Sexual and Reproductive Health

    Overview

    Reproductive Health

    The Reproductive Health Programme develops guidelines, norms, and standards for sexual and reproductive health and rights (SRH) in different contexts. The Programme supports Member States in developing, implementing, and evaluating effective policies and strategies related to sexual and reproductive health to improve SRH’s outcomes throughout the life cycle and ensure universal coverage.

    Women's Health

    Gender inequity, poverty among women, weak economic capacity, sexual and gender-based violence, including female genital mutilation (FGM), are major impediments to the amelioration of women's health in the African Region. To ensure that women and men have equal access to the necessary opportunities to achieve their full health potential and health equity, the health sector and the community need to recognize that women and men differ in sex and gender. Because of social (gender) and biological (sex) differences, women and men experience different health risks, health-seeking behavior, health outcomes, and health systems responses. Furthermore, gender social stratifications have resulted in unequal benefits among various social groups of women and men, as well as between women and men. Hence, continued support to Member States to roll out the Women's health strategy and its resolution and integrating gender into health policies and programmes have been the significant achievements.

    Women in the African Region are more likely to die from communicable diseases (e.g., HIV, tuberculosis, and malaria), maternal and perinatal conditions, and nutritional deficiencies than women in other regions. Globally, about 468 million women aged 15–49 years (30% of all women) are thought to be anaemic, at least half because of iron deficiency, and most of these anaemic women live in Africa (48–57%). It's reported that 1 in 4 deaths among adult women are caused by NCDs such as heart disease, cancer, and diabetes. Tobacco is a leading risk factor for NCDs, and its use is increasing among young women in the Region.


    Related documents

    • Sexual and Reproductive Health fact sheet English [pdf]
    • Sexual and Reproductive Health and Rights Newsletters (asekpon [at] who.int (Suscribe to the newsletter)) September 2020 - English [pdf], French [pdf] | October 2020 - English [pdf], French [pdf] | November 2020 - English [pdf], French [pdf] | May 2021 - English [pdf]
    • Global health sector strategy on sexually transmitted infections 2016-2021: implementation framework for the African Region English [pdf] | French [pdf]
    • WHO Consolidated Guideline on Self-care Interventions for Health Sexual and Reproductive Health and Rights English [pdf]

    • Self-care interventions for health: sexual & reproductive health and rights Communications Toolkit English [pdf]

    • Sexual and reproductive health interventions in the WHO UHC Compendium English [pdf]

    Disease Outbreak

    Sexual and Reproductive Health and Rights in the context of COVID-19 in the African Region: rapid assessment of continuity of services

     

    As part of the fight against COVID-19 and its adverse effects on WHO African region countries' health systems, regular assessments of the provision of sexual and reproductive health and rights services are conducted. They aims to identify gaps in the availability of essential SRHR services to populations. They serve as a decision-making and resource mobilization tool to ensure that people in the WHO African Region have access to sexual and reproductive health and rights services at all times. 


    First Round (February to May 2020)

    The COVID-19 pandemic has rapidly become a significant global public health crisis by causing disruptions in the supply and use of health services with a potential risk of adverse impact on maternal and child health. 

    The WHO Regional Office for Africa conducted a rapid assessment on the continuity of essential Sexual and Reproductive Health and Rights (SRHR) services in the African Region in the context of COVID-19. The evaluation aimed to assess the inclusion of SRHR in the Essential Health Services (EHS) package of the COVID-19 response in the countries of the African Region. The survey was conducted from June to July 2020. Purposive sampling technique was used. The questionnaire was sent to African countries that were already part of or being targeted to be focus countries of WHO SRHR projects, and countries that had reported a high number of COVID-19 cases.

    Seventeen countries  participated in the rapid assessment. Of these countries, only 2 (12%) countries , reported no integration of Sexual and Reproductive Health Services in the Essential Health Services package. All SRH components (Family planning/contraception and Comprehensive abortion care, including post-abortion care) are included in the EHS package in 12 (80%) of the 15 countries with SRH integrated. Fourteen (82%) countries , reported ongoing awareness-raising campaigns/communication messages about these services during the COVID-19 pandemic.

    In terms of disruption of services, nine (53%) countries  reported a reduction in the use of family planning since the beginning of the pandemic, in comparison to the same time in 2019. Twelve (71%) countries  reported a reduction in uptake of family planning commodities since the beginning of the health crisis. Eight (47%) countries  reported stock out of family planning commodities. The most-reported stocked out items were injectables, pills, and implants.

    Three countries  reported a decrease in comprehensive abortion care services (safe abortion where legal and post-abortion care) since the beginning of the COVID-19 pandemic.

