive package of services that includes preventing
primary HIV infection in women, preventing unintended
pregnancies in women living with HIV, preventing
transmission from pregnant women living with HIV to their
infants, and providing care, treatment and support for women
living with HIV and their families.

Health systems need to be strengthened so that

interventions to prevent mother to child transmission of HIV
infection, including the use of antiretroviral drugs, can be
safely and effectively implemented. Moreover, HIV testing in
pregnancy has a number of benefits in terms of prevention and
care for mother and child, although to avoid or minimize
negative consequences
testing must be voluntary and confidential and accompanied
by quality counseling.

Timely administration of antiretroviral drugs to the HIV-

diagnosed pregnant woman and her newborn significantly
reduces the risk of mother-to-child HIV transmission. Positive
mothers should also be provided with access to ART for the
protection of their own health.

Combination regimes appear to be most effective, but were

until recently regarded as too costly for widespread use in
low- and middle-income countries. In recent years, projects
to prevent mother-to-child transmission in resource-limited
settings have primarily focused on provision of single-dose
intrapartum and neonatal nevirapine, which cuts the risk of
HIV transmission by more than 40%. While the benefits of
single-dose nevirapine outweigh the risk of resistance in these
settings, development of affordable regimens with superior
resistance profiles is an urgent global priority.
National guideline recommendation for PMTCT (Ethiopian)

1. Women presenting during pregnancy

Facilities where ART service is functional and

available: Mother:

 Ante partum: AZT (300 mg Bid) starting at 28 weeks

of pregnancy or as soon as feasible thereafter

 Intrapartum: Single dose (Sd) NVP (200 mg) + AZT (

600 mg at onset of Labour) and 3TC (150 mg at onset
of labour and every 12 hours until delivery)

 Postpartum : AZT ( 300 mg Bid) and 3TC (150 mg

Bid) for 7 days

Infant:

 Single dose (Sd) NVP ( 2 mg/kg) + AZT (4 mg/kg

Bid for 7 days)

Note: if mother did not receive adequate dose of, i.e. less
than four weeks of, AZT before delivery, the AZT dose for
the infant should be extended for four weeks
Facilities with no ART service OR when referral to
the nearest ART clinic is not possible or difficult for
the client):

Mother:

 Single dose (Sd) NVP (200 mg) at the onset of

Labour

Infant:

 Single dose (Sd) NVP within the first 72 hours of

birth

NB. If mothers come to health institution and should be

on ART they should start the recommended regiment of
HAART any time after the first trimester with AZT based
regime(AZT + 3TC+ NVP) unless they have anemia in
which AZT is substituted with D4T (D4T +3TC + NVP).

2. Women presenting in Labour who have NOT

received any antenatal prophylaxis

Facilities where ART service is functional and

available:
Mother

 Intra Partum: Single dose (Sd) NVP (200 mg) + AZT(

600 mg during labour) + 3TC (150 mg during labour
and every 12 hours until delivery)

 Postpartum : AZT ( 300 mg Bid) + 3TC (150 mg Bid)

for 7 days

Infant

 Single dose (Sd) NVP ( 2 mg/kg) + AZT ( 4 mg/kg

Bid) for four weeks

Facilities with no ART service AND referral to the

nearest ART clinic is not possible or difficult for the
client):

Mother

 Single dose (Sd) NVP (200 mg) at onset of labour

Infant

 Single dose (Sd) NVP within the first 72 hours of life

3. Infant born to women living with HIV who do not
receive any ARV prophylaxis

Facilities where ART service is functional and

available:

 Single dose (Sd) NVP ( 2 mg/kg) + AZT (4 mg/kg

Bid for four weeks)

Facilities with no ART service AND referral to the

nearest ART clinic is not possible or difficult for the
client:)

 Single dose (Sd) NVP within first 72 hours of

birth

NOTE: The best time to initiate ARV prophylaxis for the

infant is immediately after delivery or within 12 hours
if possible

 At any time during ARV provision for the mother and

the infant; AVOID the use of double dosing of NVP

Social and behaviour change

Unlike some infectious diseases, transmission of HIV is

mediated directly by human behaviour, so changing
behaviours that enable HIV transmission is the ultimate
goal or outcome required for HIV prevention. Sexual
behaviour, which remains the primary target of HIV
prevention efforts worldwide, is widely diverse and deeply
embedded in individual desires, social and cultural
relationships, and environmental and economic processes. So
too are the behaviours related to transmission through
injecting drug use and from mother to child. This makes HIV
prevention a complex task with multiple dimensions, that
requires both policy and programmatic actions.

Effective, inexpensive and relatively simple HIV prevention

interventions do exist, but the pace of the epidemic is clearly
outstripping most country efforts in closing the coverage gap
of effective HIV prevention services. This gap reinforces the
importance of addressing the deep-rooted drivers of the
epidemic –
e.g. actions to address gender inequality and ensures that
human rights are respected.

UNAIDS policy and practical guidance on HIV prevention

stresses that effective and comprehensive HIV prevention
would require addressing both individual
risk as well as vulnerability, and reducing the impact of HIV
on individuals and communities.

In the context of HIV, risk is defined as the probability that a

person may acquire HIV infection. Certain behaviours create,
enhance and perpetuate such risk (UNAIDS, 1998). These
include behaviours such as injecting drug use, unprotected
casual sex, and multiple concurrent long term sexual partners
with low and inconsistent condom use (UNAIDS, 2007). Risk
arises from individuals engaging in risk behaviours for a
variety of reasons such as lack of information, inability to
negotiate safer sex, unavailability of condoms, etc. Over the
recent years, the approach to HIV has broadened to not only
focus on individual risks, but also on the environmental and
social factors that influence such behaviour, and the key role
that power relationships and gender inequalities play in
influencing risk (UNAIDS, 1998).

On the other hand, vulnerability from a health perspective,

results from societal factors that adversely affect one’s ability
to exert control over one’s health. Vulnerability is influenced
by the interaction of a range
of factors including certain personal, social, economic and
political factors that make people or certain groups of people
more vulnerable to infection than others. These include age,
sex, poverty, gender inequalities, certain laws, etc. Factors
affecting risk and vulnerability should be considered in
designing an effective AIDS response, more so in behaviour
change programmes.

Despite recent evidence in expansion of access to prevention,

treatment, care and support services, the fundamental role of
human behaviour in the continued spread of HIV is
increasingly clear. Fostering health enhancing behaviour
change outcomes demands a persistent commitment to
meeting the diverse and changing needs of individuals, and to
addressing the characteristics of their social, cultural and
physical environments that place them at risk.

Communication for behaviour change

Information, Education and Communication – sometimes

called IEC - are a critical part of the puzzle for achieving
the goal of universal access to HIV prevention, treatment,
care and support. However,
information, education and communications must be
combined with other interventions to succeed.

Methods of communication range from one-to-one personal

interactions to posters placed in school classrooms to
prevention messages on national television. The focus may
range from reducing stigma or decreasing HIV infection, but
the ultimate goal is behaviour change.

Effective social mobilization involves an integrated

communication strategy that includes a variety of
communication actions such as sustained advertising, peer
education, and community mobilization, all coherently
focused so as to reinforce each other. The strategy is aimed at
a defined group of people for an identified behavioral result.

Communication for behaviour change often involves reaching

out to marginalized populations whose needs and behaviours
are different from those of the rest of the community.
Information must be provided in language familiar and
appropriate to each group of people and in settings that are
comfortable for them. Outreach and education by peers
are two strategies that have been
shown to be highly successful in overcoming the mistrust of
individuals who are marginalized. For example, sex workers
can be trained to provide HIV prevention education and to
promote condom use among their peers.

National programmes must identify the array of behaviour

change needs and communication strategies throughout the
country. Resources can then be devoted to development of
programming specific to each cultural or behavioural group at
high risk of HIV infection. UNAIDS and its partners provide
technical assistance and guidance regarding the processes as
well as the needs of various communities affected by HIV.

Whatever the local epidemiological and social conditions,

effective HIV prevention programmes prioritize and focus on
the intervention needs of people most at risk of exposure to
HIV and likely to engage in HIV risk behaviours, and they
focus programme efforts on reaching adequate numbers of
these key audiences with good quality services. These
audiences should be segmented, and information and services
should be tailored to meet each subpopulation’s needs.
Segmenting in this sense means identifying subpopulations
within each key audience that are different enough to require
different approaches or messages (for example, distinguishing
transgendered persons from men who have sex with men, or
street- based from brothel-based sex workers). It does not
mean singling out those populations for blame or persecution,
or stigmatizing an HIV prevention measure as only for
specified people. Effective HIV prevention includes efforts to
ensure that segmenting the response does not lead to
stigmatization and other unintended adverse consequences.

Uniting for HIV prevention

Across the world, a small, but growing number of countries

have reduced HIV prevalence through sound prevention
efforts. However, in 2005, there were still 4.1 million new
HIV infections with over 40% of new adult infections
occurring among young people aged 15-24. According to
latest estimates, HIV prevention services reach only one in ten
of those most at risk.
In an era where the world has committed to working towards
universal access to HIV prevention, treatment, care and
support by 2010, there is clearly an urgent need to
intensify HIV prevention efforts in both size and scale to halt
growing infection rates and sustain the gains that have
already been made in the AIDS response such as increased
numbers of people on HIV treatment.

To this aim, UNAIDS is ‘uniting for HIV prevention’ with

others who share this goal – including civil society, treatment
activists, the private sector and governments -
- to call for the global community to mobilize an alliance for
intensifying HIV prevention.

At the XVI International AIDS Conference that took place in

Toronto, Canada in August 2006, representatives from
UNAIDS, the International Council of AIDS Service
Organizations (ICASO), the Treatment Action Campaign
(TAC), the governments of India and Sweden and Merck
pharmaceuticals outlined the concept of ‘uniting for HIV
prevention’
“There is an urgent need to build on good work already taking
place and mobilize an alliance for HIV prevention that goes
‘beyond the converted’ involving more than ‘the usual
suspects’, and with strong links to HIV treatment activism,”
said UNAIDS Executive Director Peter Piot.

“We need an alliance that is united by commitment to the

goal of saving lives, even if we may have different tactics. We
need an alliance that draws in the best and brightest minds of
our generations, and that is a partnership between
governments, people living with HIV, the most vulnerable
groups, civil society, faith- based organizations, business and
international institutions,” he said.

‘Uniting for HIV prevention’ is a consolidation of existing

advocacy and public mobilization efforts around HIV
prevention and aims to harness the collective strengths of
organizations in bringing about a sustainable response to HIV
epidemic. The UNAIDS policy position paper on intensifying
HIV prevention provides a common ground around which
advocacy for scaling up HIV prevention is based.
‘Uniting for HIV prevention’ aims to:

 Foster leadership on HIV prevention with key

stakeholders at the global, regional and national level
to achieve community action

 Promote and support joint activity, activism and

partnership amongst a variety of stakeholders

 Promote sound evidence and draw on the experience

of communities

 Act as a convening body around scaling-up HIV

prevention

The broad and inclusive grouping of organizations ‘uniting for

prevention’ will seek to influence policy makers as well as
generate public opinion on the need to bridge the HIV
prevention gap. Together, they seek to strengthen the
movement and create the enabling environment which is
required to achieve universal access to HIV prevention,
treatment, care and support.
‘Uniting for Prevention’ – the players and their roles

Civil society

“Uniting for prevention” will bring together a large number

of civil society organizations that work on difference facets of
the AIDS response across different sectors and with a variety
of community groups. These include networks of people
living with HIV, young people, women’s groups, human
rights organizations, faith-based organizations, AIDS service
organizations and community groups. They can bring
pressure on their constituencies to prioritize HIV prevention.

Governments

’Uniting for Prevention’ will bring together government

leaders to push for greater acceleration and resource allocation
for HIV prevention efforts.

Treatment activists

As the forerunner of treatment activism, their push for HIV

prevention is a wake-up call to the world on how gains made
in treatment will not be sustained if the rate of scale up of HIV
prevention does not dramatically increase in the next few
years.
Private sector

The growth of the private sector is dependent upon a healthy

and vibrant workforce and a healthy population that can
propel economic growth. The private sector can also help in
lending their expertise to rapidly scale up HIV prevention
efforts and invest in innovations that can make HIV
prevention simpler.

UNAIDS

UNAIDS will unite the various stakeholders involved in

global HIV prevention efforts, and lead advocacy programmes
calling for a comprehensive, scaled up and fully funded HIV
prevention response.
 CHAPTER 7
HARMFUL TRADITIONAL PRACTICES

Learning objectives
 To know the main harmful traditional practices

 To understand the concept, magnitude and effect of

violence on women’s reproductive health

 To see the problem and types of female genital

cutting

 To know the problems associated with early

marriage

7.1. Introduction
In April 1997, the World Health Organization, the United
Nation's Children's Fund, and the United Nations Population
Fund issued a joint statement that summarized the importance
as well as the challenges inherent to addressing harmful health
practices: "Human behaviors and cultural values have
meaning and fulfill a function for those who practice them.
People will change their behavior when they understand the
hazards and
indignity of harmful practices and when they realize that it is
possible to give up harmful practices without giving up
meaningful aspects of their culture." Health professionals
worldwide struggle with how to address harmful health
practices. The basic question of whether a practice is harmful
or necessary is often hotly debated—debates that sometimes
rely on simplistic divisions between "Western" and local
medical values. In many cases, this division masks more
complicated reasons for defending harmful practices, the
victims of which tend to be women and children and others
who are less powerful in their society. These reasons often
include power struggles, local and national politics, and/or
lack of understanding about the risks of the practice.
Sometimes a harmful practice is so deeply rooted that it seems
impossible to change. But in every country people have
pushed forward positive social changes, and harmful practices
have been ended. For example, foot binding was once the
norm in many parts of China. Women without tiny, hobbled
feet were considered unmarriageable. Women were
completely dependent on men since they were unable to walk
well. Yet, the practice was eliminated in a short time, in
conjunction with major political, social, and economic
changes in that society. In the nineteenth-century Europe,
women endured pain and physical damage from constrictive
whalebone corsets which caused their waists to appear slim.
This practice was also recognized as dangerous, and fell out of
favor. At the same time, Western medicine is recognizing the
benefits of some traditional health practices, which fall into
an overarching category described by some as "Indigenous
Knowledge." Traditional plants are being researched by drug
companies, and the health benefits of non-Western therapies
such as Indian yoga, Chinese acupuncture, and African
community support systems are increasingly being
recognized. As leaders in Western medicine learn more about
helpful traditional practices, and vice versa, health
professionals in all countries can draw from the best of these
worlds in order to help their clients make healthy choices.

Harmful Practices

- Female genital mutilation: primarily in Africa

- Early marriage: Asia, the Middle East, Africa

- Severely restricted weight gain during

pregnancy: Philippines, France, other countries
 - Withholding colostrum (initial breast milk with
special nutritional value) from newborn: China,
Guinea Bissau

- Low levels of breast feeding: United States, France,

other European countries

- Postpartum nutritional restrictions: Latin America

- Vaginal douching: United States, selected European

countries, other countries

- "Dry sex" practices (removal of vaginal fluid with

absorbent materials): Africa, Latin America,
Southeast Asia

- Breast and penis implants: United States, Europe,

Southeast Asia, other countries

7.2. Violence against Women

Globally, at least one in three women has experienced some

form of gender-based abuse during her lifetime. Violence
against women is any act of gender-based violence that results
in, or is likely to result in, physical, sexual, psychological
harm or suffering to women, including threats of such acts,
coercion or arbitrary deprivations of liberty, whether
occurring in public or
private life. Abuse of women and girls is best understood
within gender framework because it stems in part from
women’s and girls’ subordinate status in the society. In
addition to causing injury, violence increases women's long-
term risk of a number of other health problems, including
chronic pain, physical disability, drug and alcohol abuse, and
depression. Women with a history of physical or sexual abuse
are also at increased risk for unintended pregnancy, sexually
transmitted infections, and adverse pregnancy outcomes.
Females of all ages are victims of violence, in part because of
their limited social and economic power compared with men.

Violence against women (VAW) encompasses, but is not

limited to:

 Spousal battering

 Sexual abuse of female children

 Dowry-related violence

 Rape including marital rape

 Traditional practices harmful to women such as

FGM
 Non-spousal violence

 Sexual harassment and intimidation at work and in

school

 Trafficking in women

 Forced prostitution

 Violence perpetrated or condoned by the state, such as

rape in war

 In the 1990s, Violence against women, VAW

emerged as a focus of international attention and
concern

- In 1993, the UN General Assembly passed the

Declaration on the Elimination of Violence
against Women.

- The Cairo Program of Action recognized

gender-based violence as an obstacle to
women’s reproductive and sexual health and
rights.

- The Beijing Declaration and Platform for

Action devoted an entire section to the issue
of violence against women.
 - In 1996, the 49th World Health Assembly
adopted a resolution declaring violence a
public health priority.

- In 1999, the United Nations Population Fund

declared VAW a public health priority.

