SEXUAL & REPRODUCTIVE HEALTH THEMATIC BRIEF

2 September 2017

OVERVIEW

Health status in a population is strongly correlated to the economy of the jurisdiction.  In the case of Sexual and Reproductive Health, the health status of women and girls has a bigger dependency on the economic status from men, who are many times the ones that decide on and distribute economic sources.Health indicators and economic indicators are interlinked. Wealthier countries have healthier populations.  It is the reality that poverty adversely affects the availability and accessibility of basic sexual and reproductive health services and commodities. This is especially important because in most cases in the region, women are poorer that men.

Reproductive health problems, such as early unwanted pregnancies, HIV infections, STIs and pregnancy related illness and death, account for a significant part of the burden of disease amongst adolescents and adults.  WHO estimates that poor reproductive health accounts for up to 18% of the global burden of disease and 32% for the total burden of disease for women in reproductive age. Poor reproductive health is responsible for more than one third of all disability-adjusted life years (DALYs), lost by women during their reproductive years.

In the English and Dutch speaking Caribbean, health systems face tough and complex challenges derived in part from pressures such as distribution of national resources by different government entities which donot necessarily prioritize health; brain drain of qualified health providers; ageing populations in some countries with zero growth or decreasing populations with fertility rates below replacement level such as Antigua, Barbuda andBarbados,The Bahamas, Dominica, St Kitts-Nevis, St. Lucia and Trinidad and Tobago; and the opposite population growth with indicative age pyramids with a large percentage of people in younger ages such as Guyana, Belize and Suriname.

Existing data indicate a decrease in unmet need for family planning in some countries and persistent levels in others. In Jamaica, unmet need decreased from 22 per cent in 2008 to 12 per cent in 2013; in Guyana, it is still around 28 per cent. The chief cause is limited access to sexual and reproductive health commodities, mainly for adolescents and the poor. This situation is compounded by the effects of the Zika virus outbreak on reproductive choices.

Maternal mortality levels remain low; a significant decrease in Belize, declining from a ratio of 150 per 100,000 live births in 2013 to 45 per 100,000 live births in 2015. Jamaica’s rate moved from 110 per 100,000 live births in 2000 to 89  per 100,000 in 2008. However, these rates have stagnated in the past few years and several countries in the sub-region did not achieve MDG5. Guyana and Suriname still show ratios beyond 100 per 100,000 live births, mainly due to the lack of skilled birth attendants in the hinterlands.  Further, the profile of maternal deaths in the ESDC may be changing as Maternal Mortality  Ratios among adolescent mothers are now higher than among adult mothers.

The key underlying factors for maternal mortality in the region appear to be lifestyle-related non-communicable diseases such as obesity, diabetes and also HIV. Chronic illnesses such as diabetes, hypertensive disorders in the general population may affect the outcome of pregnancies by increasing the possibilities of developing hypertensive disorders during pregnancy, the main cause of maternal death in afro-descendant women in the Caribbean.  It is also responsible for increased incidence of breast and cervical cancer in women and prostate cancer in men. 

Pregnancy and childbearing in adolescence continues to be a health concern as well as a population and development issue in the EDSC region.  Approximately 20% of live births each year occur to adolescent mothers. Recent data show that Guyana has the highest level of adolescent birth rates, with 97 per 1,000 births, followed by Belize at 90 and Jamaica at 72. A 2009 study highlighted the median age of sexual initiation to be 12 years or younger in the Caribbean. It is argued that lack of access to quality sexual and reproductive health services, especially for adolescents younger than 18 years, and an inconsistent, sometimes contradictory, cultural and legislative environment are key contributors. Other factors are poverty, sexual violence and a reluctance to teach comprehensive sexuality education. Even though the CARICOM integrated strategic framework to reduce adolescent pregnancy in the Caribbean addresses comprehensive sexuality education, sexual violence, sexual and reproductive health, and knowledge management; cultural and legal barriers, as well as institutional weaknesses obstruct its implementation in all countries.

The Caribbean has the second highest HIV prevalence in the world; the highest levels are in the Bahamas, Jamaica, and Trinidad and Tobago, where young people account for nearly 60 per cent of new infections. Lead causes are stigma, discrimination and, in some countries, laws that restrict access to services for vulnerable populations (see Briefing Sheet on HIV and AIDS).

SRH GUIDING STRATEGIC FRAMEWORK

UNFPA STRATEGIC PLAN 2014 – 2017

Outcome 1: Increased availability and use of integrated sexual and reproductive health services (including family planning, maternal health and HIV) that are gender-responsive and meet human rights standards for quality of care and equity in access.