    The key challenges identified in most countries (71%) with regards to the provision of Family Planning/contraception and Comprehensive abortion care (CAC), including post-abortion care (PAC) services during the COVID-19 pandemic, were the fear of patients/clients to go to health facilities and the lack of information of the population regarding the continuity of these services. The funding of Family Planning/contraception and CAC/PAC services was also identified as a challenge. 

    Thirteen countries  (76%) reported implementation of self-care interventions for Family Planning/contraception or safe abortion. The most common ones implemented during the COVID pandemic are self-provision of pills and self-administered sub-cutaneous Depomedroxyprogesterone acetate (DMPA). 

    Some suggestions to improve continuity of these essential services include training and supervision of Health care providers, improving service provision at community level, offering alternative approaches to service delivery, promoting self-care interventions for SRH, and ensuring availability of Family Planning products.


    Second Round (June to September 2020)

    Fifteen (15) countries  participated in the second round of the rapid assessment of continuity of essential SRHR services in the African region in the context of COVID-19. The goal of the assessment was to evaluate the continuity of essential SRHR services with focus on safe abortion, post-abortion care and Family Planning (FP). 

    Findings

    • SRH is integrated into the the package of the national continuity of Essential Health Services (EHS) in 14 out of the 15 participating countries 
    • Comprehensive abortion care, which was missing in the 1st round, is now included in the package of the national continuity of EHS in Mali
    • Improvements in family planning were observed in contrast to the previous assessment: 
      • only four countries reported a reduction in Family Planning services compared to 9 countries in the first round - Cameroon, Guinea, and Madagascar showed improvements in Family Planning services 
      • Five countries reported a reduction in uptake of Family Planning commodities compared to 12 countries in the first round - Benin, Cameroon, United Republic of Tanzania (mainland), DRC, Madagascar, SA, and Zimbabwe showed improvements in uptake of Family Planning commodities
    • Stockout of Family Planning commodities remains an issue in eight countries  
      • Cameroon, Senegal, South Africa, and Tanzania showed improvements in this area in comparison to the first round 
      • Burkina Faso, Burundi, South Sudan, and Zimbabwe reported stockout in the second round 

    Safe abortion services decreased in three (43%)  of the seven participating countries that answered this question. Post-abortion care services decreased in six (40%) and increased in two (13%)  of the 15 participating countries. Improvements in self-care interventions were noted in the second round which were not reported in the first round: Cameroon, Guinea, Mali, and South Sudan reported self-provision of pills; Benin, Cameroon, and Senegal reported DMPA sub-cutaneous self-administered; DRC reported Self-management of Abortion (Mifepristone/Misoprostol); and Zimbabwe reported HPV self-testing.

    *CAR, Ghana, Nigeria, and Rwanda did not participate in round 2. Cote d’Ivoire and Ethiopia participated only in round 2.
     

    Related Documents

    • Rapid assessment of continuity of SRHR services in the context of COVID-19 in the African Region: Article: English [pdf]

    • Rapid assessment of continuity of SRHR services in the context of COVID-19 in the African Region: InfographicsEnglish [pdf]

    • Guidelines for the management of pregnant and breastfeeding women in the context of Ebola virus disease English [pdf]

    • Maintaining essential health services: operational guidance for the COVID-19 context English [pdf]

    • WHO online consultation in response to the COVID-19 pandemic: Planning for rapid dissemination and implementation of the WHO Consolidated Guideline on Self-Care Interventions to strengthen sexual and reproductive health and rights in the African Region English [pdf] French [pdf]

    1

    525

    Maternal mortality ratio per 100,000

    2

    27

    Neonatal mortality rate per 1000

    3

    102

    Adolescent birth rate per 1000

    4

    8%

    Percentage of maternal deaths due to abortion

    5

    23%

    Contraceptive prevalence rate, modern methods (mCPR)

    6

    13%

    Annual expenditure on SHRH from government domestic health budget

    The Reproductive Health Programme works for:

    • Control of Sexually Transmitted and Reproductive Tract Infections, and HIV/AIDS
    • Gender Mainstreaming in Sexual and Reproductive Health
    • Prevention of Cervical Cancer
    • Prevention of Unsafe Abortion
    • Repositioning Family Planning
    Control of Sexually Transmitted and Reproductive Tract Infections, and HIV/AIDS

    Sexually transmitted infections (STIs) are transmissible mostly by sexual contact and include vaginal, oral, and anal sex. Transmission is also possible through blood products and tissue transfer. Some STIs like HIV and syphilis can be transmitted from mother to child during pregnancy and childbirth. STIs can lead to severe consequences such as fetal and neonatal death, cervical cancer, increased HIV risk, and infertility. Several other infections result from risky sexual behavior. HPV, which is responsible for almost all cervical cancer, is sexually transmitted.
    Cervical cancer is the leading cause of cancer deaths in the Region. Other sexually transmitted infections such as syphilis, gonorrhea, and chlamydia, are entirely attributable to unsafe sex and still occur in several African countries.