7.2.1. Magnitude of the Problem

Violence against women (VAW) is the most pervasive, yet

least recognized human rights abuse in the world. Around the
world, at least one woman in every three has been beaten,
coerced into sex or otherwise abused in her lifetime. Two of
the most common forms of violence against women are abuse
by intimate partner violence (IPV) and coerced sex.

I. Intimate Partner Violence (IPV)

Intimate partner violence occurs in all countries, irrespective

of social, economic, religious or cultural group. Although
women can be violent in relationships with men, and violence
is also sometimes found in same-sex partnerships, the
overwhelming burden of partner violence is borne by
women at the hands of
men. A multi-country population-based household surveys in
15 countries reported life-time prevalence of physical or
sexual partner violence, or both from 15 % to 71 %, between 4
% and 54 % reported violence in one year. Although intimate
partner violence is a common cause of injury in women,
injury that requires treatment is not the most common
outcome of such violence. Thus, increasingly emphasis has
been placed on early identification of women during antenatal
care, other obstetric or gynecological consultation, primary
health- care, and mental health-services.

In Ethiopia, the life-time prevalence of physical and sexual

violence were reported to be 48.7% and 58.6%, while the
corresponding rates for the previous year were 29.0% and
44.4%, respectively. The proportion of women reporting life-
time and current experience of either physical or sexual
partner violence, or both was 70.9% and 53.7%. Research
suggests that physical violence in intimate relationships is
often accompanied by psychological abuse and in one-third to
over one-half of cases by sexual abuse.
Reproductive Health

Figure 4: The Life Cycle of Violence Against Women and its Effects on Health*

227
Reproductive Health

Events Triggering Violence

A wide range of studies have produced a remarkably

consistent list of events that are said to trigger partner
violence. These include:

 Not obeying the man

 Arguing back

 Not having food ready on time

 Not caring adequately for the children or

home

 Questioning the man about money or

girlfriends

 Going somewhere without the man’s

permission

 Refusing the man sex

 The man suspecting the woman of

infidelity

In many developing countries, women often agree with the

idea that men have the right to discipline their wives, if
necessary by force. The EDHS 2005 reported that 81

228
% of women believed a man is justified in beating his wife at
least for one reason. The most widely accepted reasons for
wife-beating are going out without telling the partner and
neglecting the children (about 64 percent).

II.Sexual Coercion

Sexual coercion exists along a continuum, from forcible rape,

to non-physical forms of pressure that compel girls and
women to engage in sex against their will. The touchstone of
coercion is that a woman lacks choice and faces severe
physical and social consequences if she resists the sexual
advances.

Sexual violence includes:

 Rape within marriage or dating relationships

 Rape by strangers

 Systematic rape during armed conflict

 Sexual harassment

 Sexual abuse of children

 Forced first sex

 FGM
  Forced marriage

 Denial of the right to use contraception

III. Impact on Health

 Physical: injuries, bruises, chronic pain syndromes,

disability, fractures, GI disorders, irritable bowel
syndrome, reduced physical functioning

 Sexual and reproductive health: gynecological

disorders, infertility, PID, pregnancy
complications/miscarriage, sexual dysfunction, STIs
including HIV/AIDS, unsafe abortion and unwanted
pregnancy

 Psychological and behavioral: alcohol and drug

abuse, depression and anxiety, poor self- esteem,
psychosomatic disorders, unsafe sexual behavior,
phobias and panic disorder

 Fatal health consequences: AIDS-related

mortality, maternal mortality, homicide, and suicide
Impact on Reproductive Health

 Women who live with violent partners have a difficult

time protecting themselves from unwanted pregnancy
or disease.

 Violence can lead directly to unwanted

pregnancy or STIs, including HIV infection,
through coerced sex, or else indirectly by
interfering with a woman’s ability to use
contraceptives, including condoms.

 One in every four women is physically or

sexually abused during pregnancy, usually by a
partner.

 Violence during pregnancy has been

associated with miscarriage, late entry into
prenatal care, stillbirth, premature labor and
birth, fetal injury, and low birth weight.
What Can Be Done Against Gender Based Violence (GBV)?

 Initiatives against gender-based violence take

many forms, including police and judicial reforms,
legislative initiatives, community mobilization to
encourage behavior change, and the reorientation of
health services.

 The most effective approach is integrated and

multi-level: in the short term it provides services for
victims and punishes perpetrators, while in the
long term it addresses the social and economic
determinants of violence.

 Prevention strategies also need to focus on:

 Empowering women and raising their status

 Combating norms of violence, and

 Reducing poverty and alcohol consumption

 PAHO's integrated strategy to address gender- based

violence, which was developed and tested in Central
America, operates at four different
 levels: the community, the clinic, the health
sector, and the macro or political level

Health care providers can do:

Health care providers can play a crucial role in addressing

violence against women because health care providers often
are well placed to recognize victims of violence and to help
them. Since violence increases the risk of other health
problems for women, early help can prevent serious
conditions that follow from abuse.

Health care providers can help solve the problem of violence

against women if they learn how to ask clients about violence,
if they become better aware of signs that can identify victims
of domestic violence, and help women protect themselves by
developing a personal safety plan.

Health workers can educate themselves about physical,

sexual, and emotional abuse, and explore their own biases,
fears and prejudices. They can also provide supportive, non-
judgmental care to victims of violence and ask clients about in
a friendly, gentle way.
Leaders of Reproductive Health Programs Can:

 Establish policies and procedures to ask women

clients about abuse

 Establish protocols that clearly indicate appropriate

care and referral for victims of violence

 Promote access to emergency contraception

 Lend facilities to women’s groups seeking to

organize support groups and to hold meetings

Why have health care providers been slow to address

violence against women?

 Lack of technical competence and resources

 Cultural stereotypes and negative social attitudes

 Institutional constraints

 Women’s reluctance to disclose violence

HCPs can screen women for domestic violence when they
come for:

 Antenatal and postnatal care

 Reproductive health services: Family planning and

prevention of STIs

 Mental health services

 Emergency departments

Supporting Women Who Disclose Abuse

 Assess for immediate danger

 Provide appropriate care

 Document women’s condition

 Develop a safety plan

 Inform women of their rights

 Refer women to community resources

Moving outside the clinic

• Community health promotion

• Communication campaigns
7.3. Female genital mutilation (FGM)

It is estimated that at least 2 million girls are at risk of female

genital mutilation (FGM) each year. FGM is practiced in at
least 26 of 53 African countries. Prevalence varies from 98
percent in Somalia and 97 percent in Egypt to 5 percent in
Uganda. The practice is also found among some ethnic groups
in Oman, the United Arab Emirates, and Yemen, as well as
parts of India, Indonesia, and Malaysia. FGM has become a
health and human rights issue in Australia, Canada, England,
France, and the United States, due to the continuation of the
practice by immigrants from countries where FGM is
common.

FGM comprises all procedures involving partial or total

removal of the external female genitalia or other injuries to the
female genital organs for cultural or non- therapeutic reasons.
In 1995, the World Health Organization developed the
following four broad categories for FGM operations:
Type I: Excision (removal) of the clitoral hood with or
without removal of part or the entire clitoris.

Type II: Removal of the clitoris together with part or all of

the labia minora.

Type III (infibulation): Removal of part or all of the

external genitalia (clitoris, labia minora, and labia majora)
and stitching and/or narrowing of the vaginal opening leaving
a small hole for urine and menstrual flow.

Type IV (unclassified): All other operations on the female

genitalia, including pricking, piercing, stretching, or incision
of the clitoris and/or labia; cauterization by burning the
clitoris and surrounding tissues; incisions to the vaginal wall;
scraping (angurya cuts) or cutting (gishiri cuts) of the vagina
and surrounding tissues; and introduction of corrosive
substances or herbs into the vagina.

These procedures are not reversible, and their effects last a

lifetime. Type I and II account for up to 85 percent of FGM
operations. Type III is common throughout
Djibouti, Somalia, and Sudan, as well as in parts of Egypt,
Ethiopia, and Kenya. While health complications occur most
frequently with Type III operations, they occur with all types
and can lead to death.

Health consequences of FGM seem to vary according to the

type and severity of the procedure. Complications may range
from immediate, such as bleeding and shock, to a wide range
of longer-term problems for women and their newborn
children. Psychological effects may be profound and
permanent. Additionally, FGM may increase the risk of HIV
or Hepatitis B, due to unclean conditions often associated with
the procedure.

Global efforts to promote alternatives to FGM are

increasing

Efforts to promote alternatives to FGM are increasing

worldwide. International health organizations and conventions
have uniformly condemned the procedure. The 1994
Programme of Action of the International Conference on
Population and Development (ICPD) included a
recommendation to ". . . urgently take steps to stop the
practice of female genital mutilation and to
protect women and girls from all such similar unnecessary and
dangerous practices." The 1995 Platform for Action of the
Fourth World Conference on Women urged governments,
international organizations, and nongovernmental groups "to
develop policies and programmes to eliminate all forms of
discrimination against the girl child, including female genital
mutilation." FGM is recognized as a human rights
violation in the
U.S. State Department's annual country reports. In 1997
United Nations agencies (WHO, UNICEF, and UNFPA)
issued a joint position paper and are increasing their efforts to
eradicate FGM.

7.4. Early Marriage (EM):

It has been a common practice, particularly in much of rural

Ethiopia to get girls married at an early age as 10 – 15 years
old. The young adolescent or preadolescent girl is not ready
physically and psychologically for intercourse, pregnancy,
child bearing and child rearing.
Some of the reasons for early marriage are:

 Parents desire to see the marriage of their

daughters and their grandchild before they die

 Strengthen the family or business ties between the

two parties to be married

 Avoid the possibility of a daughter not getting

married or becoming not eligible for marriage

 Avoid premarital sex or loss of virginity and its

consequences

Harmful effects of early marriage include:

 Psychological effect on the girl bride leading to

different somatic problems. The small genitalia are
traumatized ending up in tears, bruising, cystitis, and
damage to the urethra.

 Preclampsia, prolonged and obstructed labour leading

to fistula formation

 Haemorrhage and shock at delivery

 Still born babies

 Loveless marriage often ending in divorce

  Difficulty in managing a household by the young girl

 Deprivation of the girl of her education leading to

poor opportunity for employment and gainful income

Marriage by abduction

Is a gross violation of women’s rights. It has been common in

some parts of Ethiopia. In some cases the girl may be willing
and ready to proceed with the marriage. In these cases, the
consequences are less grave. However, when the girl objects
and fights against the abductors she can be severely hurt and
even get killed.

Reasons for Marriage by Abduction:

 Refusal or anticipated refusal of consent by parents or

girl

 Avoid excessive wedding ceremony expenses

 Ease the economic burdens of the conventional bride

price
 Outsmart rivals when the girl has many suitors and/or
the inclinations of the girl or her parents are not
predictable

 Difference of ethnic origins or economic status of

partners may also be reasons for possible abduction.

Harmful effects of marriage by abduction

 Battering, inflicting bodily harm, suffocation, and

severe disabilities and death may ensue.

 Conflict created between families may lead to feuding

lasting for generations. There are incidents of ethnic
conflicts due to marriage by abduction

 The outcome may be an unhappy, unstable and

loveless marriage

 Psychological stress on the girl. Might end up in

suicide.

 There are large expenses related to conflict

resettlements as compensation to the family or for
court cases
  Discontinuation of schooling and other
opportunities for the girl.

Other harmful traditional practices that are prevalent in

Ethiopia include Uvulectomy, milk teeth extraction, food
prohibitions for mothers, eye brow incision, and soiling the
umbilicus of the new born with cow dung. Each of these
traditional practices have mistakenly perceived advantages.

Uvulectomy is supposed to prevent problems of feeding

(swallowing), avoid noisiness and improve speech. Milk teeth
extraction is assumed to prevent diarrhoea and cure various
diseases. Eye brow incision is undertaken to prevent eye
diseases and blindness. Certain food items which contain
important nutrients are believed to cause diseases in women
and children. These harmful traditional beliefs and practices
might result in serious health outcomes including serious
bleeding, acquiring dangerous and fatal infection and
malnutrition.
Suggested intervention strategies to minimize and eliminate
harmful traditional practices include:

 Educate the community and the leaders by using

acceptable and effective methods

 Provide legal support against the negative aspects of

traditional practices and formulate legislative
measures to eliminate them

 User friendly health facilities to deal with problems

related to harmful traditional practices

 Endeavour to educate practitioners of harmful

traditional practices about the dangers of such
practices

 Imposing punishment on such practitioners if they

persist with the practice

 Should a victim be willing to testify or discuss his/her

dilemma, on the case to the public as example to
others.
References
• Heise LL, Ellsberg M, Gottemoeller M. Ending
Violence against women. Baltimore, MD, Johns
Hopkins University School of Public Health, Centre
for Communications Programs, 1999 (Population
reports, Series L, No.11)

• Krug EG et al., eds. World Report on Violence and

Health. Geneva, World Health Organization, 2002

• Reproductive Health Outlook. Gender and Sexual

Health (www.rho.org)
 CHAPTER 8
ADOLESCENT REPRODUCTIVE HEALTH

Learning objectives
At the end of the chapter, the student is expected to:

 Understand why RH focuses on adolescents

 Know the RH risks and consequences in

adolescents

 Discuss the challenges of adolescent RH

 Have some concept about adolescent RH

services

Definition:

World Health Organization defines adolescents as individuals

between 10 and 19 years of age. The broader terms "youth"
and “young” encompass the 15 to
24 year-old and 10 to 24 year-old age groups, respectively.
For girls, puberty is a process generally marked by the
production of estrogen, the growth of breasts, the appearance
of pubic hair, the growth of external genitals, and the start of
menstruation. For boys, it is marked by the production of
testosterone, the enlargement of testes and penis, a deepening
of the voice and a growth spurt.

Why Focus on Young People?

• Young people constitute a large and growing segment

of the population.

At the turn of 21st century 1.7 billion people were

between the ages of 10 and 24.

– Eighty six percent of these live in less

developed countries.

– In Ethiopia, young people age 10-24

constitute more than a third of the population.

• Certain health problems (like STIs and HIV) are more

prevalent in this age group
 • Behaviors starting in adolescence frequently lead to
health problems, which may emerge in later life, at
immense cost to the individual and their society.

• While young people face many new problems, there

are also new opportunities which if combined with the
energy and creativity of young people can bring
tremendous dividends and can help them play vital
role in their family and to the society as a whole.

• Future economic development depends on having

increasing proportion of reasonably well educated,
healthy and economically productive population.

8.1. Global Youth Today

The current generation of young people is the healthiest, most
educated, and most urbanized in history. However, there still
remain some serious concerns:

Education: Despite increasing attention given worldwide to

education, 121 million children worldwide are out of school,
with 9 million more girls than boys. As
of 2003/4, the net enrollment ratio in primary education was
86 % for developing countries and 64 % for sub- Saharan
Africa. The net enrollment ratio for Ethiopia is
42.3 %. In the least developed countries, only 22 percent of
boys and 13 percent of girls are able to continue their
education beyond the primary level. In Ethiopia, the net
attendance ratio for secondary school is only 15.6 %. The
gap between boys’ and girls’ enrollment is most apparent at
the secondary level. In Ethiopia, the ratio of girls to boys is
0.91 in primary education and 0.65 in secondary education.
Youth with low levels of education experience severely
limited future prospects for economic self-sufficiency.
Educating girls is essential to reducing child mortality,
HIV/AIDS, and other diseases. Furthermore, educated women
will most likely have healthy children who will complete
schooling. Decades of research have shown that educated
women have greater control of their reproductive lives, such
as decisions about the number and spacing of their children.
Sexuality: Globally, most people become sexually active
during adolescence. Premarital sexual activity is common and
is on the rise worldwide. Rates are highest in sub Saharan
Africa, where more than half of girls aged 15-19 are
sexually experienced. Millions of adolescents are bearing
children, in sub-Saharan Africa, more than half of women give
birth before age 20. In Latin America and the Caribbean,
this figure drops to one third. For example, unwanted and
out of wedlock pregnancy, is poorly tolerated in many
societies. If it happens, the blame is usually put on the girl and
regarded as disgrace to the family and reduced chance of
getting husband. The traditional society solves this problem or
conflict by early marriage. The need for improved health and
social services aimed at adolescents, including reproductive
health services, is being increasingly recognized throughout
the world. Approximately one billion people – nearly one out
of every six persons on the planet are adolescents; 85 percent
live in developing countries. Many adolescents are sexually
active and, in some regions, as many as half are married.
Health: Sexual activity puts adolescents at risk of various
reproductive health challenges. Each year, about 15 million
adolescents aged 15-19 years give birth, as many as 4 million
obtain an abortion, and up to
100 million become infected with a curable sexually
transmitted disease (STI). Globally, 40 percent of all new
human immunodeficiency virus (HIV) infections occur among
15-24 year olds; recent estimates are that 7,000 are infected
each day. These health risks are influenced by many
interrelated factors, such as expectations concerning early
marriage and sexual relationships, access to education and
employment, gender inequities, sexual violence, and the
influence of mass media and popular culture.

Challenges: Adolescents often lack basic reproductive

health information, skills in negotiating sexual relationships,
and access to affordable, confidential reproductive health
service. Incompetent providers further limit access to services
where they exist, as do legal barriers to information and
services. Many adolescents lack strong stable relationships
with parents
or other adults whom they can talk to about their reproductive
health concerns.

