Mental Health
Child and forced marriage
Main articles: Child marriage and Forced marriage
Poster against child and forced marriage
The practice of forcing young girls into early marriage, common in many parts of the world, is threatening their reproductive health. According to the World Health Organization:[86]
The sexual and reproductive health of the female in a child marriage is likely to be jeopardized, as these young girls are often forced into sexual intercourse with an older male spouse with more sexual experience. The female spouse often lacks the status and the knowledge to negotiate for safe sex and contraceptive practices, increasing the risk of acquiring HIV or other sexually transmitted infections, as well as the probability of pregnancy at an early age.
Niger has the highest prevalence of child marriage under 18 in the world, while Bangladesh has the highest rate of marriage of girls under age 15.[87] Practices such as bride price and dowry can contribute to child and forced marriages.
International Conference on Population and Development, 1994
The International Conference on Population and Development (ICPD) was held in Cairo, Egypt, from 5 to 13 September 1994. Delegations from 179 States took part in negotiations to finalize a Programme of Action on population and development for the next 20 years. Some 20,000 delegates from various governments, UN agencies, NGOs, and the media gathered for a discussion of a variety of population issues, including immigration, infant mortality, birth control, family planning, and the education of women.
In the ICPD Program of Action,[88] 'reproductive health' is defined as:[89]
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 its functions and processes. Reproductive health, therefore, implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in this last condition are the right of men and women to be informed [about] and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, as well as other methods of birth control which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.
This definition of the term is also echoed in the United Nations Fourth World Conference on Women,[90] or the so-called Beijing Declaration of 1995.[91] However, the ICPD Program of Action, even though it received the support of a large majority of UN Member States, does not enjoy the status of an international legal instrument; it is therefore not legally binding.
The Program of Action endorses a new strategy which emphasizes the numerous linkages between population and development and focuses on meeting the needs of individual women and men rather than on achieving demographic targets.[92] The ICPD achieved consensus on four qualitative and quantitative goals for the international community, the final two of which have particular relevance for reproductive health:
Reduction of maternal mortality: A reduction of maternal mortality rates and a narrowing of disparities in maternal mortality within countries and between geographical regions, socio-economic and ethnic groups.
Access to reproductive and sexual health services including family planning: Family planning counseling, pre-natal care, safe delivery and post-natal care, prevention and appropriate treatment of infertility, prevention of abortion and the management of the consequences of abortion, treatment of reproductive tract infections, sexually transmitted infections and other reproductive health conditions; and education, counseling, as appropriate, on human sexuality, reproductive health, and responsible parenthood. Services regarding HIV/AIDS, breast cancer, infertility, delivery, hormone therapy, sex reassignment therapy, and abortion should be made available. Active discouragement of female genital mutilation (FGM).
The keys to this new approach are empowering women, providing them with more choices through expanded access to education and health services, and promoting skill development and employment. The programme advocates making family planning universally available by 2015 or sooner, as part of a broadened approach to reproductive health and rights, provides estimates of the levels of national resources and international assistance that will be required, and calls on governments to make these resources available.
