[MUSIC] Hi, my name is Bjarke Lund Sorensen. I work with emergency obstetric and neonatal care in developing countries. Let's have a look at the trends in the five sexual and reproductive health priority areas over the last decades. Maternal and newborn health, family planning, unsafe abortion, sexually transmitted infections and sexual health. We start with maternal and new born health. Each year almost 3 million babies are born dead and as many die within the first month of life. While over a quarter of a million women die due to pregnancy and child birth. This totals more than the number of deaths caused by HIV AIDS, tuberculosis, and malaria together. Maternal and perinatal mortality is only the tip of the iceberg. It's estimated that for every woman who dies as a result of pregnancy and childbirth, 10 to 30 times as many suffer serious complications. For example damaged perineal structures. New born surviving a complicated birth may suffer life long disabilities like cerebral palsy, learning disorders or an increased risk of chronic non-communicable diseases. As good as all maternal deaths occur in low or middle income countries and are concentrated in Sub-Saharan Africa and Southern Asia. Uncertainties remain though about the exact level of maternal mortality. Only a third of countries, representing 15% of births, have well functioned civil registration systems. In 2007 the estimates were that the global number of maternal deaths were around 536,000, almost unchanged since 1990. However, in the last year's estimates are increasingly optimistic, and in 2010 the estimate of maternal deaths were 287,000, a 47% reduction since 1990. Different strategies have been employed to reduce maternal mortality over the last decades. In the 1970s with the emphasis on primary healthcare, screening and prevention, there was much faith in antenatal care. But as most maternal deaths happen around the time of birth and for women with no prior identifiable risk factors, the role af antenatal care seems to be only minor for reducing maternal mortality. Campaigns in the 1980s to train traditional birth attendants to improve the care, for the considerable number of women giving birth at home were deemed unfeasible. Though community based programs have proven effective in some countries like Pakistan and Nepal, and still one third of births takes place outside health facilities. With the formulation of of the Millennium Development Goals, the aim become to have more than 90% of births should be attended by a skilled birth attendant. But maternal mortality remained high and did not convincingly seem to be reduced by increasing the rate of health facility births. Attendance was drawn to the fact that, the quality of care within health facilities in developing countries is often a alarmingly low. And the so called skilled birth attendants are often not able to provide skilled birth attendants. A number of studies have demonstrated how health systems in developing countries widely failed to provide safe delivery care, as the quality of basic emergency obstetrics and neonatal care is severely deficient or absent. Efforts to improve emergency care, such as skills training, task shifting, criterion based audit and the promotion of outreach friendly drugs such as Misoprostol have proven effective. In Kigoma, Tanzania, the maternal mortality of the rating in the hospital was reduced by 80% over a few years by low cost interventions, as those mentioned above. Countries where the health system instead of the community has been recognized as having the main responsibility for reducing maternal mortality. And where focus has been on extending skilled birth attendants, and emergency care of good quality, have seen significant reductions in maternal mortality. For example in Sri Lanka, Malaysia and Thailand. Emergency Obstetric Care is important for the health of women, but also for their children. Especially neo natal mortality and still birth rates are closely linked to skilled delivery attendants and emergency care. Estimates are that there are 2.7 million stillbirths and around 2.9 million deaths to children in the first 28 days of life each year. The global stillbirth rate has remained almost unchanged. About half of stillbirths are directly related to poor care during birth. Neonatal mortality has been reduced moderately in the last decade, but still constitutes 40% of the under 5 mortality. A recent study at hospital level in Tanzania assessed that basic neonatal resuscitation training that as simple as I do it here, included only crying assimilation of the newborn and ventilation for those who had difficult or no breathing. [NOISE] The study demonstrates a remarkable sustained 47% reduction in early neonatal mortality and a 24% reduction in fresh stillbirths. This emphasizes the importance of assuring basic low cost emergency care of good quality for peripartum health. Maternal and neonatal mortality reduction remains a challenge. It's estimated that even with the current positive trends, only 9 out of 137 developing countries are likely to achieve both the Millennium Development Goal 4 and 