Despite these challenges, programs that meet the information

and service needs of adolescents can make a real difference.
Successful programs help young people develop life-planning
skill, respect the needs and concerns of young people, involve
communities in their efforts, and provide respectful and
confidential clinical services.

Characteristics of the adolescence period

The period is characterized by:

 The period when the individual progresses from the

point of initial appearance of secondary sex
characteristics to sexual maturity.

 It is period when psychological processes and patterns

of identification to those of an adult.

 Transition from the state of total socio-economic

dependence to relative independence.
  Period of rapid physiological changes and
vulnerability to physical, psychological and
environmental influences.

 Period of physical, biological, psychological and

social maturity from childhood to adulthood.

Transition from childhood to adulthood involves adjustment

encompassing physiological, psychological, cognitive, social
and economic changes. The process is universal, but varies by
individual and culture.
Reproductive Health

Table 5: Effects of social environment on adolescent RH behavior

Factors Positive influences Negative influences

Education Good health and sex education Early unwanted pregnancy, school dropping,
followed by correct behavior unemployment, prostitution, drug abuse,
crime, etc,
Media Spread information on healthy Pornography, smoking, crime (films, papers,
sexuality advertisement)
Entertainment Sports, in door games, Crimes, drugs and alcohol abuse,
educational films prostitution, early sexual activities
Family Integrated stable families are role Abusive behaviour in families Disintegrated
models. They can give families
appropriate information and
guidance on healthy life style

254
Residence Healthy neighborhood "negative neighborhood" e.g. prostitution
areas
Religion Spiritual support Prohibition of information on sexuality
Facilitation of the adolescents in
different activities
Health services Accessible information and Negative attitudes of health professionals on
services for adolescents adolescent sexuality
Reproductive Health

Sexual activity among women 15-19

Country Married single, sexually active

Botswana 6% 60%

Kenya 20 % 26%

Costa Rica 18% 11%

Jamaica 20% 35%

Bangladesh 48 % NA

Indonesia 18% NA

United States 5% 52%

8.2. Reproductive Health Risks and

consequences for adolescents
Adolescent reproductive health is affected by pregnancy,
abortion, STIs, sexual violence, and by the systems that limit
access to information and clinical services. Reproductive
health is also affected by nutrition, psychological well-being,
and economic and

256
gender inequities that can make it difficult to avoid forced,
coerced, or commercial sex.

8.2.1. Pregnancy:

In many parts of the world, women marry and begin

childbearing during their adolescent years. Pregnancy and
childbirth carry greater risk of morbidity and mortality for
adolescents than for women in their 20s, especially where
medical care is scarce. Girls younger than age 18 face two to
five times the risk of maternal mortality as women aged 18-25
due to prolonged and obstructed labor, hemorrhage, and other
factors. Potentially life- threatening pregnancy-related
illnesses such as hypertension and anemia also are more
common among adolescent mothers, especially where
malnutrition is endemic. One in every 10 births worldwide
and 1 in 6 births in developing countries is to women aged 15-
19 years.
Unsafe abortion: About one in 10 abortions worldwide
occurs among women age 15-19 and each year one million to
4.4 million adolescents in developing countries undergo
abortion, and most of these procedures are performed under
unsafe conditions due to:

- Lack of access to safe services.

- Self-induced methods

- Unskilled or non-medical providers

- Delay in seeking procedure

Adolescent unwanted pregnancies often end in abortion.

Surveys in developing countries show that up to 60 percent of
pregnancies to women below age 20 are mistimed or
unwanted. In Canada, Great Britain, New Zealand, and the
United States in the late 1980s, more than 50 percent of all
abortions occurred in women under 25. Pregnant students in
many developing countries often seek abortions to avoid being
expelled from school.
For example, the percentage of women aged 20-24 who gave
birth by age 20, in some regions are shown below:
China14%, Latin American/Caribbean 27-50%; North
Africa/Middle East 13-41%; Sub-Saharan African 25-
75%, South Asia 16-66%; Southeast Asia 21-33%;
United States 22%.

Induced abortion often represents a greater risk for

adolescents than for older women. Adolescents tend to wait
longer to get help since they cannot access a provider or
because they may not realize that they are pregnant; this risk
is compounded in conditions. In Nigeria, for example 50-70
percent of mothers hospitalized for complications of induced
abortion are younger than 20; 3 of 5 women seeking health
care for unsafe abortion in developing countries are under 20.
Some of the complications of abortion are infection,
hemorrhage, and intestinal perforation, injury to reproductive
organs and toxic reactions to drugs. These complications can
result in infertility, psychological trauma or death.
 Every day, 55,000 unsafe abortions take place-95% of them in
developing countries. They are responsible for one in eight
maternal deaths. Globally, one unsafe abortion takes place for
every seven births.

Table 6: Unsafe abortion: Regional Estimates of

Mortality and Risk of Death

Region Risk of dying after % of maternal deaths

unsafe due to unsafe abortion
abortion

Africa 1 in 150 13 %

Asia 1 in 250 12 %

Latin America 1 iIn 900 21 %

Eastern 1 in 1900 17 %
Europe

8.2.2. STIs, including HIV/AIDS

The highest rates of infection for STIs, including HIV, are

found among young people aged 20 to 24; the next
highest rate occurs among adolescents aged 15 to 19. Sexually
transmitted infections can lead to life-long health problems,
including infertility. Worldwide, half of all sexually
transmitted infections occur in adolescents. Approximately
333 million cases of curable STIs occur each year and each
day half a million young people are infected with a sexually
transmitted diseases, available data suggest that one-third of
STIs infections in developing countries occur among 13-20
year olds, one out of every 20 adolescents contracts STI,. In
rural Kenya, for example, 41 percent of women aged 15-24
attending maternal and child health or family planning clinics
had STI, compared to about 16 percent of all women of
reproductive age. Adolescents also are at increased risk of
contracting HIV/AIDS. Recent estimates are that over 40
percent of HIV infections occur in young people aged 15-24;
7,000 of 16,000 new infections each day. New infections
among females out number males by a ratio of 2 to 1.
Young people tend to be at higher risk of contracting STIs,
including HIV/AIDS, for several reasons. Intercourse often is
unplanned or unwanted. Even when she is consensual,
adolescents often do not plan ahead for condom or other
contraceptive use, and inexperienced users are more likely to
use methods incorrectly. Furthermore, adolescent girls are at
greater risk of infection than older women because of the
immaturity of their reproductive system. Other reasons are
little knowledge of STIs, failure to seek treatment, multiple
partners, partners with multiple partners and use of drug and
alcohol.

8.2.3. Female Genital Cutting (FGC)

FGC, the partial or complete removal of external genitalia or

other injuries to the female genitalia, is a deeply rooted
traditional practice that has severe reproductive health
consequences for girls. In addition to the psychological
trauma at the time of the cutting, FGC can lead to infection,
hemorrhage, and shock. Uncontrolled bleeding or infection
can lead to death
within hours or days. Some forms of FGC can lead to
Dyspareunia, recurrent pelvic infection, and dystocia. The
ICPD Programme of Action calls FGC a basic human rights
violation and urges governments to stop the practice. In some
countries, such as India arranged marriage of girl younger
than 14 is still common.

8.2.4. Commercial Sex

 Sexual exposure is occurring at ages as young as 9-12

years as older men seek young girls as sexual partners
to protect themselves from STD/HIV infection. In some
cultures, young men are expected to have their first
sexual encounter with a prostitute.

 Adolescents, especially young girls, often experience

forced sexual intercourse in sub– Saharan Africa,
some girls’ first sexual experience is with a sugar
daddy, who provides clothing, school fees, and books in
exchange for sex.
  Millions of children live and work on the streets in
developing countries and many are involved in
“survival sex”, where they trade sex for food, money,
protection or drugs. For example, a survey in Guatemala
City found that 40 percent of 143 street children
surveyed had their first sexual encounter with someone
they did not know; all had exchanged sex for money, all
had been sexually abused, and 93 percent had been
infected with an STD. In Thailand, an estimated
800,000 prostitutes are under age 20; of those, 200,000
are younger than 14. Some are sold into prostitution by
parents to support other family members.

8.2.5.Sexual violence
Sexual abuse occurs worldwide. One-third of teenagers
experience abuse, with in heterosexual relationships, in United
States. Rape and involuntary prostitution can result in physical
trauma, unintended pregnancy, STIs, psychological trauma
and increased likelihood of high- risk sexual behavior.
 8.2.6. The health risks of adolescent
sexuality is more than older people

1. Maternal death: Girls aged 15-19 are up to twice as

likely to die during pregnancy or delivery as women aged
20-34.

Maternal mortality per 100,000 live births by age

group: younger versus older mothers

Country 20-34 years 15-19 years

Ethiopia 435 1270

Indonesia 575 1100

Bangladesh 479 869

Nigeria 223 526

Brazil 80 108
2. Infant and child mortality: children born to
adolescents are more likely to die during their first five
years of life than those born to women age 20- 29.

3. Sexually transmitted infections (STIs): each year, 1

in 20 adolescents worldwide contracts STIs (including
HIV/AIDS).

4. Violence/sexual abuse: Adolescent girls may lack the

confidence and decision-making skills to refuse unwanted
sex.

5. Unwanted pregnancy

Every year, approximately 50 million unwanted pregnancies

are terminated. Some 20 million of these abortions are unsafe.
About 95 % of unsafe abortions take place in developing
countries, causing the deaths of at least 200 women each day.
Many adolescents face unintended births for example in sub-
Saharan Africa about 50 % of last births in women under 20
years were
unintended, in Latin America about 30 % of last births in
women under 20 years were unintended.

6. Psychological and socio-economic consequences

of pregnancy for unmarried adolescents

 Psychological stress, poor self esteem, lack of

hope and social stigma

 Disrupted education, poor academic

achievement

 Leaving home and prostitution

 Poor socio-economic future, poor earning

capacity: fewer career or job opportunities.

 Unstable marriage

 Unwanted child- mistreated, abandoned

 Their children face psychological, social and

economic obstacles
8.3 Causes for early unprotected
sexual intercourse in
adolescents

 Lack of knowledge on physiology of the reproductive

system and human sexuality

 Declining age of menarche

 Early marriage

 Urbanization, migration, (western cultural influences)

 Sexual violence and coercion

 Peer influence

 Lack of knowledge on family planning

 Unavailability and inaccessibility (including

culturally) of services

 (negative) attitude of the society (including service

providers) towards use of family planning services by
the adolescents
  Sense of guilt, fear of discovery, disapproval or
rejection

8.4 Effects of gender roles

 Expectations of sexual activity of boys and girls

 Views regarding responsibility for contraception

 Social consequences of pregnancy

Factors affecting RH needs of adolescents

o Age

o Marital status

o Gender norms

o Sexual status

o School status

o Child bearing status

o Rural/urban residence

o Peer pressure

o Cultural/ political conditions

8.5 Adolescents’ contraceptive use
Few married adolescents use contraception before first
pregnancy. After becoming sexually active, unmarried
adolescents delay use of contraceptives for about a year. Two
common reasons for non-use of contraceptives among youth
are:

 Did not expect to have sex

 Lacked knowledge about contraception

8.5.1 Barrier to Contraceptive Use

Adolescents’ contraceptive use is limited due to:

 Do not plan ahead or anticipate consequences

 Think they are not at risk

 Lack of confidence or motive to use

 Embarrassed or not assertive

 Lack power and skill to negotiate use

 Clinics not friendly to adolescent's use

  Providers reluctance to serve unmarried adolescents

 Prohibition by law/policy to serve adolescents

 Adolescent's reluctance to use service for fear of

judgment or concerned about having pelvic
examination

8.6 Adolescent Reproductive Health

Services

8.6.1. Making clinical services available

Adolescent clinical health services are best staffed by

providers trained to deal with specific adolescent health
concerns and to counsel adolescents about sensitive
reproductive health issues and contraceptive use. In all
interventions, providers must consider adolescents’ marital
status, over all health, and how much power they have in
sexual activity. Adolescents often name the following
characteristics as important to meeting their
health needs confidentiality; convenient location and hours;
youth friendly environment; open to men and women; strong
counseling component; specially trained providers; and
comprehensive clinical service.

8.6.2. Providing information

Providing appropriate and relevant information about

reproductive health is essential to any program. Clinic- based
education and counseling are important to this effort, as are
school- based programs. Obviously, parents are a key source
of information, although they may feel ill-informed or
embarrassed to discuss these topics with their children, or
simply may disapprove of young people expressing an interest
in sexuality. Youth- friendly approaches such as radio call-in
shows, drop-in centers, magazines, and hotlines also can be
effective strategies for reaching adolescents.

Adolescents need to develop practical skills for improving

their health. One approach to this challenge is the “Choose a
Future” program to be implemented such
as exercises, role-plays, and community visits, and other
means to teach health skills, including how to avoid STDs, set
goal, and improve communication with family and friends.
The curriculum should also address gender inequities that
affect health and promotes shared male- female responsibility
for health. Another example of this approach is a life planning
skills curriculum being implemented in selected secondary
schools in Kenya. In addition to providing information about
STDs, pregnancy, and contraception, the program should train
peer educators to provide school based AIDS education.

The perspectives of young people around the world are

molded by the situations in which they live. Girls with little, if
any, education may view early marriage and childbearing as
their only path in life. Children living in poverty may feel no
reason to plan for the future and protect their health. Other
factors that influence adolescent health and behavior include:

 Gender inequities and sexual exploitation

 Cultural expectations about childbearing.

Program planners must first identify clearly what group of
adolescents a new program will serve, and then involve them
in a meaningful way in the development of the program. Some
organizations like the International Planned Parenthood
Federation have done this by creating youth advisory panels to
help shape program ideas. The Street Children project,
initiated by WHO’s Programme on Substance Abuse
recommends that groups working with street children keep
current of changing needs among their clients by holding three
or four series of focus groups per year.

Open, discussions on sexuality are:

 Difficult topic to discuss openly for both adolescents

and adults

 Includes a wide range of issues, such as peer pressure,

sexual identity, sexual orientation, sexual capability,
and sexual coercion.

 Helps adolescents understand and express their

feelings.
  Promotes responsible sexual behavior thus helps
prevent unintended pregnancy and STDs.

Early sex education

 Gives adolescents skills to delay sexual activity

 Does not lead to earlier or increased sexual activity

 Can increase contraceptive use

Health clinic Designed for adolescents:

 Separate units for adolescents

 Outreach clinics with specially trained staff

 Mobile clinics

 Special hours

 Convenient and safe locations

 Youth-to-youth promotions

 Low or no-cost services

Providers’ communications skills:

 Sincerity
 Honesty
 Non-judgmental
 Respect
 Sense of humor
 Confidentiality, very critical

Range of providers are needed to reach

adolescents:

 Teachers
 Peer educators
 Health workers
 Community workers

Provider training:

 Technical knowledge
 Knowledge of issues facing adolescents
 Gender awareness
 Counseling skills
  Skills in training adolescents

Important education information topics for

adolescents

1. Risks and consequences of sexuality:

 Contraception and STDs

 Sexual education
 Fertility issues for men and women
 Gender issues

2. Potential sites for information and services for

adolescents:

 Home
 Health institutions
 School
 Youth organizations
 Mass media

3. Effective programs for adolescents:

- Identify target group and needs

- Involve adolescents
 - Work with community and parents

- Use materials designed by and for adolescents

- Make services accessible based on adolescent's

preference

- Incorporate evaluation

8.6.3. Ensuring community support

Programs for adolescents often encounter problems gaining

community acceptance since adults fear that access to
education and services will encourage adolescent sexual
activity. Program evaluations have shown this not to be the
case. Some programs have found that explaining objectives to
parents, religious leaders, and community leaders, and inviting
them to discussion sessions with adolescents helps reduce
opposition. In Nyeri, the Family Planning Association of
Kenya helps parents approach their children to share
information about reproductive health issues, and encourages
a life-long discussion about reproductive health. In Uganda,
the Program for Enhancing
Adolescent Reproductive life involves government
representatives, NGOs, community groups, young people, and
other in a program to increase awareness about reproductive
health issues, encourage advocacy, and provide service.

Establish Youth-oriented clinic services: These are

quite common in some developed and developing countries
like United States, Western Europe, and Latin America and of
course in some parts of Ethiopia. These clinics must provide a
wide range of clinical and social services, such as pregnancy
and STD prevention counseling and testing.

School-based clinics: Are available in some developed

and developing countries. The services provided vary
considerably, but at a minimum include basic health
monitoring and referral services. In developed countries, some
school- based clinics provide condoms and counseling about
pregnancy and STD prevention, as well as referral for other
contraceptive and reproductive health services. These
services often are controversial,
however. In developing countries, school- based services
often are limited by restrictive policies, personnel shortages,
lack of private areas for counseling, and poor links to
resources outside the school. Multi-service youth centers can
offer contraceptive services as part of comprehensive
programs for youth, including education, recreation, and
employment preparation.