Sustainable Development Goals
Half of the development goals put on by the United Nations started in 2000 to 2015 with the Millennium Development Goals (MDGs). Reproductive health was Goal 5 out of 8. To monitor the progress, the UN agreed to four indicators:[93]
Contraceptive prevalence rates
Adolescent birth rate
Antenatal care coverage
Unmet need for family planning
Progress was slow, and according to the WHO in 2005, about 55% of women did not have sufficient antenatal care and 24% had no access to family planning services.[94] The MDGs expired in 2015 and were replaced with a more comprehensive set of goals to cover a span of 2016–2030 with a total of 17 goals, called the Sustainable Development Goals. All 17 goals are comprehensive in nature and build off one another, but goal 3 is "To ensure healthy lives and promote wellbeing for all at all ages". Specific targets are to reduce global maternal mortality ratio to less than 70 per 100,000 live births, end preventable deaths of newborns and children, reduce the number by 50% of accidental deaths globally, strengthen the treatment and prevention programs of substance abuse and alcohol.[95] Goal 4 emphasizes the fact that no one should be left out in providing quality education. Target 4 specifically mentions the inclusion of persons with disabilities, indigenous peoples and children in vulnerable situations. In addition, one of the targets of the Sustainable Development Goal 5 is to ensure universal access to sexual and reproductive health.[96]
By region
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North America
The CDC estimated that one in five people in the US had a sexually transmitted infection (STI) totalling near about 68 million infections in 2018. 26 million new STI in 2018.[97] Almost half of new STI were among youth aged 15 to 24 in the US. New STIs total $16 billion in direct medical costs.[98]
Engaging in oral sex can carry the risk of sexually transmitted infections (STIs).[99]
Africa
Further information: HIV/AIDS in Africa
HIV/AIDS
Prevalence of HIV/AIDS in Africa in 2011
HIV/AIDS in Africa is a major public health problem. The population of Sub-Saharan Africa is the worst affected region with the disease especially affecting the young female population. According to the National Library of Medicine, "Sub Saharan Africa (SSA) is occupied by 12% of the global population, but disproportionately has more than 90% of children younger than 15 years of age and 68% of adults that are living with HIV2."[100] In Nigeria in specific, "There is early sexual maturity and considerable sexual activity between 9 and 15 years of age."[101] HIV is also transmissible through breast milk, which proves that women infected with HIV/AIDS have to deal with more health consequences. South of the Sahara, the AIDS epidemic is the leading cause of death.
World AIDS Day 2006 event in Kenya
The reasons for the high spread of HIV/AIDS can be broken down into 7 main subsections: poverty, inadequate medical care, lack of prevention and education, taboo and stigma, sexual behavior, prostitution, and sexual violence against women.[102] With a high population of individuals living in extreme poverty, condoms, HIV tests, and other forms of screening are not prioritized, leaving many individuals lacking the necessities to protect themselves from the disease. According to the International Finance Corporation, "Health care in Sub-Saharan Africa remains the worst in the world, with few countries able to spend the $34 to $40 a year per person that the World Health Organization considers the minimum for basic health care."[103] Notably, though widespread poverty, "an astonishing 50 percent of the region's health expenditure is financed by out-of-pocket payments from individuals."[103] This represents the lack of both affordability and accessibility surrounding the health care system in Sub-Saharan Africa. According to the United Nation, Sub-Saharan Africa struggles with the highest rate of education exclusion in the world; 60% of youth ages 15 to 17 are not in school.[104] With this lack of education, information regarding HIV/AIDS and prevention practices are not transmitted to a number of individuals, leading to more citizens being unaware of the severity of the disease. Stigma surrounding HIV/AIDS further contributes to the high infection rate. In African villages, an individual's life is closely intertwined with their friends, families, and neighbors around them. Individuals who have HIV/AIDS are motivated to keep it a secret in fear of isolation and alienation. The extremity of this stigma is conveyed by some of the dialogue, people living with HIV are often ridiculed as "a walking corpse", referred to as "an HIV" and even called in Tanzania, "nyambizi", or submarine, which implies that an HIV-positive person is "menacing and deadly."[105] Sexual behavior and prostitution also play a part in the increased rate of transmission of HIV/AIDS in Africa. Due to the high rates of poverty, prostitution is widespread, and sexual partners are often changing, increasing the likelihood of transmission. Africa has one of the highest rates of rape in the world, with many women getting AIDS due to raped and sexual violence by an HIV-infected offender. Similarly, gender roles within many African countries contribute to this, as "in much of sub-Saharan Africa, women are a subordinate group who are expected to become pregnant, bear children, and fulfill the sexual desires of their husbands without hesitation".[105]