    Many STIs have the effective treatment and can be cured. The incurable STIs are caused by Human Immunodeficiency Virus (HIV), Human Papilloma virus (HPV), Herpes simplex virus (HSV), and Hepatitis B virus. Prevention of STIs is through comprehensive sexuality education, behavioral change, delayed sexual debut, promotion of safer sex, interventions targeting key populations such as sex workers, STI, and HIV pre- and post-test counseling.

    The African region has the highest HIV burden globally, with 25.7 million people living with HIV and 1.1 million new infections in 2018. Adolescent girls have an increased risk because they are often married to older partners. The latter are more likely to have been exposed to HIV. About 31% of females between the ages of 20 and 24 in the African region were married before age 18.

    It is also one of the leading causes of death in the region. Efforts towards the prevention and control of disease spread include access to HIV testing and counseling, promotion of female and male condom use, use of antiretroviral medicine (ARV), and elimination of mother to child transmission of HIV (EMTCT).

    Approximately 85% of pregnant women living with HIV in the African region received ARV in 2018 to reduce the risk of prevention mother to child transmission (PMTCT) of HIV. The coverage was higher in the East and Southern African sub-regions (92%) than in the West and Central African sub-regions (59%). Besides, some countries have committed to eliminating mother to child transmission of syphilis as one of the key targets of the Global Health Sector Strategy on STIs (2016–2021), which reduces ≤50 cases of congenital syphilis per 100 000 live births in 80% of countries.

    Syphilis in pregnancy can result in fetal and neonatal death. Syphilis can be detected using a rapid test kit, and there is an effective antibiotic treatment for it. In 2018, approximately 85% of pregnant women in the African region who tested positive for syphilis were treated.

    Interventions

    This area's main objective is to provide guidance on strategies for controlling sexually transmitted infections (STIs) and reproductive tract infections (RTIs), including strategies to prevent mother-to-child transmission of HIV and other STIs and improve processes for the integration of RH and HIV/AIDS. The following outcomes are expected:

    • improved access to, and uptake of key HIV/AIDS and SRH services, a better access of people living with HIV/AIDS (PLWHA) to SRH services tailored to their needs,
    • improved coverage of underserved and marginalized populations, such as injecting drug users, sex workers or men who have sex with men, with SRH services,
    • greater support for dual protection against unintended pregnancy and sexually transmitted infections (STIs), including HIV, for those in need, especially young people,
    • improved quality of care and enhanced programme effectiveness and efficiency.
    Gender Mainstreaming in Sexual and Reproductive Health

    Gender mainstreaming is both a strategy for planning and a tool for advocacy to reduce harmful effects of the social determinants of health for men and women. However, health professionals are not adequately prepared to address women's and men's gender-specific health needs in their work. Special attention must be paid to particular groups who experience greater mortality and morbidity related to sexual and reproductive conditions than those in a better situation.

    Due to a significant societal disadvantage, girls and women have limited access to health care. As an evidence of the burden of disease related to gender inequality, it is estimated that of all adults living with HIV in sub-Saharan Africa, 61% are women. Maternal mortality is also higher in developing countries than in the industrialized world. Sexual and gender-based violence affects mostly women.

    Therefore, public health actors must be able to identify the factors that put women and men at risk and address these factors through effective interventions. The SRH Programme and the Gender and Women's Health Programme will support countries to seek structural changes focused on people's needs to ensure universal access to appropriate quality sexual and reproductive health care.

    Prevention of Cervical Cancer

    Cervical cancer is caused by the Human Papilloma virus (HPV). It is the second most common cancer among women living in the undeveloped regions due to late presentation and inadequate services. Human papillomavirus (HPV) is a group of viruses that are extremely common worldwide. There are more than 100 types of HPV, of which at least 14 are cancer-causing (also known as high-risk type).

    Two HPV types (16 and 18) cause 70% of cervical cancers and pre-cancerous cervical lesions worldwide.

    The African region has a heavy burden of Cervical Cancer due to insufficiency or lack of information and skills, lack of cervical cancer control policy, strategies and programmes, lack of collaboration and coordination of interventions, and lack of recent and comprehensive data.

    In 2018, approximately 311 000 women died from cervical cancer; more than 85% of these deaths occurred in low- and middle-income countries. Cervical cancer can be cured if diagnosed at an early stage.

    The risk of HPV infection leading to cervical cancer is higher among immunocompromised individuals.

