Dr. K. Sivapalan. Chairman, section C.

1. REPRODUCTIVE HEALTH ,dg;ngUf;f MNuhf;fpak;. Dr. K. Sivapalan. Chairman, section C. Reproductive Health

2. Definition • Reproduction is, “production of further individuals LIKE ONESELF or itself by sexual or asexual means”. • Reproductive Health is defined by the World Health Organization as, “a condition in which reproduction is accomplished in a state of complete physical, mental and social wellbeing and not merely as the absence of disease or disorders of the reproductive process”. Reproductive Health

3. Importance of Reproductive Health • Sexual and reproductive health is at the centre of human dignity, relationships and well-being. • The private nature of sexual and reproductive health does not diminish its significance on the lives of men and women in every culture. • Every where in the world sexuality and sexual behaviour have profound consequences on individuals, families, and societies. Reproductive Health

4. Magnitude of Reproduction Related Problems in the World. • Over 100, 000,000 sexual intercourses every day. • 910,000 conceptions and 356,000 Sexually Transmitted Infections occur daily. • 452,000 (50%) of these pregnancies, are unwanted. • 150,000 unwanted pregnancies are terminated: • Pregnancy related problems cause 1370 maternal deaths in the world daily. [Illegal abortions 500 /day] • Many escape with physical and mental injuries. • 25, 000 infants and 14,000 children die each day. Reproductive Health

5. Objectives Of Reproductive Health Programmes: • To have the capacity for healthy, equitable and responsible relationships and experience healthy sexual development. • To achieve their reproductive intensions – the desired number and timing of children – safely and healthfully; • To avoid illness, disease and disability related to sexuality and reproduction and receive appropriate counselling, care and rehabilitation when needed; and • To avoid injuries related to sexuality and reproduction and receive appropriate counselling when needed. Reproductive Health

6. Sexual Health Of Men And Women [Sexuality] • Mutually fulfilling sexual relationship is important for mental health of men and women. • When sexual act take place, the joy should be shared equally by both, the man and the woman • If it involves anger, violence, coercion, abuse or rape it can have serious consequences on the partner and the child conceived. • Sexuality can be affected by the environment, mental state, physical state and social state. • Sexuality is often surrounded by strict social, moral, and religious beliefs. Reproductive Health

7. Defects in Sexuality. For Men, • Erection and Ejaculation: • Physical or psychological. For Women, • Relaxation of vaginal sphincter: • Physical or psychological. False beliefs and taboos about sex exist and therefore behavioral problems must exist. The effect of war and displacement on our people’s sexuality? Reproductive Health

8. Genital Mutilation. • Females: • Circumcision- excision of clitoris. • Excision of genitalia leaving only the opening of the vagina. • [Cruel attempts to avoid promiscuity.] • Males: • Circumcision. • [reduced incidence of cervical cancer] • ? Infection, mental trauma. Reproductive Health

9. Other Problems. • Adolescents: • Sexual feelings Vs delayed marriage. • Challenge to cultural norms. • Persons with excessive or diminished sexuality. • Mental, physical or other factors. Reproductive Health

10. Reproductive tract infections • Neglect of personal, sexual and menstrual hygiene causes infections. • Sexually transmitted infections: direct contact of infected reproductive organs with that of the partners [rarely blood transfusion, indiscriminate use of injection needles]. • These include, bacterial infections like syphilis, gonorrhoea, and chlamydiosis, protozoal infection like tricomoniasis, and viral diseases like AIDS, genital herpes and genital warts. • Some diseases cause local discomfort, some serious consequences if not treated, AIDS kills [no treatment]. • CONCERN: People delay or fail to obtain appropriate treatment. Reproductive Health

11. Prevention of Sexually Transmitted Diseases. • One man - one woman as sexual partner [family] will eliminate almost all possibilities of spread. • Use of condom prevents direct contact and avoids infection if intercourse with infected partner. • But lack of knowledge, discomfort, carelessness and several other factors lead to non use of condom. • Sex workers and casual sex seems to be the main causes of the spread of these diseases. • Educate all those indulge in sex about safe sex and the importance of prevention of STD- AIDS. • Early detection and treatment of STD. Reproductive Health