Fertility rates and contraceptives
In most African countries, the total fertility rate is very high often due to a lack of access to contraception, family planning, and practices such as forced child marriage. For instance, Niger, Angola, Mali, Burundi, Somalia and Uganda have very high fertility rates. According to the United Nations Department of Economic and Social Affairs, "Africa has the lowest rate of contraceptive use (33%) and the highest rate of unmet need for contraceptives (22%)." [106] In Mozambique, despite efforts in improving access to modern contraceptive methods, the general fertility rate is "still high at 5.3 and the unmet need for contraceptives is also high at 26%." Among young women, the fertility rate has dramatically increased from 167 births per 1000 aged between (15–19 years) in 2011 to 194 in 2015 with a large increase in rural areas from 183 to 230. Contraceptive prevalence among (15–19 years) remains low at 14% in 2015 when compared to the national prevalence among the reproductive age group (15–49 years) at 25% in the same year.[107]
Types of contraceptives
The copper IUD has been provided less frequently than other contraceptive methods but there have been signs of an increase in most reported provinces. The most frequently provided methods are implants and injectable progesterone, which is not as ideal as condom usage, which is still required with this method to decrease the risk of HIV. In Nigeria, specifically, people who have multiple partners are often unwilling to protect themselves with condoms. "In a study conducted in a rural community in South West Nigeria in 1993, it was found that although 94.7% of 302 candidates aged between 20 and 54 years admitted hearing about the condom, only 51.3% admitted ever using it."[101] According to the International Family Planning Perspective, "these injectable progesterone products made up 49% of South Africa's contraceptive use and up to 90% in some provinces."[108] Though contraceptive use is rising in African countries, discontinuation rates are also high. Weak health systems challenge Sub-Saharan African countries in expanding contraceptive outreach, promotions and service.
Contraceptive accessibility
The updated contraceptive guidelines in South Africa attempt to improve accessibility by providing special service delivery and prompting awareness for adolescents, lesbian, gay, bisexual, transgender, intersex people, disabled people, chronically ill people, women who are perimenopausal, sex workers, migrants and males. They also aim to increase access to long-acting contraceptive methods such as the copper IUD, the single rod progestogen implant combined with estrogen and progesterone injectables.[109] Tanzanian provider perspectives also realized the biggest obstacle in maintaining healthy contraceptive care in their communities: lack of consistency. Contraceptive dispensaries found that the capability of providing service to patients was inconsistent and substandard. This resulted in unsatisfied reproductive goals, low educational attainment, miseducation about the side effects of certain contraceptives.[110]
Accessibility has also been hindered as a result of inadequate quantities of properly trained medical personnel. According to the African Journal of Reproductive Health, "Shortage of the medical attendant...is a challenge, we are not able to attend to a big number of clients, also we do not have enough education which makes us unable to provide women with the methods they want".[111] The majority of medical centers are staffed by people without medical training and few doctors and nurses, despite federal regulations, due to lack of resources. One center had only one person who was able to insert and remove implants, and without her, they were unable to service people who required this method of contraceptive care. Another dispensary which carried two methods of birth control shared that they sometimes run out of both materials at the same time which makes it difficult to keep up with the supply and demand chain.
Social factors effect on contraceptives
Unbalanced gender dynamics, spousal dynamics, economic conditions, religious norms, cultural norms, and constraints in supply chains all contribute to contraceptive rates and usage. One instance of this is a provider who referenced harmful propaganda about the side effects of contraceptive usage. The spread of this propaganda is one of the many examples of influential people in the community, such as elders and religious leaders, discouraging proper contraceptive care/health. In some cases, influential members of the community often convince others that condoms and contraceptive pills contain microorganisms that cause cancer.