Outcome 2: Increased priority on adolescents, especially on very young adolescent girls, in national development policies and programmes, particularly increased availability of comprehensive sexuality education and sexual and reproductive health services

CPAP 2012 - 2016

CP Output 1: Strengthened capacity of national and sub-regional institutions and organizations to advocate and deliver comprehensive and integrated sexual and reproductive health services, including in emergency situations, and particularly for vulnerable groups.

Indicators

1.1          Number of countries that implement mechanisms to track supply and demand of sexual and reproductive health commodities at all levels

1.2          Number of persons trained by UNFPA in logistics management

1.3          Number of midwives and health care professionals receiving basic and comprehensive emergency obstetric care training supported by UNFPA

1.4          Percentage of referral institutions providing adequate EMOC services

1.5          Number of persons from national and sub-regional institutions trained on MISP and SPRINT

CP Output 2: Enhanced capacity of national and sub-regional institutions and organizations to address the specific reproductive and sexual health needs of adolescents and young people.

Indicators

2.1          Number of countries that integrate adolescent sexual and reproductive health into their reproductive health policies and plans by 2015                                

2.2          Number of persons trained to address the reproductive health and reproductive rights of young people              

2.3          Number of countries that have sexuality education integrated into programmes for out-of-school youth                  

2.4          Number of countries supported by UNFPA that have established youth-friendly spaces that provide sexual and reproductive health services for adolescents and young people

PAST PROGRAMME FOCUS AND IMPLEMENTATION

Advocacy to strengthen political commitments and funding for integrated SRH services.
The SRO has supported the development of National Sexual and Reproductive Health Policies, protocols and norms. In this regard UNFPA has been advocating with Governments for the development of these policies and accordingly provided technical and financial support to the following countries:

1.       Belize, Suriname, St. Lucia, Grenada and Trinidad and Tobago that already have the policy or are in the process of completing the national policies; and

2.       Guyana, Jamaica and St. Maarten that are in the process to initiate the development of the policies.

UNFPA has supported the regional assessment on the identification and analysis of legal barriers for adolescents to access SRH services and commodities, as a response to the identified barriers. Subsequently,support was provided for the developmentof a model legislation to reduce those barriers which is being promoted in different countries for its application. This activity has focused in OECS countries and it is expected to be usedas a model for the entire Caribbean Region. UNFPA has supported technical and financially a regional study on adolescent pregnancy and subsequently collaborated with CARICOM to develop and support the implementation of a regional Integrated Strategic Framework (ISF) for the Reduction of Adolescent Pregnancy in the Caribbean.

Strengthened capacity in countries to plan, implement, and evaluate programmes that increase access and use of rights-based integrated SRH services, especially for disadvantaged and marginalized populations.
SRO has deployed technical and financial support to the EDSCcountries at various levels for the following activities:

1.       Advocacy and institutional strengthening to address the SRH needs of persons with disabilities through : (i) Development of a Facilitator´s guide for training of professional personnel in SRH for adolescents with disabilities and a training manual for health care providers and counselors to understand the SRH needs of adolescents with disabilities; (ii) Formulation of a SRH Strategy for young people with disabilities for Barbados; and (iii) Supporting the regional groups of person with disabilities and training of health providers on how to address SRH issues for persons with disabilities in Trinidad and Tobago, St. Maarten, Anguilla and Barbados

2.       Creating youth friendly spaces and working with teenage mothers in St Vincent and the Grenadines, Guyana, Suriname, Trinidad and Tobago, St. Lucia, Grenada and Jamaica

3.       The revision and update of SRH programmes, including norms and protocols to provide FP services, cervical cancer prevention and treatment services, prostate cancer prevention and treatment

4.       The strengthening of technical knowledge in SRH services by facilitating technical training on contraceptive technology, cancer prevention, emergency obstetric care services, maternal mortality reduction, and development of national protocols to identify and support victims of GBV and sexual violence

Increased capacity to implement the Minimum Initial Service Package for SRH in Crisis (MISP).
The SRO has enhanced the capacity of national and regional entities to address SRH and GBV in humanitarian setting through technical and financial assistance for the:

1.       Development of national disaster preparedness and response plans in Suriname, Trinidad and Tobago, Anguilla, St. Maarten, St. Lucia and Jamaica;

2.       Training of trainers on UNFPA’s role in preparedness and response to emergencies; and onthe MISP with national and regional actors such as from the UN, the Governments, CARICOM training Unit, IPPF, CEDEMA and other NGOs partners.

