Family and Reproductive Health

Family and Reproductive Health:

Are We Utilising the Linkages?

November 2004

Jay Satia

International Council on Management of Population Programmes (ICOMP)

For presentation at World Family Summit

Sanya, China, 6-9 Decemeber 2004

Organized by

The National Population and Family Planning Commission, China

And

World Family Organization

Family and Reproductive Health: Are We Utilising the Linkages?

Abstract

Family size, structure, composition and well-being are intimately related to reproductive health (RH) and RH status is dependent on socio-economic status of the family as well as the decisions that they make. However, the importance of these linkages are inadequately recognized and their potential for improvement in RH and family well-being has not been realised.

There is considerable diversity in RH status including fertility, maternal mortality and adolescent RH. Generally, fertility is declining but in many developing countries fertility rates are still too high, which adversely affects family economic status. On the other hand, many developed countries are experiencing fertility rates below replacement level. A response is to have family-friendly policies and programmes in both of these settings. Maternal mortality rate has generally not declined significantly during the last decade with the exception of some countries. The family members have an important role in birth-preparedness to reduce maternal deaths. The ability of parents to fulfil their roles and responsibilities for adolescent RH needs to be enhanced if the rates of teenage pregnancies and HIV/AIDS are to be reduced.

In addition, family needs to function as a nourishing unit for its members rather than as an oppressive and exploitative unit. In many cultures, patriarchal decision making has subjugated women’s rights, which leads to persistent acts of domestic violence against women and growing vulnerability to HIV/AIDS.

Several measures jointly addressing family well-being and RH have shown some success. These include involving men in RH, couple counselling, parental birth-preparedness, sexuality education for parents to address adolescent RH, and family development. Clearly much more needs to be done both to improve family well-being and RH. And a more co-ordinated approach to both can accelerate progress towards achieving ICPD and MDG goals.

Introduction

Family and RH are intimately related. However, there is considerable diversity among countries both in terms of family structure and composition and RH status. As we discuss the linkages between family and RH, there is a need to keep this diversity in mind.

To provide a frame of reference, we use the ICPD Programme of Action (POA) (United Nations, 1994) for both its call for attention to family and RH.

“While various forms of family exist in different social, cultural, legal and political systems, the family is the basic unit of society and as such is entitled to receive comprehensive protection and support. The process of rapid demographic and social change throughout the world has influenced patterns of family formation and family life, generating considerable change in family composition and structure. Traditional notions of gender-based division of parental and domestic functions and participation in labour force do not reflect current realities and aspirations, as more and more women in all parts of the world take up paid employment outside the home. At the same time widespread migration, forced shifts of population caused by violent conflicts and wars, urbanization, poverty, natural disasters and other causes of displacement have placed greater strains on the family, since assistance from extended family support networks is often no longer available…” (ICPD POA paragraph 5.1)

ICPD POA affirms: “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 relating to the reproductive system and to its functions and processes.”

It elaborates

“Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproductive and the freedom to decide if, when and how often to do so. Implicit in this last condition are the rights of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice of regulation of their fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and nor merely counselling and care related to reproductive and sexually transmitted diseases.” (ICPD POA paragraph 7.2,)

Thus, RH services have most commonly focused on family planning, maternal health, adolescent RH, and reproductive tract infections (RTI)/Sexually transmitted infections (STIs)/HIV/AIDS. Using a life cycle approach to RH, it would also include violence against women, menopausal services and reproductive cancers. Gender is considered as a very important cross cutting issue. Figure 1 provides a conceptual map of RH. In this figure, the map is flat, simply moving through the stages of life. But, as the authors point out, the map can also be imagined in layers. If Figure 1 depicts the base layer as a framework including processes, events and outcomes, we can also imagine superimposed on it a multidimensional complex layer of social and institutional arrangements that will influence the way in which the different stages in the map are experienced. These social and institutional arrangements include intimate and family relationships; community institutions such as schools, religious institutions, media and the market; preventive and curative health care services; as well as governmental institutions including the laws and policies they are responsible for implementing (Cottingham et al, 2002 and Freedman et al, 2004).

Figure 1: Conceptual map of sexual and reproductive health

Source: (Cottingham and Myntti 2002)

Therefore, the social context of the particular population should be carefully considered if the RH status of the population must improve. For instance, Adepoju (1997) has argued that the family is a vital but missing aspect of the search for a way out of the complex problems confronting countries in the sub-Saharan Africa. The link between the family and RH problems is crucial in this regard. The family stands as the locus of RH decision-making. Neglecting the family in the search for solutions to RH situation may be tantamount to inability to devise testable means of escaping the current situation (Onipede et al, 2004).