Community-based outreach programs: Are especially

important to groups such as out-of school youth,” street”
youth and girls who have limited freedom to leave their
community. These community-based projects use a variety of
formats to reach youth where they gather for “work or play”.
After attending educational sessions, interested members can
be made to join a theater group to perform in public areas and
schools to provide information to their peers.

Youth groups: such as scouting and sports programs can

also be useful in providing reproductive health information as
part of programs that focus on the
general well-being of the participants. Programs to improve
adolescent reproductive health must understand these risks
and consider the many influences on adolescents’ lives. Such
factors as whether adolescents have initiated sexual activity,
are married, are in school, or are working are important. The
impact of poverty, gender inequities, legal restrictions, and
cultural barriers must also be addressed.

Successful programs should provide necessary counseling and

clinical services and aim to help young people develop skills
to make healthy life choices. These programs should respect
the needs, concerns, and insights of young people by
including them in the design and implementation of activities.
Successful programs also should work with parents,
community groups and religious leaders to secure their
acceptance.

Participation: With the need for adolescent health services

growing fast, it is important that new and expanded programs
build upon successful experience wherever possible;
established programs should be
monitored, evaluated, and documented to ensure that their
challenges are understood and their successes are replicated.
Any health program should focus on decreasing and
preventing adolescents problems such as unwanted pregnancy
abortion, STIs’, early marriage etc... And this can be achieved
through life education of adolescents/young people who need
knowledge and ready access to appropriate contraception and
reproductive health services.

Components of successful adolescent reproductive

health programs

Reproductive health programs for adolescents tend to be

most successful when they:

(1) Accurately identify and understand the group to be

served;

(2) involve adolescents in the design of the program;

(3) work with community leaders and parents;

(4) remove policy barriers and change providers'
prejudices;

(5) help adolescents rehearse the interpersonal skills

needed to avoid risks;

(6) Link information and advice to services;

(7) Offer role models that make safer behavior

attractive;

(8) And invest in long-enough time frames and resources

 CHAPTER 9

CHILD HEALTH

Learning objectives

 To know some of the factors that can affect child

morbidity and mortality

 To understand childhood diarrhoea and its effect on

child health

 To see the problems associated with respiratory

infections in children

 To know some of the vaccine preventable diseases

 To understand the concept of expanded

programme on immunization

 To understand the concept of growth monitoring in

children
9.1 Introduction

Important progress has been made in reducing infant and child

mortality globally. Improvements in the survival of children
have the main component of the overall increase in average
life expectancy in the world over the past century, first in
developed countries and over the past 50 years in the
developing countries. Infant mortality rate declined from 92
in 1970 – 75 to about 62 in 1990 –95. However,
improvements have been slower in sub – Saharan African and
in some Asian countries where, during 1990 – 95, more than 1
in every 10 children born alive died before their first birthday.

Poverty, malnutrition, a decline in breastfeeding and

inadequacy or lack of sanitation and of health facilities are
factors associated with high infant and child mortality. In
some countries, civil unrest and wars have also had major
negative impacts on child survival. Unwanted births, child
neglect and abuse are factors contributing to the rise in child
mortality. Young children
whose mothers die at a very young age are at very high risk of
dying themselves. Child survival is also closely linked to the
timing, spacing and number of births and to the reproductive
health of mothers. Early, late, numerous, and closely spaced
pregnancies are major contributors to high infant and child
mortality and morbidity rates, especially where health care
facilities are scarce. First births carry higher risk than average
birth risks. First births may occur before a woman has reached
full physical and reproductive maturity, leading to increased
perinatal risks. Further, first time mothers are often ill
prepared to handle their new role.

Even though very young and older maternal ages at birth will
continue to be associated with heightened risk of childhood
mortality, the relationship will be expected to vary
considerably between different countries. Where infant
mortality remains high, couples often tend to have more
children than they otherwise would to ensure that a desired
number survive.
The determinants of child mortality can be divided into
three levels as indicated in the following table:

Ecology

Social and Cultural System

Sanitation

Economic factors

ULTIMATE
Political System Source
of water supply
Administration of agriculture
& other programs
Latrine availability

Housing characteristics
Household division of labour
Household decision-making
Occupation, literacy, social position,
Other parental factors
Food production by household Distribution
of food within the household
Reproductive Patterns (mother’s age at birth,
spacing…)

INTERMEDIATE
Infant care practices

Exposure to pathogens

Feeding frequency, food composition,

Seasonal variation, weaning

Practices

Low birth weight, Premature birth, Diarrhea,

PROXIMATE
Malnutrition, lower respiratory tract infections
and other causes

9.2. The objectives of child survival and

child health of ICPD are:
1. To promote the health and nutritional status of infants
and children and reduce disparities between and
within developed and developing
 countries as quickly as possible, with particular
attention to eliminating the pattern of excess and
preventable mortality among girl infants and children;

2. To improve the health and nutritional status of infants

and children;

3. To promote breastfeeding as a child survival strategy.

The five main killer diseases of children are ARI,

diarrhea, measles, malaria and malnutrition and contribute
to more than 70% of the deaths in children under five
years of age. Globally, malnutrition underlies 50% of all
childhood deaths. African children bear much greater
than their share of the burden of infectious diseases. The
percent of total deaths due to ARI, diarrhea, malaria and
measles for sub- Saharan African children is about 37%,
41%, 98%, and 63% respectively. In general, in
developing countries 39 out of 1000 live births die
 before reaching one month of age and one in every six
babies is born under weight.

This picture shows that malnutrition is the central cause of

child mortality, but most of the mortalities are not
directly because of malnutrition rather it leads to a greater risk
of dying from other common illnesses.

A brief discussion of the epidemiology, prevention and

control of these diseases follows. Malnutrition will not be
discussed (except related issues such as Growth Monitoring)
since it is dealt with in a separate course.
Reproductive Health

Figure 5: Distribution of 10.5 million deaths among children less than 5 years old in all
developing countries, 1999

291
Reproductive Health

Figure 6: Proportion of Global Burden of Selected Diseases

Borne by Children Under 5 Years (Estimated, Year 2000)*

292
9.3. DIARRHOEAL DISEASES

Diarrhoea is commonly defined as three or more loose or

watery stools per day. If an episode of diarrhoea lasts for less
than 14 days it is known as acute diarrhoea, if it lasts 14 days
or more, it is known as persistent diarrhoea. Diarrhoea in
children causes dehydration and contributes to malnutrition.
The death of a child with acute diarrhoea is usually due to
dehydration.

Diarrhoea is the leading cause of illness and death among

children in developing countries, where an estimated 1.3
thousand million episodes and 3.2 million deaths occur each
year in those under five years of age. Overall, these children
experience an average of 3.3 episodes of diarrhoea per year,
but in some areas the average exceeds nine episodes per year.
The median incidence of diarrhoea is greatest for infants aged
6 - 11 months (5 episodes/child/year). Where episodes are
frequent children may spend 15% of their days with diarrhoea.
500 million cases of diarrhoea occur
annually in children under five years old. One fourth to one
third of all deaths in children are due to diarrhoea. In
developing countries, a third of the paediatric beds are
occupied by diarrhoea cases.

The incidence varies with regions and socio-economic

conditions, where it is as high as 10 episodes per child/yr
among poor children in Latin America. Median global value
for mortality due to acute diarrhoea among under five old
children ranges from 6 to 19.6/1000 in developing countries.

Over the past 20 years, a number of studies have documented

a decline in diarrhoeal mortality over time.
E.g. Egypt (1970 - 87) comprehensive national survey showed
a fall in infant and child diarrhoeal mortality from 29.1 to 12.3
per 1000 and 4.0 to 2.3 per 1000 respectively. Also data from
surveys conducted in 40 Asian and African countries by
national CDD programs suggest a decline in mortality over
the past decade.
This is speculated to be due to:

 Improved case management

 General improvement in standard of living

 Improved nutrition

 Increase in immunization coverage and the

combination of all these factors.

Factors underlying increased risk of diarrhoeal morbidity and

mortality are:

 Low socio-economic status

 Poor personal and domestic hygiene

 Low family income

 Living in a crowded room and earthen floor

 Lower maternal education

 Lack of breastfeeding

 Malnutrition - increases severity and duration, also

some studies recently (Sudan and Mexico)
 have suggested that malnutrition increases the risk
of frequent diarrhoeal episodes.

 Low birth weight

 Measles

 Immunodeficiency or immunosupression – This may

be temporary, after certain viral infections (eg
measles) or it may be prolonged as in AIDS. When
immunosuppression is severe, diarrhoea can be
caused by unusual pathogens and may also be
prolonged.

 Age – Most diarrhoeal episodes occur during the first

2 years of life. This pattern reflects the combined
effects of declining levels of maternally acquired
antibodies, the lack of active immunity in the infant,
the introduction of food that may be contaminated
with faecal bacteria, and direct contact with human or
animal faeces when the infant starts to crawl. Most
enteric pathogens stimulate at least partial immunity
against
 repeated infection or illness, which helps declining of
disease in order children and adults.

 Seasonality – Distinct seasonal patterns of diarrhoea

occur in many geographic areas. In temperate
climates, bacterial diarrhoeas, particularly diarrhoea
caused by rotavirus occurs throughout the year,
increasing in frequency during the drier, cool months,
whereas bacterial diarrhoeas peak during the warmer,
rainy season. The incidence of persistent diarrhoea
follows the same seasonal pattern as that of acute
watery diarrhoea.

Asymptomatic Infections

Most enteric infections are asymptomatic, and the proportion

that is asymptomatic increases beyond 2 years of age owing to
the development of active immunity. During asymptomatic
infections, which may last for several days or weeks, stools
contain infectious viruses, bacteria, or protozoa cysts. People
with asymptomatic infections play an important role in
the
spread of many enteric pathogens, especially as they are
unaware of their infections, take no precautions and move
normally from place to place.

Epidemics

Two enteric pathogens, Vibrio cholerae o1 and Shigella

dysenteriae type 1, cause major epidemics in which morbidity
and mortality in all age groups may be high. Since 1961,
cholera caused by the eltor biotype of V.cholerae 01 has
spread to countries in Africa, Asia, and the Eastern
Mediterranean, and to some areas in North America and
Europe. During the same period, S.dysentriae type 1 has been
responsible for large epidemics of severe dysentery in Central
America, and more recently in Central Africa and southern
Asia.
9.3.1. Transmission of agents that cause
diarrhea

The infectious agents that cause diarrhoea are usually spread

by the faecal oral route, which includes the ingestion of
faecally contaminated water or food, and direct contact with
faeces.

A number of behaviours promote the transmission of enteric

pathogens and thus, increase the risk of diarrhoea. These
include:

 Failing to breastfeed exclusively for the first 4 – 6

months of life.

 Using infant feeding bottles

 Storing cooked food at room temperature

 Using drinking water contaminated with faecal

bacteria
  Failing to wash hands after defecation, after disposing
faeces or before handling food

 Failing to dispose of faeces (including infant faeces)

hygienically.

Situation in Ethiopia

 Diarrhoeal disease occurrence in 1983 was 4.8

episodes/child/year and a multiple indicator survey in
1995 showed a rate of 3.7 (4.5 in Kenya, 5.0 in
Uganda). Mortality due to diarrhoea was 19.2/1000
in 1983, while it reduced to 9.2 /1000 in 1995 ( 9 -
14/1000 in Kenya for the year 1987 - 1993, 18/1000
in Uganda). A longitudinal community based survey
in central rural Ethiopia indicated that acute diarrhoea
is the second commonest illness reported (24%) and
the highest incidence was among 2 - 6 months old.
Studies in the same area showed that diarrhoeal death
accounts for about 25 - 30% of all deaths in
children below
 five years of age. Earlier reports gave figures as high
as 46% for the country.

Morbidity and Mortality due to DD in 7 administrative

regions in children < 5 years old, 1984 - 1985 (MOH,
1990)

Region 2 weeks No of ortality rate

Prevalence episode/yr (per 1000)

Arsi 15.5 4.0 10.0

Addis Ababa 17.4 4.5 4.7

Gondar 23.0 6.2 15.0

Harrarge 18.4 5.0 8.3

Keffa 16.9 4.0 7.7

Shewa 16.7 4.0 17.0

Sidamo 15.6 4.0 6.9

9.3.2. Types of Diarrhea

Three clinical syndromes of diarrhoea have been defined, each

reflecting a different pathogenesis and requiring different
approaches to treatment.

Three types of diarrhoea:

1. Acute Watery Diarrhoea, representing 80% of cases and

50% of deaths

2. Acute diarrhoea due to dysentery, causes 10% of

diarrhoeal cases and 15% of deaths and

3. Persistent diarrhoea, causes 10% of cases and 35% of

deaths.

Acute Childhood Diarrhoea

This term refers to diarrhoea that begins acutely and lasts less
than 14 days (most episodes last less than 7 days), and
involves the passage of frequent loose or watery stools,
without visible blood. Vomiting may occur and fever may be
present. The most important causes of
acute watery diarrhoea in young children in developing
countries are rotavirus, Enterotoxigenic E Coli, Shigella,
Campylobacter jejuni, and cryptospridium. In some areas,
Vibrio cholerae o1, Salmonella and enteropathogenic E.coli
are also important. In Ethiopia, acute diarrhoea is more
common in low lands - partly because of lack of water and
partly due to poor hygiene. A child may have 5 - 6 episodes of
ACD/yr/child. Malnutrition affects only the duration of
diarrhoea and its bad outcomes. About 25 - 30%, the under
five mortality is accounted by ACD in African children and it
is about 46% in Ethiopia. Case fatality rate per episode of
diarrhoea is 1 - 2% and the mortality is approximately
9.2/1000 live births in the Ethiopian situation. Major etiologic
agents are Rota virus and E.coli.

Persistent Childhood Diarrhoea

This is diarrhoea that begins acutely, but is of unusually long

duration (at least 14 days). The episode may begin either as
watery diarrhoea or as dysentery. Marked weight loss is
frequent. Diarrhoeal stool volume may
also be great with a risk of dehydration. There is no single
microbial cause for persistent diarrhoea; enteroinvasive E.
coli, Shigella, Cryptospridium may play a greater role than
other agents. Persistent diarrhoea should not be confused with
chronic diarrhoea, which is recurrent or long lasting diarrhoea
due to non infectious causes such as sensitivity to gluten or
inherited metabolic disorders.

Dysentery

This is diarrhoea with visible blood in the faeces. Important

effects of dysentery include anorexia, rapid weight loss, and
damage to the intestinal mucosa by the invasive bacteria. A
number of other complications may occur. The main cause of
acute dysentery is Shigella; other causes are Campylobacter
jejuni and infrequently enteroinvasive E.Coli or Salmonella.
Entamoeba histolytica can cause serious dysentery in young
adults, but is rarely a cause of dysentery in young children.
9.3.3. Classification of Dehydration

The Integrated Management of Childhood Illnesses classified

dehydration into three classes and proposed options for
management of the sick child.

Severe dehydration

Those who have severe dehydration and who require

immediate IV infusion, nasogastric or oral fluid replacement
according to the WHO treatment guidelines described in Plan
C.

Patients have severe dehydration if they have a fluid deficit

equaling or greater than 10 percent of their body weight. A
child is severely dehydrated if he/she has any combination of
two of the following signs: is lethargic or unconscious, is not
able to drink or is drinking poorly, has sunken eyes, or a
skin pinch goes back very slowly.
Some dehydration

Those who have some dehydration and who require active

oral treatment with ORS solution according to WHO
treatment guidelines described in Plan B. Children who have
any combination of the following two signs are included in
this group: restless/ irritable, sunken eyes, drinks
eagerly/thirsty, skin pinch goes back slowly. Children with
some dehydration have a fluid deficit equaling 5 to 10 percent
of their body weight. This classification includes both “mild”
and “moderate” dehydration, which are descriptive terms used
in most paediatric textbooks.
No dehydration

Patients with diarrhea but no signs of dehydration usually

have a fluid deficit, but equal to less than 5% of their body
weight. Although these children lack distinct signs of
dehydration, they should be given more fluid than usual to
prevent dehydration from developing as specified in WHO
Treatment Plan A
Note: Antibiotics should not be used routinely for treatment of
diarrhoea. Most diarrhoeal episodes are caused by agents for
which antimicrobials are not effective, e.g., viruses, or by
bacteria that must first be cultured to determine their
sensitivity to antimicrobials. A culture, however, is costly and
requires several days to receive the test results. Moreover,
most laboratories are unable to detect many of the important
bacterial causes of diarrhoea.

Note: Anti-diarrhoeal drugs—including antimotility agents

(e.g., loperamide, diphenoxylate, codeine, tincture of
opium), adsorbents (e.g., kaolin, attapulgite, smectite),
live bacterial cultures (e.g., Lactobacillus, Streptococcus
faecium), and charcoal—do not provide practical
benefits for children with acute diarrhoea, and some
may have dangerous side effects. These drugs should
never be given to children less than 5 years old.
9.3.4. Classification of persistent diarrhea

Persistent diarrhoea is an episode of diarrhoea, with or without

blood, which begins acutely and lasts at least 14 days. It
accounts for up to 15 percent of all episodes of diarrhea, but is
associated with 30 to 50 percent of deaths. Persistent diarrhea
is usually associated with weight loss and often with serious
non-intestinal infections. Many children who develop
persistent diarrhoea are malnourished, greatly increasing the
risk of death. Persistent diarrhea almost never occurs in
infants who are exclusively breast-fed.