In regards to spousal and gendered dynamics, many women often have faced pressure from their spouse or family members to use avoid birth control which resulted in them using it secretly. This is also one of the many reasons women frequently preferred undetectable contraceptive methods which can lead to less effective contraceptives.[112]
Other common sexually transmitted infections in Sub-Saharan Africa
Sub-Saharan Africa ranks first in STI yearly incidence compared to other world regions, reiterating the major problem that public health is in African countries.[113] In Sub-Saharan Africa, STIs are the most common reasons that individuals seek medical care. According to the World Health Organization, every year in Africa "there are 3.5 million cases of syphilis, 15 million cases of chlamydial disease, 16 million cases of gonorrhea, and 30 million cases of trichomoniasis."[113]
Sexually transmitted infections and women
The majority of HIV infections, risks, and other sexually transmitted infections in Sub-Saharan Africa disproportionately impact women. Women, particularly under the age of 30, account for more than half of new infections on the African continent, employing incidence rates that are often double that of their male counterparts.[114] Not only do women contain more risk of infection, but the consequences of these diseases are often significantly worse for women, as they can affect reproductive health as well. Some consequences of bacterial STIs include "pelvic inflammatory disease, chronic pelvic pain, tubal infertility, pregnancy complications, fetal and neonatal death."[114] HIV infection is less unbalanced in gender infections, but other STIs disproportionately affect women, "who bear 80 percent of the disability."[115] Previously stated, women are also more susceptible to infection due to social stigma and gendered expectations. "Most women with STDs will not seek medical care at all, or will only present late for treatment, when complications have already developed, complications that have devastating physical, psychological, and social consequences, particularly for women and their children."[115] Women of lower-income status are often the least likely subgroup to receive any sort of medical attention.
More on LGBTQ+ health
Individuals who identify as transgender often yield significantly higher rates of HIV in comparison to other subgroups. African politics and government are silent on LGBTQ+ issues in the political sphere, which translates in part to their accessibility and prioritization in healthcare. "It is possible that the invisibility of transgender people in epidemiological data from Africa is related to the criminalization of same-sex behaviour in many countries,"[116] representative of how traditional attitudes shape one's ability to participate similarly in society. Further research conducted among transgender women in South Africa shows more "health disparities and poor access to appropriate mental, sexual and reproductive health services."[117] Still, however, there is limited data concerning transgender individuals within African countries.
Individuals identifying as part of the LGBTQ+ community, in a study conducted by BMC International Health and Human Rights, resulted all in facing some sort of discrimination by healthcare providers based on their sexual orientation and/or gender identity. Violations took four distinct forms: availability, accessibility, acceptability, and quality.[118] Facilities in South Africa lack services for specific LGBT concerns, providers refuse to care for patients identifying within the community, and if did, articulate moral disapproval. Finally, the lack of quality and knowledge about LGBTQ+ identities and health needs contributes to disproportionate negative harms, avoiding or delaying seeking healthcare with these implications.[118]
The workplace and reproductive health
Reproductive health can be impacted by exposures in the workplace. Both women and men who work during their reproductive years can be exposed to a variety of chemical, physical, and psychosocial hazards at work that can impact their fertility. Many women continue to work while pregnant, thus increasing the likelihood that both mother and baby could be exposed.[119][120]
Routes of exposure
Harmful substances can enter a woman's body through breathing in (inhalation), contact with the skin, or swallowing (ingestion).[119][121] Pregnant workers and those planning to become pregnant should be especially concerned about exposure to reproductive hazards. Some chemicals (such as alcohol) can circulate in the mother's blood, pass through the placenta, and reach the developing fetus. Other hazardous agents can affect the overall health of the woman and reduce the delivery of nutrients to the fetus. Radiation can pass directly through the mother's body to harm her eggs or the fetus. Some drugs and chemicals can also pass through a mother's body into the nursing baby through the breast milk.[121][122]
Reproductive hazards do not affect every woman or every pregnancy. Whether a woman or her baby is harmed depends on how much of the hazard they are exposed to, when they are exposed, how long they are exposed, how they are exposed, and personal factors like age, stage of menstrual cycle, stage of pregnancy or when exposure occurs. For example, exposure to a hazard could block ovulation and pregnancy only at specific times of the menstrual cycle. Exposure during the first 3 months of pregnancy might cause a birth defect or a miscarriage. Exposure during the last 6 months of pregnancy could slow the baby's growth, affect its brain development, or cause premature labor.[121]
Workplace substances that affect female workers and their pregnancies can also harm their families. Without knowing it, workers can bring home harmful substances that can affect the health of other family members—both adults and children. For example, lead brought home from the workplace on a worker's skin, hair, clothes, shoes, tool box, or car can cause lead poisoning in family members, especially young children.[121]
Occupational reproductive hazards
A number of occupational hazards can impact reproductive health and subsequently reproductive outcomes including chemical, physical, and psychosocial hazards. Although more than 1,000 workplace chemicals have been shown to have reproductive effects on animals, most have not been studied in humans. In addition, most of the 4 million other chemical mixtures in commercial use remain untested.
