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Report from the Exploratory Mission on Reproductive Health

Demography and Reproductive Health

Reproductive health has been 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'. Such a definition, however, provides no clue as to how to study reproductive health or even what topics might fall under such a heading.

This is where demographers, and more broadly the IUSSP, can provide leadership and direction. Many demographers already work in the area of reproductive health (whether or not they think in such terms), and did so long before the term 'reproductive health' was popularised, or even coined. A list of areas of demographic research that clearly fall under the general heading includes:

Contraception and sterilisation (female and male methods, prevalence, trends, use-effectiveness, side effects, continuation); Infecundity, subfecundity, primary sterility and secondary sterility (levels, trends, causes, relation to contraception and to sexually transmitted diseases and HIV/AIDS); Foetal loss (spontaneous and induced, levels, trends, correlates, determinants, sequelae especially of illegal induced abortion); Maternal mortality (levels, trends, causes, relation to induced abortion and to illegal abortion); Sexually transmitted diseases (types, prevalence, relation to contraceptive use, to fecundity, to fertility, to sterility, to HIV/AIDS); HIV/AIDS (prevalence, relation to STD's, relation to contraceptive use); The effect of birth spacing on infant health and maternal health (means of spacing, role of contraception by type, situation in areas of high prevalence of STDs and HIV/AIDS); Genital mutilation (male and female, types, relation to obstetric outcomes and infant survival, STDs, HIV/AIDS); Gynaecological morbidity (types, interventions, prevention); Over-servicing and under-servicing (for example, respectively, hysterectomy in some industrialised countries, and screening for cervical cancer in poor ones).

This list is not exhaustive. (Note, however, that it does not include fertility per se as one aspect of reproductive health, although some demographers would place it there. Certainly, the list is long enough with it.)

The value of grouping what at first sight might seem a rather diverse list of research areas is considerable. First, there are commonalities not just of demographic interest but of methodological approach. Population-based research, for example, by means of the large-scale retrospective survey, is an invaluable tool for the investigation of many of the topics although others require supplementation by, for example, prospective data collection, clinical investigation and laboratory testing.

Secondly, it is plain that reproductive health straddles two broad key areas of demographic enquiry -- fertility (and its determinants) and mortality (and morbidity, and their determinants) -- or perhaps three, if we take the interrelationship between fertility issues and health issues as a distinct area of investigation. More specifically there are important interactions between the items on our list. An obvious one is between contraceptive use and induced abortion, since more of one generally means less of the other. There are clear links also between contraceptive use and sexually transmitted diseases including HIV/AIDS, because of the role of condoms in protecting against both disease and pregnancy.

On the evidence of the three seminars conducted by the present IUSSP Committee on Reproductive Health, it appears that the IUSSP's recent work in the area of reproductive health has not capitalized particularly strongly on the contributions that demographers could make to this area of investigation. The first meeting focused with particular energy on issues of directly gynaecological and obstetric concern, specifically on maternal mortality and maternal morbidity (the 1996 Philippines seminar) and demonstrated, uncontroversially, how elusive are sound measures of obstetric morbidity. The other two meetings addressed cultural perspectives (the 1997 South African seminar) and gender perspectives (the 1998 Brazilian seminar), and thus focused more intently on issues of advocacy, of reproductive rights, and of approaches to the investigation of reproductive-health problems -- most obviously, an anthropological approach -- than on factors of substantive importance to reproductive health itself. Important work remains to be done not so much by focusing on particular research paradigms or ethical positions but by exploiting demography's methodologies and its considerable store of practical knowledge and experience, possibly drawing on other methodologies and paradigms as appropriate. Important gains are likely to flow from collaboration between committees.

Research Issues

Each of the topics listed earlier requires empirical demographic investigation, preferably in combination with one another. Are there countries or regions in which contraceptive prevalence is high but so are the incidences of failures and side effects? What are the effects on induced abortion? What are the effects on women's health?

There is a need for a concentrated programme of analysis of what can be gleaned from DHS surveys, with particular attention paid to countries that have had repeated surveys, in order to track trends in prevalence of use and, if possible, in the incidence of failures and side effects. Are there countries or regions where the contraceptive method-mix is inappropriate for its level of STDs and HIV/AIDS?

Almost all of our prevalence estimates of STDs and HIV/AIDS are based on special sub-populations (pregnant women, attenders at clinics of various kinds, prostitutes, army recruits). Is it possible to extrapolate, by means of mathematics or microsimulation or a combination, from such estimates (antenatal clinic attenders might seem the best bet) to the population at large? There is a clear link here with the work of the new Emerging Health Threats Committee.

Eastern Europe has long suffered a crisis of unavailability of modern contraception and of reliance on induced abortion. The financial and political turmoil of the 1990s has exacerbated this situation, and in addition STDs are now on the rise. What can we learn from, for example, the surveys now being conducted and analysed by the CDC? What interventions are feasible? (Link with Emerging Health Threats Committee.)

If there is a new programme of work on Forced Migration, a Reproductive Health Committee could have a role to play in terms of promoting its work on STDs (and possibly HIV/AIDS), induced abortion, and contraception.

Induced abortion remains an important option even when efficient (but still imperfect) modern contraception is available. What is the role of modern medical abortion in developing countries, now and in the future?

What is the role of emergency contraception in developing countries, now and in the future?

A Programme of Work

Without a Reproductive Health Committee, the concerted analytic effort outlined above will not be pursued. Other committees may pay attention to issues related to reproductive health, but only insofar as there is an overlap with their own primary concerns. Moreover, two committees with potentially strong ties to reproductive health, the Fertility and Family Planning Committee and the AIDS Committee, are shortly to be disbanded.

A four-year programme should not only follow its own specific research agenda but should liaise closely with other committees with overlapping concerns, most obviously the Emerging Health Threats Committee. Another possible collaborator is the Forced Migration Working Group. One might envisage stand-alone seminars, as well as joint ones.

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