All children with diarrhoea for 14 days or more should be

classified based on the presence or absence of any
dehydration:

Children with severe persistent diarrhoea who also

have any degree of dehydration require special treatment
and should not be managed at the outpatient health
facility. Referral to a hospital is required. As a rule,
treatment of dehydration should
 be initiated first, unless there is another severe classification.

Children with persistent diarrhoea and no signs of

dehydration can be safely managed in the outpatient clinic, at

least initially. Proper feeding is the most important aspect of
treatment for most children with persistent diarrhoea. The
goals of nutritional therapy are to: (a) temporarily reduce the
amount of animal milk (or lactose) in the diet; (b) provide a
sufficient intake of energy, protein, vitamins and minerals to
facilitate the repair process in the damaged gut mucus and
improve nutritional status; (c) avoid giving foods or drinks
that may aggravate the diarrhoea; and (d) ensure adequate
food intake during convalescence to correct any malnutrition.
Routine treatment of persistent diarrhoea with antimicrobials
is not effective. Some children, however, have non-intestinal
(or intestinal) infections
that require specific antimicrobial therapy. The persistent
diarrhoea of such children will not improve until these
infections are diagnosed and treated correctly.

Classification of dysentery

The mother or caretaker of a child with diarrhea should be

asked if there is blood in the stool. A child is classified as
having dysentery if the mother or caretaker reports blood in
the child’s stool.

It is not necessary to examine the stool or perform laboratory

tests to diagnose dysentery. Stool culture, to detect pathogenic
bacteria, is rarely possible. Moreover, at least two days are
required to obtain the results of a culture. Although
“dysentery” is often described as a
syndrome of bloody diarrhoea with fever, abdominal cramps,
rectal pain and mucoid stools, these features do not always
accompany bloody diarrhoea, nor do they necessarily define
its aetiology or determine appropriate treatment. Bloody
diarrhoea in young children is usually a sign of invasive
enteric infection that carries a substantial risk of serious
morbidity and death. About 10 percent of all diarrhea episodes
in children under 5 years old are dysenteric, but these cause
up to 15 percent of all diarrhoeal deaths. Dysentery is
especially severe in infants and in children who are
undernourished, who develop clinically- evident dehydration
during their illness, or who are not breast- fed. It also has a
more harmful effect on nutritional status than acute watery
diarrhoea. Dysentery occurs with increased frequency and
severity in children who have measles or have had measles in
the preceding month, and diarrhoeal episodes that begin with
dysentery are more likely to become persistent than those that
start without blood in the stool.
All children with dysentery (bloody diarrhoea) should be
treated promptly with an antibiotic effective against Shigella
because:

(a) Bloody diarrhea in children under 5 is caused much more

frequently by Shigella than by any other pathogen;

(b) Shigellosis is more likely than other causes of diarrhoea to

result in complications and death if effective antimicrobial
therapy is not begun promptly; and (c) early treatment of
shigellosis with an effective antibiotic substantially
reduces the risk of severe morbidity or death.

WHO Treatment Plan A: treatment for diarrhea with

no sign of dehydration

Plan A focuses on the three rules of home treatment: give

extra fluids, continue feeding, and advise the caretaker when
to return to the doctor (if the child
develops blood in the stool, drinks poorly, becomes sicker, or
is not better in three days).

Fluids should be given as soon as diarrhea starts; the child

should take as much as s/he wants.

Correct home therapy can prevent dehydration in many cases.

ORS may be used at home to prevent dehydration. However,
other fluids that are commonly available in the home may be
less costly, more convenient and almost as effective. Most
fluids that a child normally takes can also be used for home
therapy especially when given with food.

Recommended home fluid should be: Safe when

given in large volumes. Very sweet tea, soft drinks,
and sweetened fruit drinks should be avoided. These are
often hyper-osmolar owing to their high sugar content (less
than 300 mOsm/L). They can cause osmotic diarrhoea,
worsening dehydration and hypenatremia. Also to be
avoided are fluids with
purgative action and stimulants (e.g., coffee, some medicinal
teas or infusions).

Easy to prepare: The recipe should be familiar and its

preparation should not require much effort or time. The
required ingredients and measuring utensils should be readily
available and inexpensive. Acceptable. The fluid should be
one that the mother is willing to give freely to a child with
diarrhoea and that the child will readily accept.

Effective. Fluids that are safe are also effective. Most

effective are fluids that contain carbohydrates and protein and
some salt. However, nearly the same result is obtained when
fluids are given freely along with weaning foods that contain
salt.

WHO Treatment Plan B: treatment for diarrhea with

some dehydration

 Give initial treatment with ORS over a period of

four hours. The approximate amount of ORS
 required (in ml) can be calculated by multiplying the
child’s weight (in kg) times 75; during these four
hours, the mother slowly gives the recommended
amount of ORS by spoonfuls or sips.

Note: If the child is breast-fed, breast-feeding should

continue.

 After four hours, the child is reassessed and

reclassified for dehydration, and feeding should begin;
resuming feeding early is important to provide
required amounts of potassium and glucose.

 When there are no signs of dehydration, the child is

put on Plan A. If there is still some dehydration, Plan
B should be repeated. If the child now has severe
dehydration, the child should be put on Plan C.
PERSISTENT DIARRHOEA

 Encourage the mother to continue breastfeeding.

 If yoghurt is available, give it in place of any animal

milk usually taken by the child; yoghurt contains less
lactose and is better tolerated. If animal milk must be
given, limit it to 50 ml/kg per day; greater amounts
may aggravate the diarrhea.

 If milk is given, mix it with the child’s cereal and do

not dilute the milk. At least half of the child’s energy
intake should come from foods other than milk or
milk products. Foods that are hyperosmolar (these are
usually foods or drinks made very sweet by the
addition of sucrose, such as soft drinks or
commercial fruit drinks) should be avoided. They can
worsen diarrhoea.

 Food needs to be given in frequent, small meals, at

least six times a day. All children with
 persistent diarrhoea should receive supplementary
multivitamins and minerals (copper, iron, magnesium,
zinc) each day for two weeks.
Treatment of dysentery

The four key elements of dysentery treatment are:

Antibiotics, Fluids, Feeding, Follow-up

Selection of an antibiotic is based on sensitivity patterns of

strains of Shigella isolated in the area

(nalidixic acid is the drug of choice in many areas). Recommended

duration of treatment is five days.

If after two days (during follow-up) there is no improvement,

the antibiotic should be stopped and a different one used.

9.3.5. Feeding sick child

 Feed frequently every 3 - 4 hrs (6x a day) during the

diarrhoea
  Small frequent feedings are best since they are easily
digested and preferred by the child

 Fermenting, mashing and grinding make it easier to

digest

 Freshly prepared food minimize the chance of

contamination

 One extra meal per day after diarrhoea for two weeks
helps the child regain the weight loss

 Avoid high fibre or bulky foods such as coarse fruits

and vegetables, peels and whole grain cereals
(hard to digest) and foods with a lot of sugar (osmotic
diarrhoea)

9.4. RESPIRATORY INFECTIONS

Respiratory tract infections can occur in any part of the

respiratory tract such as the nose, throat, larynx, trachea,
bronchi or lungs. Acute respiratory infections (ARI) can be
divided as Upper Respiratory Tract
Infections (URTI) which includes Nasophryngits, Otitis
media, Pharyngotonsilitis, and Epiglottitis and Lower
Respiratory Tract Infections which include Laryngitis,
Tracheobronchitis, Bronchitis, Bronchiolitis and Pneumonia.

ARI are one of the most frequent illnesses globally and a

leading cause of death in the developing world. Among
children under five alone, about four million deaths (33% of
the deaths) annually are ascribed to ARI most of which are
due to pneumonia. That mortality due to pneumonia is 10 - 15
times higher in developing countries suggests that there is
ample room for improvement in addressing this important
public health problem. At high levels of mortality; such as
XIX century in Europe, due to ARI reduced life expectancy
by 7.5 years; more than all other infectious diseases including
diarrhoeal diseases. At that time in Europe, ARI was the top
cause of death among infants and children outside the
neonatal period. ARI mortality has been declining steadily
with improving living conditions in developed
countries, a decline that has been enhanced since the 1950s
when antibiotics became available. However, recognition of
pneumonia and other ARI as an important public health
problem in developing countries is recent, the earliest
documentation being in early 1960s. Recent international
developments indicate that ARI is given better and the
deserved attention. The World Summit of Children, held in
New York in 1990 forwarded the objective of a reduction of
deaths caused by ARI by one third by the year 2000.

Viruses are the predominant etiological agents in ARI,

especially Upper Respiratory Tract Infections (URTI). The
majority of these are benign and self-limiting. The most
common non-bacterial agents of lower respiratory tract
infections (LRTI) are respiratory syncitial virus (RSV),
adenoviruses, Para influenza and influenza A and B viruses.
Some agents are more frequently associated with some
clinical syndromes than others
e.g. RSV and bronchiolitis. In some cases, however, viral
infections are the causes of severe disease or
complicated by bacterial super infection that can end in death
(e.g. complications of influenza, measles and some adeno and
rhinoviruses). Among the bacteria, Streptococcus
pneumoniae and Haemophilus influenzae are the two
commonest organisms. Among neonates, gram negative
enteric bacilli most notably E.coli and Streptococcus group B
are said to be dominant in the developed world. The few
studies done in developing countries do not show
Streptococcus group B as an important pathogen in neonates.
Etiological diagnosis of pneumonia is very difficult to
establish in infants and children since sputum is usually
unavailable and bacterial diagnosis can only be established by
lung aspiration and blood culture which may have serious
complications and may have low sensitivity.

The classification and management of ARI in the

industrialized world are founded on epidemioilgic, radiologic
and microbiologic data in addition to clinical history and
physical examination. The syndromes of ARI which are
complex clinical conditions of varying
aetiology and severity are most frequently categorized on
the basis of anatomical location. Common diagnostic
categories for uncomplicated ARI with etiologic and clinical
correlates are described in details. ARI includes the minor
upper respiratory infections (URIs), such as colds and sore
throats, in addition to the more serious (and potentially fatal)
acute lower respiratory infection (ALRI) of pneumonia and
bronchiolitis.

However, in most developing countries health institutions

settings it is difficult to make detailed diagnosis of acute
respiratory tract infections. Fortunately, a number of
guidelines have been developed for classification and
treatment of common acute respiratory infections with easily
identifiable symptoms and signs. The Integrated Management
of Childhood Illness (IMCI) guidelines suggested assessing
and classifying a child with respiratory problems with the
following: presence of general danger signs (listed in the
guidelines) duration of cough or difficult breathing, fast
breathing, chest indrawing and
stridor in a calm child. An infant 1 week up to 2 months old is
said to have fast breathing if it has a respiratory rate of 60 or
above per minutes. An infant 2 months up to 12 months has
fast breathing if the respiratory rate is 50 or above and a child
12 months up to 5 years is said to have fast breathing if the
breathing rate is 40 or more. For each class based on the
above symptoms and signs, treatment plan and specific
treatment options are indicated.

9.4.1. Cough or difficult breathing

A child presenting with cough or difficult breathing should

first be assessed for general danger signs.

This child may have pneumonia or another severe respiratory

infection. After checking for danger signs, it is essential to
ask the child’s caretaker about this main symptom.
Classification of cough or difficult breathing

Severe pneumonia or very severe disease.

This group includes children with any general danger sign, or

lower chest indrawing or stridor when calm. Children with
severe pneumonia or very severe disease most likely
will have invasive bacterial organisms and diseases that may
be life-threatening. This warrants the use of injectable
antibiotics.
Pneumonia.

This group includes all children with fast respiratory rate for
age. Fast breathing, as defined by WHO, detects about 80
percent of children with pneumonia who need antibiotic
treatment. Treatment based on this classification has been
shown to reduce mortality.

Cough or cold
Such children may require a safe remedy to a relieve cough. A
child with cough and cold normally improves in one or two
weeks. However, a child with chronic cough (more than 30
days) needs to be further assessed (and, if needed, referred) to
exclude tuberculosis, asthma, whooping cough or another
problem.
9.4.2. The Ethiopian Situation

Ethiopians are known for normally self treating their common

colds and rarely seeking treatment from professional
practitioners. Pneumonia and other life threatening acute
respiratory infections are often brought to the attention of
health workers too late, after home treatment with traditional
medicines and modern drugs. Thirteen percent of children
under five years of age showed symptoms of ARI at some
time in the two weeks in Ethiopia and only 19 percent of all
children under five with symptoms of ARI were taken to a
health facility or provider according to the EDHS
2005.Diseases of the respiratory tract infection were the major
causes (11%) of admission among 3500 in children’s hospital
in Addis Ababa. Cases with pneumonia as the principal
diagnosis constituted 6% of
admissions and accounted for 7% of the deaths. Measles was
the principal diagnosis in 3% of the admissions with a case
fatality rate of 28%. Among 21,853 ambulatory patients in the
same year, ARI was the principal problem in 28%.

A study in the same hospital showed that the mortality rate

from ARI in malnourished children was twice as high as
among normal children. In a community based study in central
rural Ethiopia, ARI accounted for more than a third of the
infant and more than a fifth of child deaths and nearly a third
of child deaths. Among infants, ARI deaths were more
common than diarrhoea deaths and the reverse was true for
children (1 –4) years. The paper indicated that early
termination of breast feeding, late introduction of
supplementary feeding, lack of windows, illiteracy of the
parent were associated with higher under five mortality.
9.5. VACCINE PREVENTABLE DISEASES

General considerations

Vaccination is the administration of a vaccine to stimulate a

protective immune response that will prevent disease in the
vaccinated person if contact with the corresponding infectious
agent occurs subsequently. Thus, vaccination, if successful,
results in immunization: the vaccinated person has been
rendered immune to disease caused by the infectious
pathogen. In practice, the terms “vaccination” and
“immunization” are often used interchangeably.

Each year more than a third of a million children die from

immunizable diseases and diarrhoea. The eight childhood
diseases preventable by immunization (neonatal tetanus,
measles, poliomyelitis, tuberculosis, pertussis, diphtheria,
Hemophilus Influenza type B and hepatitis B viruse) are
responsible for a considerable
proportion of the high morbidity, mortality and disability of
Ethiopian children.

9.5.1. Poliomyelitis

Poliomyelitis is a disease of the central nervous system caused

by three closely related enteroviruses, poliovirus types 1, 2
and 3. The virus is spread predominantly by the faecal–oral
route, although rare outbreaks caused by contaminated food
or water have occurred. After the virus enters the mouth, the
primary site of infection is the intestine, although the virus can
also be found in the pharynx. Poliomyelitis is also known as
“infantile paralysis” since it most frequently caused paralysis
in infants and young children in the pre-vaccine era in
industrialized countries. In developing countries, 60– 70% of
cases currently occur in children under 3 years of age and
90% in children under 5 years of age. The resulting paralysis
is permanent, although some recovery of function is possible.
There is no cure if disease develops. The incubation period is
from 7 - 14 days, but may range from 3 - 35 days.
On entry through the oral route, the virus multiplies in the
oropharynx and the lymphoid tissue of the intestinal tract from
where it enters the blood stream causing viremia. The
prodormal phase corresponds with this early viremia. If the
infecting strain of the virus is highly invasive or if the host
resistance is inadequate, the virus is then able to invade the
CNS. Neurological manifestations of the result of
haematogenous spread by the virus of the anterior horn cells
of the spinal cord.

Only about 1% of the total infections are symptomatic. There

may be non-specific symptoms of infection (fever, malaise,
sore throat, headache) in a small percentage of the population.
Less than 1% will develop severe illness (typically
asymmetric flaccid paralysis of the limbs, with no sensory
loss), and the majority of these cases will have had no
prodormal symptoms.
Occurrence

Significant progress has been made towards global eradication

of poliomyelitis. More than 125 countries were endemic for
polio in 1988; by 2006, only 4 countries – Afghanistan, India,
Nigeria and Pakistan, where wild poliovirus transmission has
never been interrupted – remained endemic. A number of
previously polio-free countries have been affected by wild-
virus importation that has resulted in subsequent outbreaks,
e.g. Namibia – a popular country for tourists – in the summer
of 2006. Until all countries have stopped wild poliovirus
transmission, all areas remain at high risk of importations and
even of the re-establishment of endemic transmission.
Determinants of Patterns of Poliomyelitis

Vaccination Level of Hygien

Coverage Low High

Low Polio endemic Polio endemic

Infection universal most population

eventually infected

Cases usually less Average age of

infection may be in

severe than when in teens or young

adulthood

Polio is endemic. Case usually

relatively serious

High Polio may become Polio controlled

epidemic unless high OPV

coverage is reached Infection levels Circulation of wild

virus interrupted.
 & average age of onset Paralytic polio
extremely rare;

depend on degree of cases are imported or

vaccine

vaccine coverage associated.