Some reproductive hazards include:[123][119]
Anesthetic gases[124]
Antineoplastic (cancer treatment drugs)[125][126]
Chemical disinfectants and sterilants[127]
Certain ethylene glycol ethers such as 2-ethoxyethanol (2EE) and 2-methoxyethanol (2ME)[121]
Carbon disulfide (CS2)[121]
Epoxies and resins[128]
Ethylene Oxide[129]
Formaldehyde[130]
Heat[131]
Infectious agents[132][121]
Lead and other heavy metals[133]
Noise[134]
Pesticides[135]
Ionizing radiation[136]
Non-ionizing radiation[137]
Secondhand smoke[138]
Smoke and by-products of burning[139]
Solvents[140]
Shift work and long working hours[141]
Strenuous physical demands (e.g. prolonged standing, heavy lifting, bending)[121]
Many chemicals are not evaluated for reproductive toxicity and occupational exposure limits are developed based on nonpregnant adults. Exposure levels considered safe for an adult may, or may not be safe for a fetus.
Reproductive health problems that might be caused by workplace exposures
Workplace hazards can lead to certain reproductive health problems, such as:
Reduced fertility or infertility
Erectile dysfunction
Menstrual cycle and ovulatory disorders
Women's health problems linked to sex hormone imbalance
Miscarriage
Stillbirth
Babies born too soon or too small
Birth defects
Child developmental disorders
Childhood cancers[142]
Occupational hazards and female reproductive health
Some workplace hazards can affect reproductive health, the ability to become pregnant, and the health of unborn children. Most women can safely keep working in their job during their pregnancy. But some jobs involve exposures that are harmful to pregnant or breastfeeding women. Some female health problems that may be caused by workplace reproductive hazards include the following:[142]
Disruption of the menstrual cycle and hormone production
High levels of physical or emotional stress or exposure to chemicals such as pesticides, polychlorinated biphenyls (PCBs), organic solvents and carbon disulfide, may disrupt the balance between the brain, pituitary gland, and ovaries. This disruption can result in an imbalance of estrogen and progesterone, and lead to changes in menstrual cycle length and regularity and ovulation. Because these sex hormones have effects throughout a woman's body, severe or long-lasting hormone imbalances may affect a woman's overall health.[121]
Hazards that can disrupt the menstrual cycle and/or sex hormone production include:[143]
a variety of pesticides
carbon disulfide (CS2)
polychlorinated biphenyls (PCBs)
organic solvents
jet fuel
shift work
Infertility and subfertility
About 10% to 15% of all couples are infertile or have subfertility, which means that they are unable to conceive a child after 1 year of trying to become pregnant. Many factors can affect fertility, and these factors can affect one or both partners. Damage to the woman's eggs or the man's sperm, or a change in the hormones needed to regulate the normal menstrual cycle are just a few things that can cause problems with fertility. More common causes of infertility include:[121]
Damage to the woman's eggs
Damage to the man's sperm
Infertility can be caused by change in the hormones needed to regulate the normal menstrual cycle and uterine growth.[121] Hazards that can reduce fertility in women include:[143]
cancer treatment drugs, including antineoplastic drugs
lead
ionizing radiation, including x-rays and gamma rays
nitrous oxide (N2O)
Miscarriages and stillbirths
About 1 in every 6 pregnancies ends in a miscarriage—the unplanned termination of a pregnancy. Miscarriages can occur very early in pregnancy, even before the woman knows she is pregnant. Miscarriages and stillbirths occur for many reasons, such as the following:[121]
The egg or sperm may be damaged so that the egg cannot be fertilized or cannot survive after fertilization.