Family and Reproductive Health

Family and Fertility

The ICPD consensus recognized that enabling couples and individuals to freely determine the number, timing and spacing of their children would speed progress towards smaller families and slower population growth, contributing to economic growth and reducing poverty, at both household and macro levels.

High fertility impacts on a family’s poverty in several ways:

• Smaller families share income among fewer people, and average income per capita increases.
• Fewer pregnancies lead to lower maternal mortality and morbidity, and often to more education and economic opportunities for women.
• High fertility undermines the education of children, especially girls.
• Families with lower fertility are better able to invest in the health of each child, and to give their children proper nourishment

Conversely it is understood that not addressing needs and major gaps in RH would help perpetuate high fertility, high maternal mortality and rapid population growth, undermining poverty prospects (UNFPA, 2004).

Family’s economic status affects the use of modern contraception, as seen in table 1 (Gwatkin, 2004).

Table 1. Coverage of modern contraception by wealth

Region/Country / Coverage rate in lowest 20 percent / Coverage rate in highest 20 percent
Africa/Tanzania / 5.6% / 32.1%
Latin America/Peru / 36.8% / 58.0%
S. Asia/India / 23.8% / 55.2%

The fertility has been declining almost everywhere. In the poorest countries, however, a very rapid population growth persists, and it is undeniably a hindrance to national economic development as well as a degradation to environment (Sachs quoted by Crosette, 2004). While globally, the world has experienced dramatic declines in fertility – from a TFR of 5.0 in 1960 to 2.7 in 2001 -- still an estimated 134 million women who wish to space or limit their childbearing do not have access to effective contraception that would enable them to do so. The result is approximately 70 to 80 million unintended pregnancies each year in developing countries alone (Singh et al, 2004 and WHO, 2004). Family-friendly policies are needed to address high fertility, which would include girl child care and education, pre-martial counselling, family income-generation support, family counselling and comprehensive RH services with quality of care.

In many developed countries, on the other hand, major transformations have taken place in the role and structure of families, brought about by both gender and economic changes. Fewer marriages, declining fertility rate and family size, and growing incidence of divorce, have changed the realities of families. For instance, in Singapore, the TFR has declined to 1.25 in 2003, and the general divorce rate (the number of divorces and annulments granted to those 20 years and above during the year, out of every thousand married residents in the same age category) doubled from 3.8 to 8 during the period 1980-2003. In 2003, the mean age at first marriage for non-muslim brides was 27.5 years and for muslim brides was 25.2 years. Meanwhile the dual income families were 43 percent of all families in 2003. Thus, family institution is facing increasing challenges. Efforts to support families to face these challenges include promoting family-friendly work practices, facilitating the development of good quality services to meet the changing needs of families and young children, public education, extended paid maternity leave, use of insurance for pre-delivery expenses, and enhanced baby bonus. Schools and work places offer family life education and counselling to support marriage is offered by many organizations. (Seh, 2004).

Thus, both high and low fertility have serious consequences for the society as a whole. Family friendly policies, albeit of different nature, are needed in both settings.

Maternal Health

Progress in reducing maternal mortality has been even more elusive. Despite 15 years of the Safe Motherhood Initiative, overall levels of maternal mortality are generally thought to have remained unchanged, with the latest estimate of deaths standing at approximately 530,000 per year (WHO, UNICEF et al, 2003). More than 60% of maternal deaths occur after the baby has been born (Starrs A et al, 2004). When a new born’s mother dies, that baby faces a much higher risk of death – as much as 10 times higher than one with a living mother. When mother dies consequences can also be profound for older children and other family members, who lose their primary caretaker. By a rough estimate, therefore, every year there are 530,000 families which lose their primary caretaker.

Maternal deaths have not declined significantly in any region during the last decade, although some countries have made progress. Women and new-born need timely access to skilled care during pregnancy, child health and the post-partum/new-born periods. Too often, however, their access to care is impeded by several delays – delays in deciding to seek care, delays in reaching care and delays in receiving care. These delays are present for many causes, which include logistical and financial concerns, unsupportive policies, and inadequate services, as well as low community and family awareness and knowledge about maternal and new-born health issues.