Strengthened community engagement, partnerships, and networks to advance integrated SRH programmes that meet the needs of individuals and communities.
Financial and technical support has been provided to:

1.       Support the  engagement of NGOs in the advancement of SRH programmes, providing them with technical and financial support for training of their personnel on RH matters;

2.       Developa policy of reintegration of young girls who are pregnant to the school system.  The policy for Jamaica and Saint Lucia is completed and being implemented. UNFPA has provided technical assistance to the Government of Jamaica to assess its implementation capacity. Creation and functioning of youth friendly spaces in several countries, which allow  young people the access to  age-appropriate  information about SRH;

3.       Support different studies on SRH status on adolescents, HIV and SRH linkages and adolescent pregnancies determinants;

4.       Advocating for  the development and update of norms, protocols and policies to provide SRH services and commodities, including FP, cancer prevention and treatment, maternal and neonatal mortality and morbidity reduction, prevention and treatment of victims of GBV and SV and inclusion of SRH services in humanitarian settings.

Creating evidence- based guidelines and support health services and other sectors to improve the access to health services and commodities for adolescents.

Progress in this area has been realized through implementation of the following activities:

1.       Support the national study on adolescent fertility and poverty in Suriname 2011.

2.       Support the study: Strengthening the evidence base on youth sexual and reproductive health and rights in the Eastern Caribbean (Dominica, Grenada, St. Lucia and St. Vincent and the Grenadines), 2012.

3.       Support the regional study on adolescent pregnancy in the English and Dutch speaking Caribbean (Jamaica, St.Vincent and the Grenadines, Suriname and Trinidad and Tobago) 2013.

4.       Advocate with CARICOM to include the issue of adolescent pregnancy in their last three Council for Human and Social Development (COHSOD) agenda and allowed UNFPA to do a specific presentation in the three COHSOD.

5.       Support the development of an Integrated Strategic Framework to reduce adolescent pregnancy in the English and Dutch speaking Caribbean.

6.       Support the development of National Adolescent Pregnancy reduction strategies in Anguilla, St. Martin, Grenada, Dominica, Suriname, Guyana, Jamaica, Belize, Trinidad and Tobago, Barbados, British Virgin Islands, Antigua and Barbuda, and St. Lucia.

7.       Implement a High Level Consultation on Adolescent Pregnancy in 2013.

Support local legislators to review and revise local laws that make obstacles for adolescents to access services and commodities.

Progress in this area has been realized through implementation of the following activities:

1.       A legal Gap analysis of adolescent SRH in the OECS (Antigua and Barbuda, Commonwealth of Dominica, Grenada, Monserrat, St Kitts and Nevis, St Lucia, St Vincent and the Grenadines with Anguilla and British Virgin Islands as associate members), 2012.

2.       Reproductive Health Care Services and Protection Bill (a Model legislation to improve access to SRH services and Commodities for adolescents in the OECS) 2013.

3.       Presentation for approval of the Model Legislation to Council of Ministers of Human and Social Development and the OECS Secretariat for endorsement previous to present to Cabinets, ongoing Consultation.

4.       Presentation for approval of the Model Legislation in the meeting with Attorneys-General and Ministers of Legal Affairs in March 2015.

5.       Support the development of a National Policy to re-integrate adolescent mothers to school system in Jamaica.

6.       Support local chapters of NGOs working with adolescent mothers, with focus on live skills development in St. Lucia, Grenada, Jamaicaand Guyana.

Raising awareness of health issues in adolescents related with the well-being and national development of countries.

Progress in this area has been realized through implementation of the following activities:

1.       Raising awareness of health issues for young people among the public and Ministries of Health, Youth and Sports, Education, Finances at regional level.

2.       Raising awareness of health consequences of condone traditional harmful practices with decision makers at regional level.

3.       Making recommendations to Governments on how to improve adolescent health and create adolescent friendly health services at regional level.

4.       Make recommendations to Governments to include age-appropriate sexuality education in the national education curricula.

5.       Support the development of a regional Parenting education programme with emphasis in SRH matters.

6.       Support the capacity building of Health and Family Life Education trainers and facilitators at regional level.

OPPORTUNITIES AND KEY CHALLENGES AFFECTING SRH PROGRAMME IMPLEMENTATION

1.       The lack of skilled personnel as health providers; the brain drain of skilled medical personnel.

2.       Weak capacity for on the job training for health service providers and outdated protocols for different services such as FP, cancer prevention and treatment; cultural norms that are pervasive for the health of women and girls; and inadequate reproductive health services for men.

