What is reproductive health care? Adrienne Germain and Jane Ordway have described a reproductive health approach to providing services as one that enables women to:

• Regulate their fertility safely and effectively;
• Remain free from disease, disability, or risk of death due to reproduction and sexuality;
• Terminate unwanted pregnancies; and
• Bear and raise healthy children (54).

• AIDS and other STDs,
• Education about reproductive health and sexuality; and
• The impact of unsafe abortion on women (4).

In Tunisia the National Family Planning Program (ONFP) was able to provide more comprehensive reproductive health care in one hospital by stressing the cultural significance of the 40th day postpartum, the end of seclusion for mothers and their newborns. ONFP designated the 40th day for follow-up visits and made available neonatal, postpartum, and family planning services to women in a single clinic visit. A 1987 study showed that 83% of new mothers returned for their 40th-day check-up. Of these, 56% began using a family planning method (27). The approach is now being expanded to the entire country.

In Bolivia, where infant mortality is higher than in any other country of the Western Hemisphere except Haiti, the Ministry of Health has launched one of the most comprehensive reproductive health campaigns ever in Latin America. The campaign addresses four components: family planning, prenatal and postnatal care and safe delivery, breastfeeding, and prevention of illegal abortions. A special logo appears outside selected clinics where trained staff members can respond to people's reproductive health needs. A radio and television campaign alerts the public to reproductive health and urges them to visit the clinics (11, 82, 175).

Safe childbirth. Better delivery care and better access to delivery care would substantially reduce maternal deaths and illnesses (168, 187, 189). Nearly all maternal deaths and most maternal illnesses occur in the developing world. The number of maternal deaths worldwide each year is estimated to be 500,000 but may be even higher because of underreporting (67). Also, each year many millions of women suffer life-threatening, chronic, or other serious health problems resulting from pregnancy and childbirth (102).

Yet adequate delivery care remains the exception rather than the rule. In 12 of 26 countries that conducted DHS between 1986 and 1989, at least half of all births in the five years before the survey took place without the help of a formally trained attendant (59).

Because delivery care services are so few, pregnancy is often the most hazardous activity women in developing countries undertake. On average, in the developing world a pregnancy is 16 times more likely to end in the woman's death than in the developed world (112). For example, between 1976 and 1985, 30% of all deaths among women ages 15 to 44 in Matlab, Bangladesh, were related to childbearing (42).

Safe abortion. The challenge of dealing with the millions of unsafe abortions that women undergo must be met in the 1990s, according to many respondents to the Population Reports questionnaire. Abortion should be "safe, legal, and rare," according to US President William J. Clinton (272). As Miguel Trias of Profamilia in Colombia writes, "The abortion issue will still confront us in the next decade" (263). Jos Barzelatto of the Ford Foundation urges, "The issue of abortion as a back-up need for contraceptive failure should not be avoided in preparing for the 1994 International Conference on Population and Development" (217).

The statistics are striking: An estimated 10 to 22 million women undergo clandestine abortions each year in countries where abortion is legally or otherwise restricted (66, 120). Of these women, 100,000 to 200,000 die from complications, accounting for 20% to 40% of all maternal deaths (66). Even where contraceptive use is widespread, abortion should be safe because no form of contraception is perfectly effective, and women will seek abortion when contraception fails (217, 229, 255).

Although women who have just undergone abortions may be highly motivated to use contraception, few family planning programs offer postabortion family planning services (28, 240, 244). Where abortion is legal, family planning programs should work with abortion providers to make postabortion family planning services and counseling more available. Family planning programs also can educate women about the importance of obtaining abortions as early as possible in pregnancy (229).

Where abortion is restricted by law or practice, family planning programs can work with hospital emergency staff and gynecological wards to provide family planning counseling and appropriate health care services to women being treated for abortion complications (75, 96). The US Senate Committee on Appropriations has encouraged USAID to provide support for women who suffer abortion complications and to offer postabortion services (197).

AIDS and other STDs. Worldwide, more than 250 million new cases of sexually transmitted diseases (STDs) are diagnosed each year, of which at least 1 million are infection with human immunodeficiency virus (HIV), which leads to AIDS. In many countries STDs are common among women attending antenatal, family planning, and gynecological clinics. Screening studies at such clinics find that as many as 18% of clients have gonorrhea or syphilis, and 30% have trichomoniasis (92).

In women particularly, symptoms of STDs may not appear until an advanced stage of the disease. If left untreated, STDs can result in pelvic inflammatory disease, chronic pelvic pain, cervical cancer, ectopic pregnancy, and sterility, and may lead to death. Untreated STDs greatly increase the risk of contracting AIDS. STDs in pregnant women can cause stillbirth, congenital malformations and disease, infant blindness, and infant death.

Family planning clinic visits can be opportunities to combat STDs and AIDS by informing, protecting, screening, and treating clients (41, 53, 96, 246, 249). Many family planning providers already are overworked, however, and many programs lack resources to provide additional services (226, 235). "The challenge is making AIDS prevention and family planning work together rather than compete for scarce resources" (222).

Meeting this challenge will require many programmatic changes, including more training for staff and more funding (231, 249, 265). For example, most family planning programs will need to obtain larger supplies of condoms—the contraceptive method that best guards against STDs while at the same time preventing pregnancy.

Family planning programs are trying various approaches to combatting STDs and AIDS. IPPF affiliates in Africa and Latin America typically offer counseling and referrals for clients with symptoms (58, 167). Other family planning programs provide further services. For example, in El Salvador the Asociacion Demografica Salvadorea, a nonprofit family planning organization, screens and treats clients for STDs and provides community outreach, distributes condoms, and notifies the sexual partners of infected people (1). (See Population Reports, Controlling Sexually Transmitted Diseases, L-9, June 1993.)