Reproductive health is no longer a new issue in the world. It has assumed great significance following the International Conference on Population and Development (ICPD) in 1994. The concept now offers a comprehensive and integrated approach to the current health needs for healthy human reproduction. Reproductive health, according to the ICPD, is a condition in which the reproductive process is accomplished in a state of complete physical, mental and social well-being. This implies that the people have the ability to reproduce and the freedom to decide if, when and how often to do so.

Progress

The key indicators of reproductive health have improved worldwide in the past two decades. The maternal mortality ratio has declined by 47 per cent. The contraceptive prevalence rate has increased from 55.2 per cent in 1990 to 62.7 per cent in 2010, according to the World Health Organisation. However, the progress has been uneven and the reproductive health problems remain the leading cause of ill health and death for women of childbearing age. Nearly 800 women die every day from complications during pregnancy and childbirth, almost all in developing countries. It is also estimated that approximately one-third of maternal deaths could be avoided annually if women who did not wish to become pregnant had access to and used effective contraception.

Nepal has also made remarkable progress in reproductive health in the last 20 years. The maternal mortality ratio has declined from 539 in 1996 to 281 in 2006. It is estimated to have declined to 229 in 2009. Similarly, women receiving antenatal care from skilled providers, women giving birth with assistance from a skilled provider and contraceptive prevalence rates have significantly increased. However, the contraceptive prevalence rate is reported to have slightly declined from 44 per cent in 2006 to 43 per cent in 2011. The total fertility rate declined from 4.6 per cent in 1996 to 2.6 per cent in 2011.

Knowledge of at least one modern method of family planning is now nearly universal. Despite this progress, there are still several challenges to achieve the MDG target to reduce maternal mortality to 134 by reducing the fertility rate to 2.5 per cent and increasing the contraceptive use to 67 per cent by 2015. At the moment, we are far behind the two targets.

A few months back, when this scribe visited one of the family planning/reproductive health service centres run by Marie Stopes International in Jumla, a woman of 35 years was seeking abortion service there. She already had four children, two sons and two daughters, and she had given birth to all of them at home. The four-month pregnant woman had never used any contraceptive. The centre could not offer the service past the first trimester. She, therefore, went to the district hospital. It also could not offer the service as there was no trained doctor.

At the hospital, there was also a man seeking vasectomy service. In the absence of a trained doctor, he could not receive the service either. This is not the case of Jumla alone. Many public health facilities in remote and rural areas do not have adequate trained health personnel to provide safe abortion, long acting and permanent methods of family planning. There are large variations in access and utilisation of reproductive health services across the country.

In the absence of informed choices for reproductive health services, many women are bound to have unwanted pregnancies and are using abortion as a form of birth control, which is again not easily accessible and affordable in many parts. So it would be an injustice to a large population living in the remote hills and rural areas, when we talk about the success of the reproductive health programmes by looking at the national statistics. The current method of mixed contraceptives is in fact a reflection of current availability, not the client’s choice. A full range of contraceptives is yet to be attained in the rural and remote areas.

Experience

With the experience of the past, we now know more about strategies that succeed and those that fail. Partnering with private organisations, increasing access to family planning services, making skilled attendants available at all births, and timely emergency obstetric care have surely played a vital role in reducing the maternal mortality ratio.

A weak health system, poor coordination between public and private partners, limited transportation in the remote and rural areas, resource needs, including financial, technical and material, are among the major challenges to reproductive health. As a large number of young people are entering their reproductive years, the demand for reproductive health is rising. That means, we will need to explore innovative approaches to motivate the public and private sector in cost recovery, cost subsidy, willingness to go beyond the urban areas to reach the disadvantaged groups and youths and meeting their specific needs. Without this, achieving universal access to reproductive health by 2015 will be limited to a dream and a slogan.