3.       Adolescent pregnancy is another challenge for SRH in the Caribbean.  It is correlated to the ambivalence about contraception, which is based in cultural and religious reasons or misconceptions from the health provider and the users about methods and side effects. 

4.       Significant disparities in the rate of unintended pregnancies exist between different socioeconomic, educational, ethnic, age and racial groups in the Caribbean. 

5.       Poverty and having already been a young mother may predispose women to a cycle of unintended pregnancies.

6.       Weaknesses and inconsistencies in the legislation related to SRH access especially for young people and other marginalized groups.

7.       Some young people in the Caribbean receive limited or no sex education in schools.  Many parents are usually uncomfortable with discussing prevention of STIs and unwanted pregnancies with their children or they are ignorant on the topic.

8.       In some countries young pregnant mothers are not allowed to continue their education during the pregnancy and are forced to stop attending school.

9.       The high prevalence of non-communicable chronic diseases that affect the outcome of pregnancies is also a serious challenge in the Caribbean.  The high incidence of high blood pressure in women, obesity and diabetes are directly related with maternal and neonatal mortality and morbidity. Poor health seeking behaviour among men directly is correlated to the high incidences of prostate cancer.  The culture of having multiple partners also influence in the transmission of STIs such as HIV and HPV.

10.    SRH in the EDCS is a flagship and strategic component of UNFPA presence and work in the Caribbean. The limited capacity and availability of internal human resources in this area represent a key challenge in the delivery of the SROC mission, especially in 2016.

11.    The centrality of youth development in the regional and national development frameworks and the UN MSDF represent key opportunities for UNFPA policy dialogue and advocacy for universal access to SRH especially among young people.

SROC 2016 SRH PROGRAMME FOCUS AND ACTIVITIES

The 2016 SRH programme was developed within the context of relevant global and regional frameworks including the CPAP, and through consultations with the Liaison Offices, Caribbean ministries of health and other regional and national stakeholders.  A technical assistance tool was used with liaison offices to collect inputs on local need and key areas of focus.  The findings gleaned were reviewed by the directorate after which a prioritization exercise was conducted to agree on the most strategic actions for implementation considering our limited resources.  The following areas were selected for 2016 programming:

1.       Continuing the support for the implementation of the Integrated Strategic Framework to reduce unwanted pregnancies in adolescents in the region with emphasis on the development of adolescent reproductive health national policies and to increase the prevalence of use of contraceptive for adolescents.

2.       Support for regional activities in response to the Zika-virus Epidemic.

3.       Support for the development of SRH National Policies in the region

4.       Support to MOH to reduce Maternal Mortality and Morbidity by increasing access to commodities and health services in the region.

5.       Training in the Contraceptive Technology for Health Care Providers in selected countries with emphasis on the human rights approach.

KEY PARTNERS

The SROCpartners with the MoH in the region, utilizing the SRH assessment guidance note and tools for situation analysis and the SRH framework from HQ.The main partners in the SRH activities included the Ministries of Health, Ministries of Education, NGOs and UWI campuses in Trinidad and Tobago and Barbados.

2016 SRH ACTIVITIES

Activity 2.1:  Strengthened advocacy in support of FP for the marginalized people:

Increased demand for RH commodities, by poor and marginalized women and girls - strengthened advocacy in support of FP for the marginable

2.1.1       Regional capacity building for national institutions on contraceptive technology, logistics, forecasting, procurement, programming and promotion of RHCS for at least five (5) priority countries.

2.1.2       Support the regional political dialogue on adolescent sexual and reproductive health commodity security and access to services for at least six (6) priority countries.

2.1.3       Support the development of sexual and reproductive health national policies, including family planning in their strategies and protocols for countries that requested UNFPA assistance.

2.1.4       Monitoring and evaluation and provision of technical support in regards of RHCS at regional and national level.

Activity 2.2:  Strengthened capacity to advocate and deliver SRHS:

Strengthened capacity of national and sub-regional institutions and organizations to advocate and deliver comprehensive and integrated sexual and reproductive health services, including in emergency situations, and particularly for vulnerable groups

2.2.1       Development of national prevention and response plans for Zika aligned with UNFPA global/regional prevention and response plan in all 6 countries.

2.2.2       Evaluation of SRH policies in the region and the extent to which ASRH is integrated into                 existing policies.

2.2.3       Technical support for the development of an SRH Policy for the Commonwealth of Dominica.