    HPV vaccines have been developed and approved to prevent infection from the HPV types 16 and 18, responsible for about 70% of cervical cancer cases worldwide. WHO recommends a 2-dose schedule of HPV vaccination targeting young adolescent girls aged 9-14 years old. The recommendation is 3-doses for immunocompromised and/or HIV-infected girls.

    As of December 2019, only 15 countries in the African region had instituted HPV vaccination as part of the routine immunization system.

    WHO recommends that women of 30 years and above undergo screening with high-performance tests for abnormal cervical cells and pre-cancerous lesions and treatment. This will aid early detection when chances for cure are higher. The age requirement does not apply to HIV positive women who are encouraged to go for screening as soon as they know their status.

    Women identified with cervical disease (precancer or cancer) should receive treatment and care as part of tertiary prevention of cervical cancer.

    Prevention of Unsafe Abortion

    There are 56 million induced abortions each year worldwide.

    In 2017, the African region had the highest maternal mortality ratio, estimated at 525 maternal deaths per 100,000 live births. It is estimated that 5.2% - 17.2% of maternal deaths annually in Sub-Saharan Africa are due to abortions. Abortion-related complications are hemorrhage and sepsis.

    Additional consequences of unsafe abortion include lost productivity, economic burden on public health systems, stigma, and long-term health problems, such as infertility.

    Providing Safe abortion and Post Abortion Care can help to reduce maternal deaths drastically in the Region.

    The laws concerning a woman's right to abortion are mostly restrictive in the African region, and this promotes unsafe abortions, which can result in high rates of maternal mortality.

    Most of the abortions conducted in the African countries, where it is illegal, are unsafe.

    Only four countries in the African region, Angola, Cabo Verde, Sao Tome & Principe, and South Africa permit abortion to be provided legally upon the woman's request, with no justification requirement, up to a certain gestational limit.

    It is entirely prohibited in Senegal, Mauritania, Madagascar, Guinea Bissau, Gabon, and Congo. In the remaining 40 countries in the region, abortion is restricted with legal permission only under certain circumstances.

    A significant challenge to understanding the severity and extent of unsafe in the African region is the absence of reliable data due to the stigma and fear attached to abortion in countries, especially when it is unlawful.

    Post-abortion care is the management of complications resulting from incomplete abortions or miscarriages. Health facilities (public or private) that provide primary health care services and higher levels are expected to have post-abortion care capacity.

    A study, which looked at the capacity of national health systems to provide post-abortion care in 7 African countries, revealed that less than 10% of primary-level facilities could provide basic post-abortion care in 5 (71%) of those countries. In addition, less than 50% of referral facilities could provide comprehensive post-abortion care.

    For more information: 
    WHO African Region's Countries Abortion Health Profiles
    Global Abortion Policies Database

    Repositioning Family Planning

    Family planning enhances efforts to improve family health. However, traditional beliefs, religious barriers, and lack of male involvement have weakened family planning interventions. Research has confirmed a high "unmet need" for family planning in sub-Saharan Africa in terms of the number or percentage of married women who say they prefer to avoid a pregnancy but are not using any contraception method.

    Family planning services include counseling and provision of contraceptive methods. Modern contraception methods include oral contraceptives, implants, injectable contraceptives, intrauterine devices (IUDs), condoms (male and female), emergency contraceptive pills, lactational amenorrhea method, basal body temperature method, among others.

    The proportion of the need for family planning satisfied by modern methods, Sustainable Development Goals (SDG) indicator 3.7.1, was 75.7% globally in 2019. Yet, less than half of the need for family planning was met in Middle and Western Africa.

    Approximately 17% of all women in Sub-Saharan Africa and 23% of married or in-union women have an unmet need for family planning. These women would like to stop or delay childbearing but are not using any form of contraception and are thus more likely to have unplanned pregnancies or closely spaced childbirth.

    Only about 28% of married or in-union women (15 – 19yrs) in the region are using modern family planning methods, and 52% have their demand for family planning satisfied by current methods.

    SRH Programme is supporting countries to: (i) raise awareness at policy and political level on the benefit of family planning, (ii) develop or review family planning policies, (iii) improve the quality of family planning and other reproductive health services, and (iv) foster integration of family planning into reproductive health.

    For more information: Family Planning health profiles 2019

    Featured news

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    Raising awareness of the African Region’s SRHR stakeholders on the WHO guidelines on self-care interventions for SRHR and Safe Abortion Care
    South Africa
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    Nigeria and Sierra Leone
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    Events

    The International Day of Zero Tolerance for Female Genital Mutilation (FGM)

    5 February 2021

    Inaugural Meeting of the WHO Reproductive, Maternal, Newborn, Child and Adolescent H...

    25 November 2020

    World Contraception Day and International Safe Abortion Day

    28 September 2020