12. Fertility Regulation • ? Fertility is a natural phenomenon and whether we have the right to interfere with it. In the past • Reproductive tract infections, pregnancy wastage and other factors caused reduced fertility. • High child mortality also necessitated high fertility. Now, as a result of improved health care, fertility and child survival have increased. Fertility regulation has become a necessity. Reproductive Health

13. Perspectives Of Fertility Control • Population summit of the world’s academics in 1993: If the population grows as predicted and human activity remains unchanged, science and technology may be powerless to prevent widespread poverty and irreversible damage to the environment. • Prevention of unwanted pregnancy while maintaining sexuality. • Increasing the time space between pregnancies. • Empowerment of women to take charge of their lives, pursue carriers for economic development, and contribute to society as men Reproductive Health

14. Factors Affecting Fertility Regulation • Attitudes favouring high fertility [value of women is determined by the number of children she has] • Men dominating in decisions about fertility regulation and choice of contraceptives. • Disadvantages of contraceptive methods causing failure or rejection. • Lower fertility rates are associated with employment, education, urban location , land shortages, increased costs of child rearing, late marriage and participation of women in decision making. Reproductive Health

15. Knowledge And Attitude Of Local Population About Fertility Regulation Mothers at antenatal clinic at teaching hospital, Jaffna with more than 3 children, • 80 % felt that they should have used contraceptive methods. • 49 % had objections from relations. • 28 % had objections from husbands. • 25 % felt that contraceptives are bad for health. • 25 % had no access to family planning methods. • 20 % family planning is against religion [Muslims]. • 17 % wanted to have more children. [Muslims] Reproductive Health

16. Knowledge and attitude about Contraceptives Study on MALE school teachers in Jaffna: • 29 % had adequate knowledge, • 47 % had moderate knowledge and • 24% had no knowledge. • Among the married teachers only 31 % had adequate knowledge. • Of the married, 66.5 % had followed contraceptive method and 37 % of them had given it up due to various reasons • 90% thought that family planning will reduce economic burden. • 57 % considered that it is good for maternal and child health. Reproductive Health

17. Indigenous Medical Practitioners About Contraceptives. • 53.1% did not accept family planning as a necessity; • 78% prescribe family planning methods. • Their knowledge was grossly inadequate. • Inadequate knowledge in the society. Reproductive Health

18. New Developments In Fertility Control • Vaginal hormonal implants which can be removed when bleeding is desired • Anti progesterones as post ovulatory and post coital contraceptives. • Condoms made of new polymers- to permit better transmission of physical sensation. • Transcervical methods for female sterilization- permanent or removable block. • Simplified techniques of vasectomy. Reproductive Health

19. Problems in Funding Research Reproductive Health

20. Impact Of Environment On Fertility • Effects of environmental factors: sub fertility, intrauterine growth retardation, spontaneous abortion, and various birth defects. • Infectious diseases, malnutrition, and poor living conditions are important in developing countries. • Chemical pollution, radiation and stress have become major threats in developed countries • Average sperm count was 113 million/ml in 1940 and 66 million in 1990, and the volume of the semen was 3.4 ml and 2.75 ml respectively Reproductive Health

21. Infertility • 60-80 Million couples are infertile worldwide. • Only 3-5 % is core infertility . Rest – acquired and therefore, preventable. • Acquired causes of infertility: • Reproductive tract infection by a variety of organisms; commonly sexually transmitted. • In Females pelvic infections or reproductive tract infections after abortion or child birth. • Husband, wife or both could be infertile. Reproductive Health

22. Infertility ctd. • Alcohol is associated with oligozoospermia, poorly motile, abnormal sperms, Impotence. • Stigma of infertility often leads to marital disharmony, divorce, or ostracism [of the wife]. • In most couples defects can be corrected and they could have normal conception. • When it fails, assisted fertilization can be of help [success rate is only 33% at present]. Reproductive Health

23. Health Of Pregnant And Lactating Mothers [Safe Motherhood] • Pregnancy is not a disease. It is a physiological state for the family and survival of the society. • Every year, about 30 million mothers develop complications, which are fatal in 515,000 cases. • This represents the greatest disparity between developed and developing countries: 99 % of the maternal deaths occur in developing countries • Maternal mortality remains high in all countries of the South Asian region except in DPR Korea, Sri Lanka and Thailand. Reproductive Health