May be susceptible population if

unvaccinated pockets.

Incidence

Before the advent of polio vaccines, an estimated 600000 new

cases of paralytic polio occurred worldwide every year.
Paralytic polio leads to lifelong disability, and the sequelae of
past diseases has left between 10 and 20 million youth and
adults disabled today. In contrast to its significance as a
cause of disability, the contribution of polio to mortality of
children under five is relatively modest; an estimate in
Senegal suggests a contribution to mortality of < 2-5 per 1000
live births, or about 1% of all deaths of under five children.
Based on this fact, we
can see the significant effect of poliomyelitis is it’s morbidity
rather than its mortality.

Vaccine

There are two types of vaccine: inactivated (IPV), which is

given by injection and oral (OPV). OPV is composed of the
three types of live attenuated polioviruses. Because of the
low cost and ease of administration of the vaccine and its
superiority in conferring intestinal immunity, OPV has been
the vaccine of choice for controlling epidemic poliomyelitis in
many countries.

Most industrialized countries use IPV, either as the sole

vaccine against poliomyelitis or in schedules combined with
OPV. Although IPV suppresses pharyngeal excretion of wild
poliovirus, this vaccine has only limited effects in reducing
intestinal excretion of poliovirus. For unvaccinated older
children and adults, the second dose is given 1–2 months,
and the third 6–12 months, after the first dose. There is
continued debate over which form of vaccine (OPV or IPV)
is most suitable for use in
developing countries. WHO is still recommending the use of
OPV.

Success with the eradication of smallpox has prompted

discussion of feasibility of the eradication of various other
diseases and polio is no exception. There has been a massive
attempt to eliminate it from the Americas, and it appears to
have paid off, with no case of flaccid paralysis since 1991.
Like smallpox, polio is limited to the human host - there is no
animal reservoir. Also there are no long term carriers.
Effective vaccines are cheap and readily available.

Unlike smallpox, however, 95 -99% of infections are

asymptomatic which renders containment much more difficult
(as does its ease of transmission). Smallpox eradication used
as a strategy, mop up around cases,
i.e. vaccination of contacts. In the case of polio this is much
more difficult, since the spread is much larger and mop up
would have to include very large areas.
Unlike smallpox, persons not vaccinated against polio are not
easy to identify (smallpox scar). This is especially important
since more than one vaccination is required to be protective.
Finally, polio vaccines are much less stable. However, despite
these constraints, based on the success in the Americas, the
general consensus currently is that polio can be eradicated,
but it may take longer than the year 2000.

The strategies adopted for the eradication in the

Americas, and to be adopted elsewhere are the following:

1. Routine immunization

This is the foundation of eradication policy. By 1990, 80% of

the children born in that year had received a basic course of
immunization against polio, diphtheria, pertussis, tetanus,
measles and tuberculosis by the age of one year. Eighty three
percent had received a basic course of three doses of OPV.
However, it has been shown that routine immunization in
developing countries
will not result in eradication. Outbreaks have occurred in
countries where coverage is higher than 90% due to the
accumulation of unimmunized children in localized areas of
poor immunization services.

2. National immunization days

Nationwide mass campaigns, known as National

Immunization Days, will be needed over several years to
eradicate polio in endemic countries. WHO recommends that
all children less than 5 years of age receive 2 doses of OPV
during NIDs regardless of their pervious immunization status.
The 2 rounds should be 4 - 8 weeks apart and each round
should be completed within one week.

3. Outbreak response immunization

A single case of paralytic polio suggests that there is a low

level immunity in a community and the current
recommendation is that whenever a case of suspected polio is
detected, all children less than 5 years of age
living in the vicinity of a case should receive one dose of OPV
regardless of immunization status.

4. Mopping up immunization

This involves house to house immunization in high risk areas:

- Any area which and a case within the past 3 years

- Urban slums

- Areas with low immunization coverage often NIDs do

not work in these areas: better coverage is obtained
when the vaccine taken to the child. Two doses are
given, one month apart, to children less than 5.

Now, how effective have these strategies been ? While the

annual incidence of the disease in the years 1986 - 88 was
200000 - 250000, by 1992 it had dropped to an estimated
140000. More significant than that, however, is the
distribution of case worldwide. The last case of
polio in the Americas occurred in Peru in 1991. There has
since been no new case and the Pan American Health
Organization has now declared that polio has been
eliminated from the Americas.

REFERNCES

Hull HF et al (1994). Paralytic Poliomyelitis: seasoned

strategies, disappearing disease." Lancet 343:1331 - 37.

Jamison DT et al. (1991). Poliomyelitis: What are the

prospects for eradication and rehabilitation. Health policy and
planning 6(2):107 - 118.

Jamison DT et al (1993). Poliomyelitis. In Jamison et al ( eds)

Disease control priorities in developing countries. Washington
DC: World BAnk.

Wright PF et al (1991). Strategies for the global eradication of

poliomyelitis by the year 2000. NEJM 325(25):1774-79.
9.5.2. NEONATAL TETANUS

Tetanus is a completely preventable disease caused by

contamination of wounds with anaerobic bacillus, Clostridium
tetani. The organism is ubiquitous in soil and dust and has the
ability to form highly resistant spores. It exists harmlessly in
the gut of many animals, including man. If the pathogen is
introduced into necrosis tissues, it multiplies and produces a
powerful neurotoxin. Tetanus is an endemic environmental
hazard rather than communicable disease, and consequently
does not spread in explosive epidemics.

Neonatal tetanus occurs mainly as a result of umbilical cord

contamination with tetanus spores at birth. The disease
manifests itself commonly between the third and the twenty
eighth day after birth when an apparently healthy baby stops
nursing, becomes progressively more rigid, has convulsions
and dies within a few days. In the developing world, some
85% of the newborns contracting neonatal tetanus will die.
Unhygienic birth practices afford many opportunities for the
umbilical cord
to be contaminated with tetanus spores. They organism finds
the umbilical cord an ideal tissue in which to multiply and
produce powerful toxins. Each case of neonatal tetanus is the
result of failure to protect the mother with an anti-tetanus
immunization together with lack of hygiene during and after
delivery.

Prevalence

In many developing countries, neonatal tetanus still represents

about half of all neonatal deaths and about 25% of infant
mortality. It is estimated that worldwide, about 775000
newborn children die every year from this disease.

Estimates of neonatal tetanus mortality in Africa have varied

from 4 per 1000 live births in Zimbabwe to 12 - 18 per 1000
live births in Malawi, Uganda and Ivory Coast. In many of
these countries, neonatal tetanus has been concentrated in
certain regions. In Punjab, Pakistan the neonatal mortality
rates were twice as high in rural cattle and horse raising
areas (43 per 1000) than in urban
slum areas (21 per 1000 live births). In Egypt, the risk of
death from neonatal tetanus was 5 times greater for rural
births than for a birth in urban areas. The risk of neonatal
tetanus for a birth in upper Egypt ( regardless of whether in
urban or rural area) was 4.7 times greater than for a birth
occurring in lower Egypt.

In Ethiopia, neonatal tetanus is a commonly fatal disease for

newborns, with nearly two thirds of all tetanus deaths
occurring among neonates. A community based survey in
rural Gamugofa region reported a mortality rate of 6.7/1000
live births and an estimated incidence rate of 8.4/1000 live
births. The study that found the incidence rate in males to be
2.5 times higher than in females. High risk factors included
cutting the umbilical cord with unsterile instruments, the
traditional practice of applying potentially infectious material
(such as cow dung) on the stump, and home delivery attended
by untrained traditional birth attendants. A community based
study in rural and urban Gondar region reported a higher
neonatal mortality rate among babies delivered at
home (4.5/1000 live births) than those delivered in hospitals.
The study found only 22.5% of the mothers to have been
vaccinated and recommended training of traditional birth
attendats and immunization of all expectant mothers with
tetanus toxoid as a measure for controlling neonatal tetanus.

Prevention and Control

Neonatal tetanus is a preventable disease which can be

eliminated by two complementary strategies: vaccinating
women with tetanus toxoid; and ensuring a clean and safe
environment for the umblical cord during and after delivery.

Antitetanus immunization has had remarkable results in some

developing countires. After achieving 95% coverage with two
doses of tetanus toxoid, the annual number of neonatal tetanus
cases adimitted to a hospital in Maputo Mozambique fell
from 170 - 250 cases during the period 1976 - 79 to zero in
1986. Similar results were achieved in Harare, Zimbabwe and
in Sri Lanka by combining two strategies: the
immunization of women with hospital deliveries. Sri Lanka is
an example of a country in which immunization program has
exerted a clear impact on neonatal tetanus incidence. Since the
introduction of the EPI in 1978, neonatal tetanus incidence
declined 36 times from 2.16 to 0.06 per 1000 live births.

Immunize all women of child bearing age

Immunization against tetanus is achieved by vaccinating

different target groups with vaccines such as DPT, DT, TT
and Td (tetanus - diphteria with a reduced component of
diphteria antigen) all of which contain tetanus toxoid. TT and
Td are suitable for adults, whereas DPT is given to children
less than 5 years old, and preferably during infancy. The DT
vaccine is used for young children unable to receive DPT,
and is mainly administered in schools.

In areas where neonatal tetanus is an endemic disease,

antitetnaus immunization is a priority and is indispensable for
the elimination of neonatal tetanus, particularly in rural areas
where the health care
infrastructure is inadequate. Immunization is also
indispensable in many urban areas, as a large proportion of
the population has no access to health facility or hospital
delivery, for a variety of reasons, besides which health facility
or hospital delivery is not always a guarantee against neonatal
tetanus.

WHO's recommendation for the antitetanus immunization of

women (see table) and infants is five doses of antitetanus
vaccine at regular intervals. The level of antibodies present in
the mother guarantees protection of the mother and baby, as
the antitetanus antibody is easily passed from the mother to
the fetus through the placenta. Tetanus toxoid can safely be
administered from the first month of pregnancy.
 Table 7: Tetanus Toxoid Immunization for Women

Dose Schedule Protection

Percent Duration

TT1 first contact Nil None

TT2 > 4 weeks after 80 3years

TT1

TT3 > 6 months 95 5 years

after TT2

TT4 > 1 year after 99 10 years

TT3

TT5 > 1 year after 99 30 years

TT4
While to be effective, the tetanus toxoid should never be
frozen and should be kept below 80C, it is a relatively durable
vaccine. TT costs about $0.02 per dose in multi dose vials, can
withstand temperatures of 37C for at least 6 weeks, has more
than 95% efficacy, when used according to the correct
schedule, and is extremely safe.

To achieve a high rate of immunization, all women of

childbearing age including pregnant women need to be
immunized, taking advantage of any visit they make to a
health centre, whether public or private. When mothers bring
their children for immunization, antitetanus vaccine should be
available and also offered to them. This provides an
opportunity of rapily increasing immunization rate. Any visit
to a health facility provides an opportunity to determine their
tetanus immunization status and to initiate or complete the
recommended five doses immunization schedule.

Ideally, women entering their childbearing years already

should have received 5 doses of TT, which can be in the form
of properly spaced doses of DPT or DT in
childhood, and TT. The prevailing belief in many countries
that 2 doses of TT are sufficient must be changed. In addition,
the earlier the protection the greater the reduction of neonatal
tetanus as well. This is important since the highest age
specific incidence of tetanus after the neonatal period in
developing countries is among children.

There is no global blueprint for neonatal tetanus control.

Strategies need to be determined locally and may differ from
one area to another within the same country. And more than
one strategy is often indicated.

Ensuring Clean and Safe Delivery

This is an essential and complementary part of the strategy for

eliminating neonatal tetanus. It is achieved by respecting the
following rules.

- Clean hands of the birth attendant

- Clean cutting and care of the umbilical cord

- Clean surface where the delivery is performed.

This strategy has been very effective in the industrialized
world and has reduced dramatically the incidence of perinatal
infections.

However, it is worth noting that many cases of neonatal

tetanus reported in the developing world have occurred in
infants delivered in public and private health facilities. This
gives cause for concern, since there may have been lack of
hygiene or improper care of the cord after discharge in a
mother not adequately immunized.

The training of delivery staff (health workers and traditional

midwives) and their supervision are indispensable if the
strategy is to succeed in the long term. Adherence to the rules
mentioned above is not a substitute for immunization, but
should be introduced as a complement to it. Despite clean
delivery and the initial handling of the umbilical cord, certain
traditional practices may pose an additional risk of tetanus.
REFERENCES

Shewatatek, L and Gebresellasie, O.(1993)."Childhood

Disease and Immunization". In H. Kloos and Zein A.Z (eds).
The Ecology of Health and Disease in Ethiopia. Boulder,
Westview Press.

Steinglass, R et al. (1993). “Tetanus". In D Jamson et al

(eds).Disease Control Priorities in Developing Countries.
Washington DC: World Bank.

WHO. (1991). Maternal and Perinatal Infections: Geneva:

WHO.

9.5.3. MEASLES

Disease

Measles is a highly contagious infection; before vaccines

became available, this disease had affected most people by the
time of adolescence. In 2007, measles still affected large
number of children, and the number of global measles deaths
was estimated to be
242,000. Common complications include middle-ear
infection and pneumonia. Transmission, which is primarily by
large respiratory droplets, increases during the late winter and
early spring in temperate climates, and after the rainy season
in tropical climates.

NATURAL HISTORY

Transmission is by droplet and it is highly infectious. The

transmissibility of the measles virus is very high. The attack
rate is estimated to be about 75% vs approximately 30% for
mumps and about the same for smallpox. This has
significance in terms of the epidemiolgy of the disease.

The natural history of the disease is completely different in

industrialized countries compared to the developing world. It
tends to affect children at a later age and with much severity
in the developed world. The CFR is much less than 1%,
whereas in LDCs it is estimated to be 3 - 15%, highly variable
depending on a number of risk factors.
The disease usually presents with what appears to be URI
with conjunctivitis and nasal discharge, followed by a rash.
While it is often limited to this in the developed world, in
LDCs sequeale are common. GI problems are amongst the
most frequent. Painful mouth often prevents children from
eating properly. In his 1973 study in Nigeria, Morley showed
that a quarter of the children he studied lost more than 10% of
their body weight which took up to 2 months to regain.
Diarrhoea is a frequent complication with seriuos
repercussions. In a study in Bangladesh , the CFR for measles
was 11.9% if the child has diarrhoea, compared to 4% in
those without diarrhoea.

Post measles pneumonia is a major cause of measles

associated mortality in LDCs. Of the measles associated
mortality in three studies, 44 - 93% was attributable to
pneumonia.

In a study in Sri Lanka, 44% mortality was due to pneumonia,

25% due to diarrhoea, 19% to convulsions and 9% to coma.
In addition to mortality, the long term disability due to
measles is significant. One of the chief causes of blindness in
LDCs is acute vitamin A deficiency secondary to measles.
Also chronic malnutrition is a significant problem.

The risk factors for mortality from measles are:

1. Age: variable from country to country. Generally, the

younger children are at greatest risk.

2. Gender: more in females.

3. Socio - economic status.

4. Intensity of exposure: a number of studies have shown that

measles acquired in the household carries with it a greater
risk of death due to intensity of infection. Also the attack
rate in the same household of susceptible is approximately
90% vs 75% non household contacts.

5. Nutritional status (Vit A)

6.Vaccination status: This is the strongest correlation

(negative) with mortality of any of the risk factors.
EPIDEMIOLOGY

Most infants are protected at birth by passively acquired

transplacental maternal antibodies. Breastfeeding affects
neither the level nor the persistence of measles antibodies. The
mean duration of the protection provided by these antibodies
varies considerably, ranging from 3 - 6 months in some
populations to 12 months or more in others.

Three factors contribute to the interpopulation differences:

1. Geographic variability among mothers: in certain areas,

mothers have more measles antibody to pass on. For
example, one study in South Africa showed that women
who had 8 times higher levels than those in a population
in Taiwan.

2. Genetic or environmentally determined differences in the

efficiency of the placenta in transporting IgG.

3. Differences in the efficiency with which children maintain

passively acquired immunity.
The gradual disappearance of the maternal antibody brings a
gradual increase in the number of susceptible in the
population. Without vaccination, once the maternal Ab has
disappeared, virtually all children will contract measles; only
the age of infection differs among population density. In the
absence of immunization, the age distribution of cases
depends on the rate of maternal Ab loss and age related
changes in the frequency of contact with other persons.
Measles tends to infect children at a younger age in LCDs
than in developed areas. Before immunization, the median age
at which children were infected in Africa were 1.5 - 2.5 yrs in
urban areas, and 2.5 - 5 yrs in rural areas. In the US, the
figures were 4 - 9 and 6 - 10 respectively. In urban areas of
Africa, most children will have been infected by age 2, while
in the more isolated areas of rural Africa, that figure is
approximately age 5. Incidence, however, varies cyclically.
Factors affecting incidence are the size of the susceptible
population, and the frequency of contact between infectious
individuals and the susceptible.
Widely divergent age patterns of measles transmission is
described as follows.