5 targets by 2015. Let's turn to the second priority area. Family planning brings health benefits to women and their children. It's been estimated that about 90% of global abortion related and 20% of obstetric related mortality could have been averted by use of effective contraception by women wishing to postpone or cease further child bearing. There are many different contraceptive methods, for example, the intrauterine device. The hormone implant, and the female condom. Contraceptive use in developing regions have increased dramatically from around 10% in 1960 to 60% in 2000. Since then, their increase has stagnated. The Global Fertility Rate declined from 6 children per woman in 1960 to 2.8 in 2000. Still about a third of the 210 million annual pregnancies are unintended. There's still great disparity in access and use of family planning. Poor, rural, uneducated women have lower use and higher levels of unintended births. In Sub-Saharan Africa, progress is particularly limited. Here contraceptive use in 1990 was 12%, in 2007 22%. While fertility rates remain at close to 5 children per woman. About 215 million women, one quarter of the women concerned have an unmet need for family planning. This number is likely to increase unless efforts are accelerated. The reasons for non-use, include lack of access to contraception, but also fear of side effects, infertility, and of husband or community disapproval. It has long been conventional understanding, that contraceptive levels are dramatically increased if child mortality decreases. However there's evidence that a few developing countries have seen mejor reductions in birth rates without a previous reduction in infant mortality. Other examples have demonstrated that in the absence of high quality family planning programs, a decrease in child mortality apparently has little effect. Public policy plays an extremely important role. Until the 1960s, family planning was illegal in many countries. In other cases, it's been coerced upon men and women. Since 1979 it's been considered a human right to have access to effective family planning, but the political support for programs is often not strong enough. In many countries, unmarried persons, mainly adolescents, do not have access to family planning, counseling and faith based pro-natalist movements have increasingly influenced public and political opinion in many developing countries. Infertility receives little attention in international literature, though it often causes severe psychosocial problems and great concern for those affected. Areas of Africa have experienced up to 40% secondary infertility, mainly caused by untreated reproductive tract infections as well as unsafe abortions. Out of the annual 210 million pregnancies worldwide it's estimated that 44 million are terminated by induced abortion. In 2012, half of these were unsafe abortions performed by untrained persons or in an unsafe environment The proportion of abortions globally has remained stable, while the proportion of unsafe abortions has increased between 1995 and 2012 from 44 to 49%. Meanwhile, the number of deaths caused by unsafe abortions have declined from 69,000 in 1995 to 47,000 in 2012. Only 90 of these deaths were in high income countries. Two determinants are of particular interest in the efforts to eliminate unsafe abortion, contraception and legal regulation. There is exceptionally strong evidence that the access to quality contraception reduces abortion rates. Modern contraception is estimated to avert 112 million abortions every year. In Eastern Europe until two decades ago, contraception was not widely available and abortion rates were extremely high. In the last two decades contraception has become much more available and abortion rates have decreased remarkably, even with stable birth rates. As mentioned earlier, countries in middle and East Africa have very low contraceptive prevalence rates, and the abortion rates almost all illegal and unsafe, are two to three times higher than in Western Europe. Another determinant is legal regulation. Abortion rates are increasing where abortion is legally restricted and decreasing, where laws are less restricted. In other words, making abortion illegal does not result in fewer abortions. On the contrary, it is related to more abortions especially more unsafe abortions. One very well documented case is Romania, where both abortion and access to contraception were severely restricted in 1967, as part of a pro-natalist policy of the Ceausescu regime. As a result Romania in 1989 had the highest recorded maternal mortality rate of any country in Europe. An estimated 87% of those deaths were due to illegal and unsafe abortion. Immediately after the 1989 revolution, the new government removed restrictions and contraception, and legalized abortion and maternal mortality dropped by 75% the following years. Thereby actually meeting the Millennium Development Goal number 5, before it was even declared, with just a single legal intervention. Another example is South Africa, where the mortality from abortion dropped by over 90% after the abortion law was