Public Health AffairsReproductive Health in The Middle East:Achievements and challenges [Archives:2005/887/Health]

October 20 2005

By Dr. Saleh Al-Habshi
Msc. in Public Health

Reproductive health (RH) is a relatively new concept that comprehensively addresses all of the health issues regarding reproduction for both women and men, whether young or old. RH sometimes addresses women's health issues as a whole, since most of them are closely related to reproduction. The countries of the Middle East (ME) region face unprecedented challenges to promoting social and economic development in this rapidly changing and competitive world. Governments in the region are struggling to sustain the improvements in the quality of life of their citizens that they have worked hard to bring about. Each government tries to achieve equity in terms of the basic needs of all citizens, and to guarantee the rights of each individual, while respecting the cultural values of the people and preserving the unity and integrity of the country.

In terms of health outcomes ME countries have achieved significant improvements during the last three decades. For instance, total fertility rates declined remarkably in the 1980s in several countries, and infant mortality rates decreased in most ME countries as well. Despite these achievements, however, some RH problems persist, while unfortunately new issues have emerged to increase the burden. The major RH problems in the ME region, which represent the current challenges, include high maternal mortality in several countries; high fertility and a slowing of the decline in fertility rates; early marriage and high teenage fertility; increasing prevalence of sexually transmitted diseases (STDs) including HIV/AIDS; and female genital mutilation (FGM) in Egypt and Yemen. Maternal mortality ratios (MMRs) remain high in several ME countries such as Yemen, Egypt, and Morocco, and the rate has increased in Iraq. Among the 18,000 maternal deaths in the region each year, 7,800 occur in Yemen, 3,000 in Egypt, and 1,600 in Morocco. Overall, a leading cause of death among women of reproductive age is pregnancy-related illness. The major causes of maternal mortality are bleeding, infection, and pregnancy-induced hypertension: about 25-30 percent of maternal deaths are attributable to severe bleeding. The share of maternal deaths caused by unsafe abortion in the region is lower than the global average. In Egypt, one-quarter of maternal death cases involved the death of the fetus also, and one-third of the cases involved the subsequent deaths of infants that were born alive. Both increased prenatal care coverage and increased rates of deliveries assisted by skilled attendants correlate with a decrease in MMR. The most effective intervention for preventing maternal deaths is attendance at birth by health professionals trained in lifesaving skills, with backup for care of severe complications. Better postpartum care and postabortion care also reduces MMR. Among ME countries, there are significant gaps between urban and rural areas in terms of access to and quality of services, and the gaps are particularly large within lower-income countries and countries with higher MMRs. This indicates that interventions should be targeted to decreasing maternal deaths among the underprivileged population. Although fertility has declined substantially in the ME countries over the past 15 to 20 years, the region has the second-highest rate of natural increase in the world. The total fertility rate (TFR), or expected number of children per woman, is approximately 5 in the ME region, much higher than the global average, which reached 3.2. Among ME countries, TFRs range from less than 3 in Iran and Tunisia to almost 6 in Yemen, Saudi Arabia, and West Bank and Gaza. The decline in fertility in ME is due to the increased age of women at marriage, increased age at first childbirth, and increased use of contraception. Fertility decline started to occur in the region in the early 1970s and accelerated considerably in the early to mid-1980s. In several countries, however, the pace of decline slowed in the 1990s. Fertility decline is encouraged by several factors, including low infant and child mortality, high female literacy and education, and active family planning programs. Even without widespread use of contraception, fertility decline may occur as a result of broader changes in the social environment that affect the status of women, better health services that reduce infant mortality, and increased income levels and urbanization. In the ME region, however, the relationship between income and fertility is less clear-cut: TFRs in ME countries are high compared with those of countries in other regions that have similar income levels. High fertility and rapid population growth place pressure on various sectors and can therefore hinder economic and social progress. Frequent, closely spaced births often take a toll on the health status of both mothers and their children.

Despite recognition of the negative impacts of rapid population growth, fewer than half the countries in the region have explicit policies to lower fertility, and access to family planning is still limited. The prevalence rate of modern contraceptive methods is only 10% in Yemen and is less than 30% in countries such as Oman, Syria, and the United Arab Emirates. The two primary reasons for not using family planning services or for discontinuing the use of contraceptives are the desire for another child and the fear of side effects. Lack of access to quality services is a major reason for unmet need, indicating that both access and quality issues must be addressed. Expanding the mix of methods, improving counseling, and strengthening the technical competence of providers are essential steps for improving access and quality. To some extent, higher income levels, increased health expenditures, and rising educational levels for women are each linked to a decrease in MMR as proved by many studies. However, contrary to the global experience, these factors do not necessarily correlate with the expected number of children per woman in ME countries. In addition, women's increased share of household income does not correlate with either decreased MMR or the expected number of children per woman.

Although the estimated prevalence of STDs in the ME region was the second-lowest among six developing regions, around 12 million people in the region suffer from STDs. Compared with other regions, estimated adult HIV prevalence also remains low; however, the total number of AIDS deaths has increased almost sixfold since the early 1990s. Main transmission routes include intravenous drug use in Iran and sexual contact in Yemen. About 1.6 million girls are married before age 20, and every year about 900,000 babies are born to teenage mothers. High teenage fertility in ME countries is due to the high incidence of early marriage. Approximately 60% of married women are under age 24 in Yemen and Oman, and more than 40% in Egypt were married before the age of 20. Teenage fertility rates in Yemen, Oman, and Libya are twice the global average. The health risks associated with pregnancy and childbirth are generally higher for young teenage mothers than for women in their twenties.

Despite international condemnation and a government ban, FGM of young girls is practiced in many ME countries particularly in Egypt and Yemen. Most Egyptians have a positive attitude toward the practice, and almost all Egyptian women have undergone the procedure. FGM is practiced in Yemen as well, particularly in rural and coastal areas.

RH problems in the ME are attributable to complex factors, and issues are deeply related to a country's levels of social and economic development and gender equity. Compared with countries at similar income levels in other regions, the ME region is unique with regard to its high total fertility and adolescent fertility. Countries with high maternal mortality have an urgent need to improve maternal care; those with high fertility need to develop effective strategies and improve access to and quality of services; and all countries should strengthen STDs/AIDS prevention programs. Strategies and interventions will differ depending on each country's economic and social situation. Potential policies and strategies for improving RH in the region should be developed. Strong political commitment is essential to overcoming social and cultural constraints. A Comprehensive approaches will work best in this regard, by focusing on priority issues. Solutions could be reached by overcoming all obstacles, such as shortage of financial and human resources, and cultural resistance. Developing sustainable financing mechanisms to ensure access to essential services and to provide incentives that encourage preventive care would be of great help. A fundamental issue is raising awareness and changing behaviors of individuals through effective information, education, and communication, particularly among community leaders and decision-makers. Regionally, health system reform efforts must include RH services in public and private sector. For ensuring realization of fruitful results, sustainability of RH activities and women empowerment by promoting their participation in decision-making and overall developmental process are crucial to be considered.