Reproductive Health envisages that people should be able to lead their reproductive life and exercise the reproductive choices without any fear of adverse outcomes. This means that those, who want to produce a baby, should be able to do so without risk and fear, and those who want to restrict family- should also be able to do that. Options to prevent and treat the factors and conditions that can possibly lead to infertility should be available and affordable. Quality care services to ensure healthy antenatal, intra-natal and post-natal period should be available, so that healthy baby is born without any threat to health of mother and baby. Those who chose to restrict their fertility, and want to adopt temporary or permanent methods of contraception, should be able to access and get these services, without any apprehension of side effects or any other financial barrier.

‘Quality of care’ was the central conceptual thread in the concept of reproductive health. This was in clear deviation from the previous concepts that were target oriented and were engrained in the health programmes known by various names in the previous era: like Safe mother hood programme, or Child Survival and Safe Motherhood programme etc. This conceptual change had occurred due to understanding that in the race of achieving targets for contraception, quality is getting compromised, more people are getting complications and contraception service is adopted when already couples have produced many children. Thus there is hardly any impact on the fertility rate. Moreover, contraceptive choices were not offered and focus was only on permanent method.

How far we are successful even after introduction of the concept of reproductive health and reproductive rights? And what are the issues and challenges? Out of many issues, I will deliberate only on few in this article. Anaemia and Reproductive Tract Infections are two important barriers to exercise both the reproductive choices: Fertility and Contraception. Anaemicpregnant women are at significant risk to their own life and to the lives of their newborns. Anaemic women are also ineligible for adopting permanent method of contraception; but still they are made eligible on paper and are operated to achieve the targets, putting their lives at risk. Following examples will illustrate the issues around anemia. While doing verbal autopsy for neonatal deaths, still births and maternal deaths, we came across many examples where an antenatal mother under labour pains was referred from primary health centre (PHC) to community health centre (CHC) to district hospital (DH) to tertiary care hospital (TH); because she was severely anaemic, and health facility was not competent to deliver the severely anaemic mother. This happened despite the fact that most of antenatal women had 3-4 antenatal checkups and were registered by govt. health system during first trimester. This invariably resulted in adverse pregnancy outcome.

One of the important reason is that our health system facilities are not able to check hemoglobin with valid methods and diagnose the severity of anemia. In one case, severely anaemic mother under labour pain was referred from CHC to DH. After checking hemoglobin at DH, this mother was referred back to CHC with comments that she is not severely anaemic. CHC again tested the hemoglobin and again referred the mother to DH with comments that she is severelyanaemic. DH again tested hemoglobin, and referred mother to TH. In this entire process her labour pains increased and eventually she delivered at the gate of TH. This raises two fundamental issues: lack of sensitivity of the health system and non -availability of standardized tests for the most basic parameter: Hemoglobin assessment, for a population where anemia is rampant. Second reason is inappropriate prescription for anemia. Invariably, women are put on prophylactic doses of iron and folic acid (IFA), even if they required therapeutic doses or injection iron and sucrose or even blood transfusion depending on severity of anemia and pregnancy gestation period. There are ample examples showing that health workers are not able to distinguish even between pediatric IFA and Adult IFA. There are frequent stock outs of IFA as well.

Third important reason is non compliance to consumption of IFA. Non compliance is also related to inappropriate counseling to mothers about possible side effects, and how to overcome these, and also to lack of follow up support to them. There are experiences showing that compliance can be improved with proper counseling and follow-up. We have tried to follow-up the anaemic women through mobile phones. Experience so far suggests that it is helping women to improve compliance. Second important issue is - reproductive tract infections/ Sexually Transmitted Infections. Many community based studies have shown high prevalence of RTIs/STIs.^1,2 Due to non availability of examination and diagnostic services, an important concept of syndromic management of RTIs/STIs had emerged that allowed treatment according the level of diagnostic service available. Studies have been done showing the validity of syndromic diagnoses.^3,4 Despite limitations, syndromic management remain important tool in settings with no or low resources. Various studies have also shown that prevalence of much feared infections like Chalamydia and gonorrhea is not high in general population.^1,5 However, bacterial vaginosisemerged as important problem.¹ Clinically many women do report vaginal discharge and low back ache.^2,3 When such population with high RTIs, is offered some contraception – temporary or permanent, it is mandatory to diagnose and treat infections. However, this protocol is often missed. This results in high complication rates including expulsion of copper –Ts, and post operative complications. Often, community based studies label it is myth and misperception of women: that I am having this pain / problem since my operation was done! This further results in thenon acceptance of the contraception methods in the community. Root problem is again in the insensitivity, lack of training and awareness and lack of resources in the health systems to provide quality health services. It is often challenging to introduce such services in the community.⁶

There is also evidence, that there is higher probability of newborns getting infected when they pass through infected reproductive tract. This may result in high neonatal sepsis and higher neonatal deaths due to sepsis. Higher institutional rates have helped to put breaks on the neonatal tetanus and neonatal sepsis due to unhealthy cord cutting practices prevalent during home deliveries by untrained birth attendants. Still, pockets of such practices are prevalent that need to be looked after. Important challenge for community based RTI/STI services is to convince women to get them examined. Studies show that many asymptomatic women also are having RTI.^1,3 However, they do not perceive it important and do not show up for examination, even if the RTI camp is organized in their own village.

In conclusion, conceptually lot of progress has been done to move towards quality of care and reproductive health. However, on ground, health systems are not prepared even to address two most important problems of Anaemia and Reproductive Tract Infections. These two services do not require much budget. However, these do require priority, sensitization and accountability, at all levels of health systems.

None.

The author declares no conflict of interest.

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