24. Prevention of Complications and Deaths Related to Pregnancy • Proper antenatal and post natal care and nutrition can prevent most of the ill health and complications. • Preparedness to face any obstetric emergency could save more lives of mothers and babies. • Identifying at risk mothers at the Primary Health Centres and hospitalising them early and • making good transport facilities from rural areas to the hospital in case of unexpected emergencies • Positive and negative aspects of traditional practices of caring mothers and babies need investigation. Reproductive Health

25. Unwanted Pregnancies and Abortion. • As mentioned earlier, about 50 % of all pregnancies are unwanted. Causes of an unintended pregnancy: • Lack of access to, or failure to use, a contraceptive method or failure of the method itself. • Forced sexual intercourse and male dominance in matters of sexuality and reproduction may be indirectly involved in many cases. Reproductive Health

26. Problems of Unwanted Pregnancy • Mortality, morbidity and suffering [economic, physical and mental] • Burden on health resources of poor countries when women seek abortion as a solution. • Addition of unwanted persons into the society. Reproductive Health

27. Induced Abortion. • Where it is illegal, complications of abortions are serious infections, haemorrhage, and death. • Where abortion is legal, safely performed abortions also carry minimal risks: • injury to the cervix or uterus, • haemorrhage, • incomplete evacuation, and • pelvic infection. • Research is going on to develop chemical induction of abortion without any harm. Reproductive Health

28. Induced Abortions Admitted to Teaching Hospital Jaffna. In 1991 • 23 % were induced. All were women with 3 or more children. All of them were infected. In 1998, • 28.3 % were induced. Of these,11.76 % were unmarried. Reproductive Health

29. Legality of Induced Abortion. • Induced abortion: • should it be legalised for safety of the sufferer? or • prohibited for moral issues and risks involved? • GOSL prohibits; but people consider it as legalised. • LTTE has legalised: • Within 12 weeks of amenorrhoea provided that it is done by a qualified doctor. Reproductive Health

30. Child survival • In the world as a whole, child mortality (per 100,000 births) has declined from 165 in 1970 to 105 in 1990. • 33% die in the 1st month, 33% 1 – 12 months and 33% 1 - 5years of age. • Many deadly diseases have been controlled by vaccination and improvements in health care. • Child mortality continues to fall. But, • Malaria proves to be difficult to combat. HIV/AIDS threatens to offset the gains of the child survival programmes. Reproductive Health

31. Other factors affecting child survival • Avoiding breast feeding • Short spacing between children • Teenage motherhood • Low birth weight • Foetal tobacco syndrome [50% of the still births associated with smoking fathers] • Foetal alcohol syndrome. • Non availability of health services. Reproductive Health

32. Birth weight in Jaffna. • Mean birth weight in the Teaching Hospital Jaffna was 2.884 Kg in 1990. [Sri Lankan value 2.990] • 21.6 % of the babies were born with low birth weight [Sri Lankan value 23.8%] • The number of low birth weigh babies is a serious concern. Reproductive Health

33. Child development: Rights of the child. • Children, because of their vulnerability, need special care and protection. • Full and harmonious development requires: family environment, atmosphere of happiness, love and understanding . • Rights: Survival, Health, Education, Development, Evolving capacities, Name, Nationality, Preservation of identity and respect to their opinion etc. • Freedom of expression, association, protection of privacy, and access to appropriate information. Reproductive Health

34. Problems of child Education. Absenteeism among secondary school students: • priority not given to education- 39.3% • illness of student- 24.5% • illness of others in the family- 7.6% • inadequate facilities- 9.48% • necessity to work- 8.58 % • no proper teaching in school- 4.83% • insecurity- 3.2% Reproductive Health

35. Child Abuse – Study in Galle. Abusers of 18.5 % boys [of 474 studied] were: • neighbors 27, older women 19, relations 23, Brothers 5, priests 5 and teachers 4. Abusers of 4.6 % females [of 420] were • Uncles, brother in law, and enemy; • Many girls did not mention the abuser which suggest that it might have been the immediate family member [incest]. 5.6 % of the males have abused others [most of them abused as children] Reproductive Health