A problem may exist in the hormone system needed to maintain the pregnancy.
The fetus may not have developed normally.
Physical problems may exist with the uterus or cervix.
Birth defects
A birth defect is a physical abnormality present at birth, though it may not be detected until later. About 2% to 3% of babies are born with a major birth defect. In most cases, the cause of the birth defect is unknown. The first 3 months of the pregnancy is a very sensitive time of development because the internal organs and limbs are formed during this period. Many women are not aware that they are pregnant during much of this critical period.[121]
Low birth weight and premature birth
About 7% of babies born in the United States are born underweight or prematurely. Poor maternal nutrition, smoking, and alcohol use during pregnancy are believed to be responsible for most of these cases. Although better medical care has helped many underweight or premature babies to develop and grow normally, they are more likely than other babies to become ill or even die during their first year of life.[121]
Developmental disorders
Sometimes the brain of the fetus does not develop normally, which leads to developmental delays or learning disabilities later in life. About 10% of children in the United States have some form of developmental disability. Such problems are often not noticeable at birth. They can be difficult to measure, may be temporary or permanent, and range from mild to severe. Developmental problems may appear as hyperactivity, short attention span, reduced learning ability, or (in severe cases) intellectual disability.[121]
Other health problems
Even if a woman is not trying to become pregnant, her general health can be harmed by reproductive hazards that alter the production of sex hormones. Sex hormones have effects throughout a woman's body. Some workplace exposures can cause an imbalance of estrogen and progesterone levels in the blood. This disruption can increase vulnerability to:[121]
Some cancers, such as endometrial or breast cancer
Osteoporosis
Heart disease
Tissue loss or weakening
Effects on the brain and spinal cord, including symptoms of menopause[121]
Occupational hazards and male reproductive health
A number of workplace substances have been identified as reproductive hazards for men[144] such as:
Lead
Dibromochloropropane
Carbaryl (sevin)
Toluenediamine and dinitrotoluene
Ethylene dibromide
Plastic production (styrene and acetone)
Ethylene glycol monoethyl ether
Welding
Perchloroethylene
Mercury vapor
Heat
Military radar
High levels of kepone
High levels of bromine vapor
High levels of radiation
Carbon disulfide
2,4-dichlorophenoxy acetic acid (2,4-D)
Exposure to occupational hazards can impact:[144]
Number of sperm. Some reproductive hazards can stop or slow the actual production of sperm. This means that there will be fewer sperm present to fertilize an egg; if no sperm are produced, the man is sterile. If the hazard prevents sperm from being made, sterility is permanent.
Sperm shape. Reproductive hazards may cause the shape of sperm cells to be different. These sperm often have trouble swimming or lack the ability to fertilize the egg.
Sperm transfer. Hazardous chemicals may collect in the epididymis, seminal vesicles, or prostate. These chemicals may kill the sperm, change the way in which they swim, or attach to the sperm and be carried to the egg or the unborn child.
Sexual performance. Changes in amounts of hormones can affect sexual performance. Some chemicals, like alcohol, may also affect the ability to achieve erections, whereas others may affect the sex drive. Several drugs (both legal and illegal) have effects on sexual performance, but little is known about the effects of workplace hazards.
Sperm chromosomes. Reproductive hazards can affect the chromosomes found in sperm. The sperm and egg each contribute 23 chromosomes at fertilization. The DNA stored in these chromosomes determines what someone will look like and their our bodies will function. Radiation or chemicals may cause changes or breaks in the DNA. If the sperm's DNA is damaged, it may not be able to fertilize an egg; or if it does fertilize an egg, it may affect the development of the fetus. Some cancer treatment drugs are known to cause such damage. However, little is known about the effects of workplace hazards on sperm chromosomes.
Pregnancy. If a damaged sperm does fertilize an egg, the egg might not develop properly, causing a miscarriage or a possible health problem in the baby. If a reproductive hazard is carried in the semen, the fetus might be exposed within the uterus, possibly leading to problems with the pregnancy or with the health of the baby after it is born.