1. High density urban population countries ( E.g. Kenishasa,

Zaire). In 1993 coverage among 12 - 39 months of age
children was 62% whereas, transmission rate among 6 - 8
months was 18%, 9 -
11 months, 19%, one year olds 40%, and 2 year children
had 10% occurrence. Seventy seven percent ccurred before
3 years (Taylor and others, 1981).

2. Rural population developing countries with low vaccine

coverage ( E.g. Matlab, showed 23% occurrence in under 2
years, 34% in children aged between 2 - 3, 22% in
children 4 - 5 years, and 22% in 6 - 10 years ( Koster and
others, 1981).

3.Rural population in developing countries with high vaccine

coverage in 1990 and as a result, there was a significant
change in age at which measles infection occurs and 60% of
it was noted in children over 5 years of age.
4. Population in industrialized countries with high vaccine
coverage. In America, during the prevaccine era, measles
was primarily a disease of children. Childhood
immunization coupled with mandatory school
immunization has reduced measles incidence by 98%
(Markowitz and Ornestein, 1990). Peak ages of measles
incidence occurence now are 1 - 4 and 15
- 19 years 25% pf cases each, and below 1 year 10%, the
rest range from 5 - 10%. As the incidence of disease
increases, those infected either die or become immune.
Therefore, the size of the susceptible population decreases.
Then, the chance that an infectious person will come into
contact with a susceptible decreases. Sporadic case of
measles will not then, set off an epidemic because the
infected individual will not come into contact with an
uninfected individual. The incidence of disease decreases,
and the population of susceptible gradually increases with
new births, It reaches a threshold at which point there is
increased frequency of contact between the two groups and
incidence rates increases.
The length of interepidemic interval depends on the rate of
accumulation of susceptible (related to the birth rate and
migration patterns) and on the population density. In urban
areas of Africa before immunization the interepidemic interval
was 1 - 2 years, and in rural Africa, 5 -7 years.

The main foci for transmission of measles are health centres,

households, and festivals/markets. Immunization programs
have significant effects on measles epidemiology. They slow
down the rate of entry of new susceptible into the population
and therefore decrease the incidence of disease. They leave
some children susceptible till an older age and therefore shift
the age distribution of disease to the right. They also lengthen
the interepidemic interval.

The period of low incidence, following the introduction of

widespread immunization, termed the "honeymoon period" is
generated during the shift from preimmunization to post
immunization age distribution. Rapid achievement of high
coverage induces a period of
low incidence, after which the system settles to a higher level
of incidence (but lower than preimmunization) with an
interepidemic period longer than that preimmunization. The
higher coverage achieved, the lower the accumulation of
susceptibles, and the longer the interepidemic interval.

Complications (acute or chronic)

Investigation of 2386 cases in Sri Lanka documented

complication frequencies as follows. Diarrhoea in 37%,
respiratory infections in 30%, ear infection in 7% and
convulsions in 2% in 1985. Ten percent of these children lost
body weight and they regained it in 4.5 weeks time for those
who did not have diarrhoea and
8.1 weeks for those who developed diarrhoea. In Bangladesh,
an investigation of 5775 children with measles found a CFR
of children with diarrhoea to be 11.9%, while it was 4% for
those with no diarrhoea. Fifty percent of diarrhoea lasted for
more than 7 days compared to 25% for those without measles.
WHO ( Fecheam and Koblinsky, 1983) reported
that
immunization prevents upto 0.6 - 3.8% of all diarrhoeal
episodes and 6 - 26% of all diarrhoeal deaths.

Post measles pneumonia is the main killer in developing

countries. Fifty six percent of measles associated deaths in
community based study in India and 92.8% of measles
associated deaths in hospital in lloria, Nigeria ( Fagbule and
Orifumishe 1988). Mortality risk factors are mentioned above.

Immunization programs aim to interrupt measles transmission

by including herd immunity; The resistance of a group to
attack by measles since a large proportion of the members are
immune thereby reducing the chance of contact between an
infectious person and a susceptible.

But herd immunity is difficult to achieve with measles

because of high transmissibility of measles, low vaccine
coverage, and poor vaccine efficacy ( 80 - 90%). It has been
estimated that 95% coverage with a vaccine that is
100% effective would be necessary to induce herd immunity.
Coverage in all Africa in 1992 was 53%.

Vaccination schedule

The current recommendation of the WHO is that vaccination

should be given as soon after 9 months as possible. But this
leaves a window of from about 4 or 5 months to 9 months
when the child might become infected. It is during this period
that maternal antibodies are falling to levels at which they are
not protective, are still able to prevent adequate by the
vaccine. Bart suggests that 45% of measles occur in children
under 9 months of age. Other estimates are 20 - 30%. In any
case, the numbers infected before the recommended age of
immunization are significant. A lot of effort has been
expended in developing vaccines that would be immunogenic
at an earlier age. Two vaccines, Edmonston - Zagreb (EZ) and
high titre Schwartz were developed in the 1980s and proved
promising. The EZ was more effective, but both vaccines
showed improvement over the standard vaccine in causing
seroconversion in children 6 months and younger. Both of
these had a much higher concentration of the live attenuated
virus than did the standard.

The WHO in 1989 changed its policy such that these vaccines
were to be used in infants 6 months of age in areas of high
measles transmission. Limited amount of vaccine were
available and the use was therefore restricted to these areas.
Field test proved that they were effective. However, in 1991 a
paper published in the Lancet by Garenne suggested that there
was an increased mortality in these high titre vaccines: the
RR of death using EZ was 1.8 and for high titre Shwarcz,
1.5. Further studies confirmed these findings and in June
1992, the WHO reversed its policy decision and returned to a
policy of vaccination at 9 months with standard vaccine.

There are currently attempts to develop other strategies to

address the issue of infection in the 4 - 9 month age group.
One proposal is to use the standard vaccine at six month
and revaccinate later. However, there is
concern that this will affect immunogenecity of the second
dose. Much work remains to be done in this area.

Measles Strategies for the 1990s: At the global level, there is

considerable debate as to the appropriate long term measles
objective: control, elimination or eradication.

Control: the reduction of measles morbidity and mortality to

a level that is no longer a public health problem: Elimination
the interruption of measles transmission in a geographically
defined area, island, nation or continent. Eradication: the
interruption of person to person transmission, the
elimination of the virus reservoir and the termination of
prevention procedures.

The current WHO/UNICEF goals of 90% reduction in

morbidity and 95% mortality are consistent with control.
Measles elimination has been targeted for the US, Europe and
the Caribbean.
Eradication has been proposed because of the high cost of
control. Much of the advocacy results from the eradication of
smallpox and the similarities that exist between the two: both
are rashes, both give lifelong immunity, neither has animal
reservoir and neither has a chronic carrier state. Dissimilarities
however, are notable ( as seen below).

Measles Smallpox

Infectivity High (70% attack rate) Less (33%)

Age of infection 12 - 18 months 4 -5 years

Age vaccination9 months Birth

Ease of diagnosis Hard Easy

(acute & chronic)

Vaccine efficacy 80 - 90% 99%

Vaccine stability Cold chain needed 1 yr ambient T0

Outbreak control Difficult Easier

Comparison of Measles and Smallpox with a view of measles

eradication.
Theoretical models predict that if more than 98% of
susceptible young children can be protected against measles,
the disease can be eradicated ( assuming a homogeneous
population and rare vaccine failures). However, if these
assumptions are not correct, then 100% protection is
necessary. Therefore, eradication is not feasible given the
current vaccine and coverage levels.

Achieving the 1995 Measles Targets

At the September 1991 World Summit for Children, the WHO

1995 target for morbidity and mortality reduction were
affirmed at 90% and 95% respectively. This will require
increases in both coverage and efficacy. Eleven strategies
have been outlined to achieve these targets.

1. Vaccinate in the first year of life. Vaccination of older

children in LDCs will be less effective since many will
already have become immune or died through exposure
to the wild virus.
2. Reduce missed opportunities. Causes (see below):

i. False contraindications

ii. incorrect screening by health worker

iii. vaccine not available iv. clinic too crowded

v. cancellation of scheduled session for variety of

reasons

vi. inconvenient time vii. health worker will not waste

vaccine ie will not open vial for 1 child. etc.

3. Increase community participation

4. Registration and follow up of newborns

5. Use accelerated immunization strategies (ie

immunization days). But these should be used under
specific circumstances.

6. Vaccinate high risk groups: refugees, hospitalised

children, urban infants etc.

7. Adopt 2 doses schedules

8. Provide Vitamin A supplementation in Vitamin A
deficient areas.

9. Treat severe measles with Vitamin A

10. Treat measles complications effectively

11. Expand infrastructure

9.6. THE EXPANDED PROGRAM OF

IMMUNIZATION

The Expanded Program of Immunization was launched in

1974 by the World Health Assembly. Although WHO took the
lead in the development of the program, it has since been
joined by other UN agencies and multi and bilateral
development organizations. Each developing country
generally has EPI office housed in the Ministry of Health.

EPI was initiated in Ethiopia in 1980. The program had

planned to make immunization services available to 10% of
the population in 1980 and to increase immunization access
by 10% each year. However, in
1986, only 10% of the country's eligible children were fully
vaccinated. After launching of Social Mobilization of
intensification of EPI to attain Universal Child Immunization
(UCI), the coverage increased to 59% by 1990. Subsequently,
as a result of the escalating civil war and public unrest, the
EPI coverage for DPT3 dropped from 59% to 21% in 1991,
and 13% in 1992,with only 59% of the country's static health
facilities in accessible areas rendering EPI services. With the
revival of EPI in 1993, DPT3 coverage reached 28% by the
end of the year (UNICEF, 1994), coverage report for the year
1995 was 43% (MOH).

In general, childhood immunization programs are expected to

face the following challenges.

 Maintaining coverage levels

 Reaching as yet uncovered populations

 Dealing with rising vaccine costs

 Finding resources to deliver newly available

vaccines
Vaccine Quality Control

Quality control relates both to the management of the cold

chain and the process of sterilization.

Causes of Damage to vaccines:

1. Time (Expiry date)

Vaccines deteriorate with time and this deterioration is

accelerated by heat and sunlight which damage all vaccines
- especially polio and measles. All vaccines lose potency
when exposed to heat, but some are more sensitive than
others (see table)

2. Measles and BCG vaccines are very sensitive to light at all

times.

3. Freezing damages DPT and TT as well as inactivated polio

vaccine and Hepatitis B vaccine.

Therefore, the safest policy is to keep all vaccines at the

correct COLD temperature ( 0 - 8 degrees - but not freezing),
and in a dark place.
4.Chemicals, antiseptics, detergents, soap etc, can inactivate
vaccines, and therefore should not be used to sterilize.

Here is the order of vaccines in order of their sensitivity

Most sensitive OPV

Measles

Yellow fever

Hepatitis B

Inactivated polio vaccine

DPT

BCG

Least sensitive TT

Sensitivity of vaccine to heat

Cold Chain: A system of people and equipment which ensures

that the correct quantity of potent vaccines reaches the people
who need it.
There are 4 ways of monitoring the cold chain:

1. Regularly monitoring the storage, which should always be

kept between 0 and 8 degrees centigrade. A chart should
be affixed to the front of the fridge and the morning
and afternoon temperature should be recorded.

2. Determining whether or not the vaccine has been

frozen - the shake test for DPT and TT vaccines.

3. Using the cold chain monitor / freeze watch indicator.

4. VVM for OPV. If the colour of the central part becomes

similar or darker than the surrounding, the vial should be
discarded.

5. Potency testing: If cold chain failure occurs, one may

consider testing the potency of the vaccines. This is
indicated only if large numbers of doses are involved. It is
therefore, likely to be of limited value at the health facility
level. The following table shows the minimum numbers of
doses that justify testing. If there is doubt
 about vaccines at a lower number of doses than the
above, it is more cost effective to discard them.

Minimum Numbers of Dose of EPI Vaccines that

Justify Testing

OPV 25000

Measles 7000

BCG 20000

TT 20000

DPT 20000

Sterilization

Another aspect of quality control relates to the sterilization of

vaccination equipment. Every health facility must be able to
provide vaccines with sterile needles and syringes. There is no
point in providing potent vaccines, if you kill the child with
AIDS or hepatitis. This means that every health centre should
be able to sterilize its equipment or have adequate stocks of
disposable needles and syringes.
1. Equipment needed

Sterilizers, Drums or Racks to hold needles and syringes, A

clock, A source of heat, A regular supply of energy. Boiling
could be used, but it is not as effective as sterilization. It
should only be used until steam sterilizers are available.
Steam at 121 - 126 degree centigrade kills everything.
Steam sterilizer can be fitted with either drums or racks.
Both fit in to the sterilizer and hold the needles and
syringes. A rack must stay in the sterilizer to keep needles
and syringes sterile, while drum is a sealed unit that may
be separated from the sterilizer.

Drum has two advantages: Weighs less than sterilizer and

rack and is easier to transport to outreach sessions; need
fewer sterilizers, since you can use one sterilizer to
sterilize more than one drum.

2. Estimation of needs for sterilization equipment

Each rack or drum holds 42 syringes and 50 needles. There

are 3 sizes of sterilizers: 1 - 2 and 3 unit. So,
42, 84, or 126 syringes. Need one back up rack or drum
filled with sterilized needles and syringes at each session.
Calculations are based on the following assumption:

BCG immunization is 100%

For every BCG immunization given, you also need 3 DPTs,

1 measles and 1 TT immunization. So for example, you
know that on your busiest day will not give more than 7
BCG injections. It means that you assume to give 35
injections of the other 3, for a total of 42. Therefore, you
need one rack plus one reserve. So, you will need either 2
singles or 1 double or triple rack ( drum) sterilizer.

If the health unit does both static and outreach

immunization sessions a day you need more sterilization
equipment.
3. How is the condition of the equipment?

The safety valve and rubber seal and the clock all need
to be checked.

4.Is the right kind of injection equipment used?

Recommendation: Plastic reusable needles aims
syringes is steam sterilizer is available. The alternate is to
use disposable needles and syringes. Reusable needles can
generally be used 50 times. Rate of
replacement of syringes depends on the hardness of the
water used in sterilizers: severely hard 30X, moderately
hard 50x, soft 100x.

Estimation of numbers needed: as for vaccines and spare

parts, but keep 100% reserve if you have enough space.

Supply
The system can be used for any commodity such as FP.

Estimating requirement for an existing store.

When reordering supplies, we have to keep in mind four
things:

1. How much stock used since last order

2. How much reserve stock should be kept for

emergencies?

3. How much stock was left over from the previous

supply period?

4. How long will it take for new supplies to arrive?

All assume a reasonable inventory and recording system.

Unexpected changes in demand may relate to an epidemic, a
flood, a sudden influx of people or outside the catchment
population area, or due to increase in demand through health
education program, reserve stocks take in to account normal
variability and emergencies. Generally, use 25% reserve.
Useful for power failures, transport problems and epidemics.
Stock balances should be done continuously.
Estimating vaccine requirements for the first time:

Need to know;
Total population = # births/yr Coverage: = # < 1 children

Wastage rate = # doses per antigen Reserve = # of doses per

vial Times 12 months

Transport
Plan for this could be made based on what is available,
working conditions of the means of transport ( it is a vehicle) ,
number of workers engaged in vaccination at a time, number
of sites available and the efficiency of each in terms of cost,
convenience and timing.

Assessment of EPI coverage

- Health facility reports (requires a good HIS)

Targets (under one) - in Ethiopia it is 3.5% of the total
population according the 1984 census. Women in
reproductive age group constitute about 20 - 22% of the total.
Findings from reports could be compared and counter
checked with the number of doses of a vaccine
given to these children over the same time period (during the
past 12 months) over the target population.

- The EPI coverage survey

Often routine reports are inaccurate and one may have to
resort to EPI coverage survey to determine the coverage, and
provide additional information. WHO has developed a rapid
survey methodology which is valuable not only to determine
vaccination coverage, but also reasons underlying for failure
to vaccinate children. The main advantages of this
methodology are that it can be completed quickly and it is
technically easier to carry out than a simple random sample
survey in populations that are not censused.

Its principal disadvantage is that it allows one to draw

conclusions about the population as a whole; one cannot
compare sub - populations. For example, one can not
compare rates between the boys and the girls in the sample
population using the standard thirty by seven cluster
methodology. However, with modification of sample size, this
too is possible.
The standard cluster survey methodology involves choosing
30 different clusters of 7 - 10 households. A cluster is a
randomly selected group which for the EPI coverage survey
contains 7 - 10 children of appropriate age (12 - 23 months).
Thus, each unit randomly selected is a group of cluster of
persons rather than an individual.