36. Child Abuse Among Tamils. • Among the medical students in the university of Jaffna, 22.8 % were abused as children; 55.1 % of them were abused sexually • Knowledge about child abuse was adequate among primary school teachers in Jaffna. • 10 % of them were abused as child, by parents, teachers or principal. • The abused teachers had POSITIVE ATTITUDE about child abuse Reproductive Health

37. Vicious Cycle of Child Abuse. • Prevalence of childhood abuse among promiscuous individuals was greater than the normal population. • Pedophilic activity was high among those who were abused in childhood Reproductive Health

38. Harassment Among GCE O/L Completed Students [150 males, 150 females]. Reproductive Health

39. Adolescent Health. • Sri Lanka and Thailand have brought down maternal mortality rate and achieved a high contraceptive prevalence rate. • Therefore, the reproductive health programmes are focussing on development of adolescent health services Reproductive Health

40. Sexuality of Adolescents. • For adolescents in several countries, knowledge about reproduction and contraceptives were low or incorrect. • Knowledge does not translate automatically into practice of safe sex. • Lack of knowledge does not mean that young people will abstain from sexual intercourse • Large numbers of adolescents become sexually active before marriage. Reproductive Health

41. Consequences of Adolescent Sexuality • Immature reproductive tract is easily infected. • Adolescent pregnancy, abortion and disease • As a result, a young woman may face: • interrupted education, • undesirable marriage, • social stigma, • health dangers, • infertility and • death. Reproductive Health

42. A Mexican study on pregnant girls • Girls who choose abortion continued their studies and were assertive • Those who continued with pregnancy discontinued studies or stopped working. • They continued with pregnancy because they did not have enough money. • They tried self induced abortion by injection of different drugs, tea infusions, eating quinine tablets, engaging in heavy physical activity and so on. Reproductive Health

43. Knowledge And Attitude About Sex Among Adolescents In Jaffna. • Boys knew more about contraceptives than girls even though inadequate. • 10 % of A/L students thought that woman can conceive by kissing, touching etc. • In the college of education 50 % of the females avoided talking about sex because shyness but 15.4 % males and 2.8% females had premarital sexual intercourse. • Most female undergraduates, including Medical, had inadequate knowledge. Reproductive Health

44. Sexual Stimulation And Out Let. • 58 % of arts and 73% of medical students in the UOJ consider that novels and films are major source of sexual stimulation. Reproductive Health

45. Prevention of Adolescent Sexual Activity. • Adolescents indulge in sex because of lack of sports and other facilities. • So providing adequate facilities for recreational activities will lead to development of more healthy, respectable and responsible younger generation. Reproductive Health

46. Sexual violence during adolescence It invokes, • a sense of vulnerability and powerlessness • shame, guilt, fear of sex, and • inability to distinguish affection from sexual exploitation Reproductive Health

47. Teenage Pregnancies And Marriages When women who had their first pregnancy at teen age and attended the teaching hospital were studied (in 2002): • 6% were unmarried; and • 7.9% conceived before marriage. • 56.2 % eloped but now have parental support. • 87.1 % had no idea of contraception before becoming pregnant. Reproductive Health

48. Teenage Pregnancies And Marriages 47 females who married before the age of 20 in two villages near Jaffna (in 2002): • Only 24 were legally married. • 10.7 % proposed; and 89.3 % were love marriages. • 54.8 % met their partner on displacement, 23.8 % were school love, others started love while living in same place etc. • 38.5 % were involved in premarital sex and 19.3 % conceived before they were married. Reproductive Health

49. Domestic violence and Sexual abuse • The World Conference on women, held in 1995, advanced the idea of women’s fundamental human right to reproductive and sexual self-determination. • Violence against women is defined as “any act of gender based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women”. • Wife beating, rape, or sexual abuse is increasingly recognized as major social and public health problem. Reproductive Health

50. Sexual Abuses All acts of violence against women sexual and other that are perpetrated by non family members. • Sex selective abortion, • Forced sex by dating partners, • Sexual assault by strangers, • Female genital mutilation, • Violence against women in conflict situations and among refugee populations, • Trafficking in women and forced prostitution. Reproductive Health