Much of the current attention to reduce maternal deaths is on providing skilled birth attendants and having adequate number of health facilities that can provide care for complications of pregnancies. However, attention to the role of family in birth-preparedness[1] is inadequate, even though its importance in birth preparedness is recognized, linked to reducing maternal deaths. As an example in Thailand, Asia, it was pointed out that a dialogue on safe motherhood does not often include the voice of women, families and communities. Without their involvement, interventions may not meet the needs of the people for which they were designed. (MNH, 2004). In Zambia, Africa, participants in a workshop recognized the need to get accurate information to families and communities and the importance of ensuring that appropriate supplies and staff are available at health facilities.

RH services are centrally important for women, especially poor women (Gwatkin, 2004). This inequity is perhaps the most visible for skilled birth attendant at delivery as seen from Figure 2. (Ruari et al, 2003).

Figure 2.

The nutritional anaemia is a serious cause of maternal morbidity. The prevalence of anaemia varies greatly among and within countries and is often related to poverty. By some estimates, levels among pregnant women reach 70 percent in South Asia. In sub-Saharan Africa outside of South Africa they exceed 40 percent. Anaemia often develops among girls in adolescence due to poor nutrition and the demands of growth and menstruation. Therefore, the role of family in differential allocation of food between girls and boys has an important bearing on the persistence of anaemia among pregnant women. Anaemia in pregnancy contributes to maternal death and disability, premature births, low birth weight and fetal impairment. The resultant reduction in women’s productivity places an economic burden on their families, communities and societies. (PAI, 2001).

Therefore, all stakeholders – policy makers, programme managers, providers, communities, families and pregnant women – need to be involved in policy and programmes if maternal mortality is to be reduced significantly.

Adolescent RH

Ensuring the health and well-being of the world’s adolescent and young people, equipping them with life skills, and creating educational and employment opportunities for them is a fundamental necessity in meeting the development challenges of the 21st century (UNFPA, 2004). The ICPD gave unprecedented attention to adolescents’ diverse needs with regard to RH, as both a human rights priority and practical necessity. This has become even more critical as nearly half of the new HIV infections are among the young people. The ICPD framework recognises that parents have the right and responsibility to guide their children in matters related to their reproductive and sexual health. Although it emphasises that these rights should not overshadow those of adolescents to make their own decisions (Kowalski-Morton, 2004).

Several factors influence the RH outcomes. Research from the United States has found that programmes that identify and when possible, modify the social context that influences young people’s lives are more likely to improve health (RHO 2004). The contextual factors include individual, household, family, peers and partners institutions, and community. Education and economic level of family, family attitudes and harmonious relations with family were the family variables. A study in Ghana echoes these findings and concludes that, “adolescent behaviours are influenced by a large number of factors operating at several levels (individual, family, community and society). Because of the number and diverse nature of factors related to adolescent behaviours, it is unlikely that a single “magic bullet” intervention will be found to markedly change adolescent sexual risk-taking in Ghana (or elsewhere)” (Ali et al, 2000). Therefore, programmes that involve youth, community leaders, and parents can identify programme’s goals and needs more effectively and can ensure broad community support.

The above mentioned Ghana study found that

• Communication with family members regarding avoiding and delaying sex was associated with a lower likelihood of ever having had sex for youth of both genders and, among females, with fewer lifetime sexual partners and a higher likelihood of having used a condom at first sex.
• Communication with family members regarding use of contraceptives was associated with a higher likelihood of condom use at last sex and consistent condom use with one’s current partner.
• Higher levels of perceived support from family members regarding use of contraceptives was associated with a higher number of lifetime sexual partners for male respondents.

In most cultures, however, parents do not communicate with their children on issues regarding sexual and RH, although generally more mothers are able to and do talk with their daughters. Young people do talk with their parents when they feel they can, and when parents and communities support the provision of sexual and RH services and information to adolescents. We will later discuss sexuality education programmes for parents.

Discriminatory Family Decision Making

While influence of family on RH is critical, family is many times seen as an oppressive unit rather than as a nourishing unit. Family decision making structures are often inequitable. As a result of the patriarchal nature of many societies, male dominance is perceptible in virtually every sphere of life. The consensus among scholars in this area of knowledge is that there is unequal power relation between men and women in the family, and that men, being heads of households, act as the major decision-makers while their female counterparts play compliance roles (Onipede et al, 2004). Looking deeper in to the role models, the extent of food, health facilities, education and employment opportunities that men and women will receive in relation to each other is defined by virtue of their predetermined status. (Gupte, 1998)