In order to select the clusters, one must first know the total
population of the area under consideration, as well as the
populations of the various towns, villages or other centres in
the area. These population centres are listed with their
populations and a cumulative population besides it. A
sampling interval is determined by dividing the total
population by 30. A random number will be selected between
and the determined sampling interval. The community for
which the cumulative population equals or exceeds the
random number is selected. It will contain the first cluster and
so on until all the thirty communities have been chosen. Large
communities may contain more than one cluster. Once the
communities have been selected, one then chooses the
cluster. This is done by selecting a household. If the
community had been censused and list of households
available, this will be a relatively easy procedure. One
numbers the houses and selects at random one house the first
house. If no household number exists, one goes to the centre
of the community (churches, mosques, schools, market places
etc) and selects a random direction in which to proceed
(usually by a spinning a bottle). One then counts the number
of houses between the centre and the periphery of the selected
quarter and selects one house at random, this becomes the
starting house. The second household to be visited is the one
closest to the first (ie the household with the front nearest
door) and so on until you complete the required cluster
number. If any of the households contain more than one child,
it is advisable to include them all. The vaccination status of
each child is determined usually by card. Once all 30 clusters
have been finished one will have 210 or up to 300 children.
So, after this procedure we know where we are in terms of the
coverage of vaccination for the target group concerned.

What next? In addition to determining coverage survey allows

one to identify reasons for immunization failure. For all those
in the target group who are found not to have been completely
vaccinated, the mothers are asked to identify the major reason
why from the list below. The majority of the reasons have
been found to fall into one of these categories.

Table showing the common responses given by caretakers

when asked about the reasons for failure to be immunized.
They may be divided into three main categories:

1. LACK OF INFORMATION
1. Unaware of need for immunization

2. Unaware of need for return for second or third

dose

3. Place and/or time of immunization unknown

 4. Fear of side effects

5. Wrong ideas about contraindications

2. LACK OF MOTIVATION
1. Postponed until another time

2. No faith in immunization

3. Rumours

3. OBSTACLES TO IMMUNIZATION
1. Place for immunization too far

2. Time of immunization inconvenient

3. Vaccinator absent

4. Vaccine not available

5. Mother too busy

6. Family problem, including illness of mother

7. Child ill - not brought

8. Long waiting time

Challenges for EPI

Four of the commonest are:

Dropouts

Missed opportunities

Never reached despite having access

Lack of geographic access

1. Drop outs

A dropout is defined as a woman or a child who failed to

return for subsequent doses for which she or he is eligible.
Dropout rates are among the most important problems
countries are facing throughout the world in increasing
coverage rates. People start immunization and fail to complete
it for different reasons. WHO ( 1987) states that most
vaccination programs show dropout rates between first and
third doses of DPT/OPV of 20 - 40%, the main reasons being
lack of knowledge and difficulty of access to health facilities.
In Ethiopia, Tsegaye (1990) found a dropout rate of 25% for
childhood immunization in Ketena 2 of Addis Ababa.
Similarly Tolessa (1991) found that 180 (21.2%) children
surveyed in health institutions in Arrsi Region in 1991 were
defaulters. Worku (1994) found the drop out rate in Wolliso to
be about 32%. These studies found rates lower than the
national figure for defaulter rate which is between 40 - 45%
(Worku 1994).

Drop out rates are calculated as follows:

Over all drop out rate: Coverage with BCG - Coverage with
measles Coverage with BCG

Drop out rate for a single antigen ( OPV)

Coverage with OPV1 - Coverage with OPV3 x 100

Coverage with OPV1

There is a problem whenever the drop out rate is greater than

10%. It is essential to determine why the failure occurred.
This determination can be made through qualitative research
(focus group discussions with
community leaders, care takers and health workers). Another
useful method is the 75 Household Survey: a non random
survey of 75 households to determine reasons.

Frequent responses to questions concerning the reasons for

drop out are:

1. Health workers do not explain the need.

2. Unsure of dates to return

3. Long wait at the centre

4. Centre opens at inconvenient hours

5. Health workers nasty

6. Mother usually busy on other engagement

7. Family left the place for a while

8. Child developed side effects or was sick on the

appointed date
2. Missed Opportunities

Missed opportunities occur when women or children who

need immunizations are not immunized even if they are at the
health facility (for example if they are there to obtain curative
services). Current policy is that all people at a health facility
for any reason should be screened for immunization status and
vaccinated if eligible. The frequent occurrences of missed
opportunity for immunization are regarded as one of the
major problems in the delivery of immunization services.
Several clinic based studies have shown that missed
opportunities occur in high percentages of consultations.
Missed opportunities occur in two settings: 1. during visits for
immunization and other preventive services and 2. during
visits for curative services. In both cases, eliminating missed
opportunity has the potential to raise overall immunization
coverage in a population.

It was found in Mozambique and Guinea Conakry that missed

opportunities and inappropriately timed
immunizations subsequently reduced immunization coverage
achieved in these countries. In Mozambique 8% and in Guinea
Conakry 19% of the eligible children missed the opportunity
of being immunized. Missed opportunity studies in Ethiopia
are limited. Rates of missed opportunities have been found to
range from 35% to 47% ( Bekele 1994).

Based on information such as that presented above, UNICEF

has concluded that for all vaccines, and in almost all
countries, the two outstanding opportunities for increasing
immunization coverage in the next few years are to reduce
drop out rates and missed opportunity. Both could be
exploited at almost no extra cost and both depend on making
better use of existing resources rather than major new
expenditures. For all immunization programs, bringing the
child into contact with the clinic is more than half the battle.
Screening all children who present to clinics for whatever
purpose and either vaccinating them or referring them for
vaccination,
is therefore, a way of quickly increasing vaccination coverage
using existing staff and facilities.

Secondly, if all children who receive a first dose of vaccine

were to complete the full course, the 80% target would
already be reached in most countries.

To determine if there is a problem with missed opportunities,

it is important to talk to the community and observe health
service activities at the health facility. Also one can conduct
an exit survey at health facilities to find out the
immunization status of women and children as they have the
health facility. If they are eligible for vaccination, but have
not received it, the reasons can be determined.

Common causes for missed opportunities include:

1. Workers do not know the policy

2.Workers screen, but tell patients/people to return later

 3.Workers only vaccinate women with TT if they are
pregnant

4.Workers will only open a vial if there are enough

clients who need it.

5. False contraindications

6. Vaccine not available

7.Only one vaccine is given when more than one is

indicated

8.Mothers are not immunized when their children are

3. People never reached

These are people who never use the services provided for
reasons other than lack of geographic access. As mentioned
above, informal interviews and the 75 household survey may
be used to determine the reasons. Possible explanations
include:

1. Cost (including fees and transport)

2. People unaware of the services

 3. People unaware of the importance of the services

4. Time constraints (women headed households)

5. Cultural or ethnic barriers (beliefs, rumours)

4. Geographic barriers

A person has geographic access if he/she lives within a

reasonable distance of the services, or if there is outreach. It
should be possible for all countries to provide immunization
services to its population either through health facility or
through outreach. If any village does not have access to health
services or outreach immunization, there is a problem.
However, this too is not insoluble. In those countries where
distances are large and populations are scattered,
immunization campaigns can be used. For example, Brazil
achieved very high coverage rates and significant reduction in
morbidity and mortality by twice yearly immunization
campaigns.
The above four categories of causes of low vaccination
coverage have potential solutions. Once the underlying causes
are identified, possible solutions can be determined.

1. Social mobilization

2. Drop out or defaulter tracing mechanisms

3. Respond to community's need

4. In-service training for health workers and other

motivation mechanisms

5. Supervision and support

6. High level advocacy (use influential people including

other sectors)

7. Local immunization and supplementary immunization

program

8. Ensure financial and logistic supply

9. Get commitment by the local leaders

10. Monitor coverage periodically and carry out disease

surveillance continuously.
9.7. GROWTH MONITORING
Growth Monitoring (GM) has a long history. Baby weighing
was carried out as long ago as 1910 in Jamaica, and the Infant
Welfare Movement in the UK in the early 1920s used
volunteers to weigh babies and to provide advice on child
rearing to mothers. The concept of the under five clinic was
popularised in the 1960s by David Morley in Nigeria. He
developed a growth chart that was easier to use, and made it
the cornerstone for the assessment and treatment of under five
children.

In the 1970s, many programs adopted a shift of responsibility

for GM from the health service into the community, giving
as much emphasis to education of the community as to
health service delivery. When UNICEF announced GOBI
(GM, oral dehydration, breastfeeding, immunization) as its
operational strategy in 1982, the use of GM as a basic strategy
for child health programs was given an important impetus in
developing countries. Most programs suggest that children
under two years of age be weighed monthly,
and thereafter, quarterly. Most sever growth faltering occurs
in the first year of life and during weaning period.

Triple A Cycle:

GM can be seen as a measurement strategy for household and

community levels whose aim is to provide data for
assessment, analysis and action (Triple A). An
assessment is made through weighing the child; an analysis
is made through comparing the child's weight with the weight
during the previous weighing and if weight loss or retardation
of growth is observed; the care giver is counselled about
possible causes and suggestions are made about more relevant
actions. Ideally, these actions are feasible and are taken by the
care giver at the household. After some time, the child is
weighed again - a reassessment is made, followed by new
analysis and new actions as necessary.
Rationale for GM

Growth charts can be seen as useful for three purposes:

1.Screening: to assist health workers to diagnose children who

are suffering from or in danger of suffering from
malnutrition and to select those children who are seriously
malnourished and may need treatment and/or referral.

2. Education: to assist health workers to educate mothers

about child growth and nutrition.

3. Evaluation of nutrition programs and interventions.

The Triple A process is the basis for the use of GM. But
what happens in reality is the process has many steps. The
theoretical pattern is as follows:

Assessment: The caregivers and children arrive, are

registered, the child is weighed by one worker and the weight
is recorded usually by another.

Analysis: One of the workers, usually the most senior is

supposed to look at the chart, determine whether there
is a problem, examine the child if indicated, and provide an
intervention if required.

Actions: If it is determined that an intervention is indicated,

one of the following applies: treatment, counselling, referral
or some combination of the above.

In the experience of many countries, GM programs limit

themselves to the first A - Assessment. Children are weighed
and charted, and the process stops there.

In 1985, the first comprehensive review of the operational

experience of GM was published. Since then, a number of
other critical appraisals of GM programs have appeared in the
literature.

The concerns in terms of the above stated three purposes for

GM are as follows:

Screening

Screening tests are designed to discriminate between people

who are likely to have a condition and those who are unlikely
to have it. Screening is useful only if the clinical outcome for
persons picked out by screening is
better than it would have been, had the persons not been
screened. The potential benefit of anthropometry as a
screening tool lies in its ability to predict a child's risk of
future morbidity and mortality so that steps can be taken to
prevent these problems.

Is this being done in GM programs? A number of

problems have been found:

Lack of sufficient supply of charts frequently hampers

successful implementation of GM programs.

Poor recording: GM is relatively simple in concept, but

difficult to use; there are frequent inaccuracies. A common
source of error occurs when workers fail to leave a blank
space for each month the child has not been weighed, giving a
falsely optimistic impression of the child’s growth. A postal
survey of 322 health personnel in over 50 countries (in
Gerein, 1988) who had used growth charts for at least 4 years
in their programs found significant problems with various
aspects of the process:

78 % determining the month of birth

 49% plotting the weight

43% interpreting the weight curve

30% weigh correctly.

The difficulties with interpretation are myriad. Much of the

program based on the concept of graphical representation of
figures and often workers have no capacity to visualize or
analyse in this way. Workers have difficulty understanding
what it all means and also difficulty with the concept of trend.
In a study in Indonesia, 40% who had not gained weight were
classified as gaining and 20 who had gained weight as losing.

Establishing the reasons for growth faltering is usually done

by questioning the care giver and examining the child.
However, Nabarro and Chinnock suggest that the reasons for
growth faltering may be too complex for health workers to
understand.
Thus, though growth charts may be theoretically a useful
diagnostic tool, in practice all the evidence indicates that they
often lead to the wrong diagnosis.

More importantly, what might happen in the majority of the

cases when remedial action is indicated, often no action is
taken. For example, in a study of three programs in Zaire,
30% of children with weight loss or inadequate weight gain
received no intervention.

Education

The second purpose for which growth charts are employed is

in education, to teach mothers about the relationship between
food and growth, and how they can improve the nutrition of
their children. However, for growth cards to be an effective
educational tool, several factors are necessary. The diagnosis
of the child as malnourished should be accurate, health
workers need to take time to talk to individual mothers if their
child is found to be malnourished or having growth faltering,
and mothers must understand what is signified by the growth
chart. Finally, once they have received the nutrition advice,
mothers must put it into practice.

Unfortunately, in a number of places, there is evidence that

none of these stages are successfully implemented. As
discussed above, a large percentage of all children are
misdiagnosed. Even if correctly diagnosed, it is very unlikely
that the mothers will be given any nutritional advice. A study
of MCH clinics found that 71% of the consultations took less
than 2 minutes. In this time, the child was weighed, examined,
vaccinated and treatment was given. In only 10% of all
children seen was nutrition advice given, and the advice was
usually non specific e.g.: “eat more greens". Thirdly, there is
good evidence that mothers do not understand the meaning of
growth charts. Two studies found that only 6% and 34% of the
mothers were able to correctly identify a “good" growth chart
as indicating good development as compared to a "bad" chart.
The 34% figure relates to educated urban mothers.
Finally, there is evidence that nutrition education does not
lead to improved nutrition of their children. Studies in Papua
New Guinea have shown that while mothers are usually aware
of the correct feeding practices as taught by MCH programs,
they still tend to follow traditional feeding practices. But if
they did follow the messages that they have received, there
is evidence to suggest that poverty and maternal malnutrition
leading to low birth weight and poor milk supply are more
important factors. If this is the case education of mothers on
how to feed their children will have little effect.

Evaluation of programs

In theory, GM could be an effective means by which to

evaluate community nutrition and PHC programs. In reality,
evaluation is rarely carried out, and in addition, the reliability
of the data collected through GM is often too poor to be used
to reliably evaluate programs.
UNICEF has recently evaluated GM programs worldwide. In
addition to the above problems, the evaluation showed:

 Lack of time for mothers to carry out advices,

especially during harvest seasons.

 Lack of knowledge in preparing energy dense

foods.

 Lack of variety on winning foods.

 Nutrition advice too general and/or simplistic and/or

prescriptive.

 Some mothers have problems following advice, due

to lack of money, time and food.

 Health workers do not share analysis with mothers

and often behave in unpleasant manner.

 No physical exam carried out during GM and no

referral made.
 REFERENCES

 International Conference on Population and Development

Programme of Action. May 13, 1994:
http://www.unfpa.org/icpd

 WHO. Reproductive Health Report by the Secretariat.

Fifty Seventh World Health Assembly. April 15, 2004

 Global Health Watch 2005-2006. An Alternative World

Health Report pp. 134-146

 Anna Glasier, A Metin Gülmezoglu, George P Schmid,

Claudia Garcia Moreno, Paul FA Van Look. Sexual and
reproductive health: a matter of life and death. The Lancet
2006;368: 1595-1607

 Guillermo Carroli, Cleone Rooney, and Jose Villar. How

effective is ANC in preventing maternal mortality and
serious morbidity? An overview of evidence
 Safe motherhood fact sheets. FHI. 1999

 www.rho.org (safe motherhood)

 EDHS 2005

 Antenatal care in developing countries: promises,

achievements and missed opportunities: an analysis of
trends, levels and differentials, 1990-2001. WHO and
UNICEF, 2003

 The Lancet Maternal Survival Series. 2006

 Investing in Maternal Health

 Two Decades of the Safe Motherhood Initiative. Obstet

and Gynecol 2007

 WHO. Unsafe abortion. Fifth edition, 2007

 The Lancet Series on SRH. Unsafe abortion, 2006

 UN. World Abortion Policies, 2007

 Lancet Series on SRH. Family planning: an unfinished

agenda
 Men’s surveys. New findings. Population Reports 2004,
Series M, Number 18

 The Reproductive Revolution Continues. Population

Reports 2003, Series M, Number 17

 Jane T. Bertrand, Robert J. Magnani, Naomi Rutenberg.

Handbook of indicators for FP program evaluation.
December 1994

 Judith Bruce. Fundamental elements of the quality of care:

a simple framework. Studies in FP. 1990, Vol. 21, No.2.
pp 61-91

 Saumya RamaRao and Raji Mohanam. The Quality of

Family Planning Programs: Concepts, Measurements,
Interventions, and Effects. Studies in Family Planning.
2003; 34[4]: 227–248

 RTIs. RHO (www.rho.org)

 STI Fact Sheet 2004

 Lancet SRH series 5: Global control of STIs, 2006

 WHO. Prevention and Control of STIs: draft global
strategy. May 2006

 WHO. Sexually transmitted and other reproductive tract

infections. 2005

 WHO. Training modules for the syndromic mx of STIs.

2nd edition

 Heise LL, Ellsberg M, Gottemoeller M. Ending Violence

against women. Baltimore, MD, Johns Hopkins
University School of Public Health, Centre for
Communications Programs, 1999 (Population reports,
Series L, No.11)

 Krug EG et al., eds. World Report on Violence and

Health. Geneva, World Health Organization, 2002

 Reproductive Health Outlook. Gender and Sexual Health

(www.rho.org)

 Adolescent Reproductive Health. Reproductive Health

Outlook (www.rho.org)
 The Lancet Series on SRH. Sexual behavior in context.
2006

 Factors that shape young people’s sexual behavior:

systematic review. Lancet 2006

 National PMTCT guideline 2007/2008, MOH.

Ethiopia
Reproductive Health

ANNEX

408