liberalized in 1994. Even in countries where abortion on demand is illegal and performed unsafely, related maternal mortality can be reduced by post abortion care which is legal and promoted in most countries. Better quality of post abortion care globally explains the declining rates of maternal mortality related to unsafe abortions. It has been demonstrated that even mid level health providers can treat a septic abortion by simple manual vacuum aspiration, as simple as this, by applying suction [NOISE]. Another explanation could be that unsafe abortions can become less unsafe. An example is the promotion of Misoprostol, a cheap prostaglandin that can be administered at home either orally or per vagina, to induce abortion. In Uruguay where abortion on demand is illegal, health institutions have offered women with unwanted pregnancies, ultrasound and counselling and Misoprostol with instructions for it's use, to those who wanted to terminate the pregnancy. Almost all women opted for an abortion, and the women performed the abortion themselves without the involvement of the health professionals, and complications were minimal. The fourth priority area is, sexually transmitted infections. With the exception of HIV, it is not visible in the Millennium Development Goals despite the considerable burden of disease and death. Every year, around 450 million new cases of common and treatable, bacterial and protozoan sexually transmitted infections occur throughout the world. Causing an estimated 60 to 80 million women to suffer involuntary childlessness. It's clearly an area that has received very little attention. HIV infection represents the main cause of adult mortality in Africa and is arguably the only single disease which has caused a long term decline in life expectancy in the whole region. In countries in Southern Africa, life expectancy declined by up to 20 years between 1980 and 2000. Almost half of all new HIV infections are among young people and about twice as many young women as men are infected with HIV in Sub-Saharan Africa. Even so, this area has seen remarkable progress. Preventative interventions have shown their effectiveness and antiretroviral treatment is saving millions of lives. The number of new HIV infections have decreased from 3.1 million in 1999 to 2.7 million in 2010. And the number of deaths from 2.1 million in 2004 to 1.8 million in 2010. It is particularly notable that there has been great progress in stabilizing or declining HIV epidemics and scaling of access to treatment in Sub-Saharan Africa. Eastern Europe and Central Asia on the contrary, show signs of further deterioration with sharply increasing HIV epidemics due to a lack of implementation of evidence based prevention, interventions and the low antiretroviral treatment coverage. Cancer of the cervix of the uterus is caused by the sexually transmitted human papilloma virus. Each year half a million women are diagnosed, and a quarter of a million die from cervical cancer, that is the second leading cause of cancer related mortality in females worldwide. A vaccine gives immunity against a number of the oncogenic papilloma virus subtypes and reduces the risk of cervical cancer when given before the start of active sexual life. The price of the HPV vaccine is around $800 per treatment and is therefore not affordable in the development context. There's not yet been a pressure on the pharmaceutical industry to offer the vaccine at more reasonable prices, with less demand for a profit, to low income countries. As was the case with antiretroviral treatment after long public pressure. The fifth priority area is sexual health that is defined by the World Health Organization as a state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. In addition to what has already been discussed, sexual health for example also covers sexual dysfunction, violence related to gender and sexuality and discrimination of specific groups. Up to one third of the adult population in developed countries are estimated to experience some kind of sexual dysfunction, which is associated with common mental illness like depression and low quality of life. Sexual violence can take a variety of forms but the most prevalent is violence towards women, exercised by the intimate partner. Violence has been shown to be a key factor in unwanted pregnancies, in the transmission of sexually transmitted infections and in sexual dysfunction. Groups with particular sexual health issues include people whose sexual lives do not conform with dominant ideas about gender and reproduction. For example unmarried, adolescents, disabled and homosexuals, who often experience drastic forms of discrimination, exclusion and violence exercised by other individuals or by state institutions. For example, presently in 77 countries homosexuality is illegal, and in 7, punishable by death. Until very recently, sexual health was close to invisible in academic literature and technical debates. But in the last few years it's gained some prominence in international policy debates, attempting to arrive at discussion and consensus. Thank you for watching. [MUSIC]
