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Within the framework of the World Health Organization's (WHO) definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health, or sexual health/hygiene, addresses the reproductive processes, functions and system at all stages of life.[1] UN agencies claim, sexual and reproductive health includes physical, as well as psychological well-being vis-a-vis sexuality.[2]

Reproductive health implies that people are able to have a responsible, satisfying and safer sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. One interpretation of this implies that men and women ought to be informed of and to have access to safe, effective, affordable and acceptable methods of birth control; also access to appropriate health care services of sexual, reproductive medicine and implementation of health education programs to stress the importance of women to go safely through pregnancy and childbirth could provide couples with the best chance of having a healthy infant.

Individuals do face inequalities in reproductive health services. Inequalities vary based on socioeconomic status, education level, age, ethnicity, religion, and resources available in their environment. It is possible for example, that low income individuals lack the resources for appropriate health services and the knowledge to know what is appropriate for maintaining reproductive health.[3]

The WHO assessed in 2008 that "Reproductive and sexual ill-health accounts for 20% of the global burden of ill-health for women, and 14% for men."[4] Reproductive health is a part of sexual and reproductive health and rights.

According to the United Nations Population Fund (UNFPA), unmet needs for sexual and reproductive health deprive women of the right to make "crucial choices about their own bodies and futures", affecting family welfare. Women bear and usually nurture children, so their reproductive health is inseparable from gender equality. Denial of such rights also worsens poverty.[5]

Reproductive health should be looked at through a lifecycle approach as it affects both men and women from infancy to old age. According to UNFPA, reproductive health at any age profoundly affects health later in life.[5] The lifecycle approach incorporates the challenges people face at different times in their lives such as family planning, services to prevent sexually transmitted diseases and early diagnosis and treatment of reproductive health illnesses. As such, services such as health and education systems need to be strengthened and availability of essential health supplies such as contraceptives and medicines must be supported.

Contents

Access to reproductive health servicesEdit

Access to reproductive health services is very poor in many countries. Women are often unable to access maternal health services due to lack of knowledge about the existence of such services or lack of freedom of movement. Some women are subjected to forced pregnancy and banned from leaving the home. In many countries, women are not allowed to leave home without a male relative or husband, and therefore their ability to access medical services is limited. Therefore, increasing women's autonomy is needed in order to improve reproductive health.[6] According to the WHO, "All women need access to antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth".[7]

The fact that the law allows certain reproductive health services does not necessary ensure that such services are de facto available to people. The availability of contraception, sterilization and abortion is dependent on laws, as well as social, cultural and religious norms. Some countries have liberal laws regarding these issues, but in practice it is very difficult to access such services due to doctors, pharmacists and other social and medical workers being conscientious objectors.[8][9]

About 220 million women worldwide have an unmet need for birth control.[10]

Sexual healthEdit

A WHO working definition for sexual health is that it "is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled."[11] However, while used by WHO as well as other organizations, this is not an official WHO position, and should not be used or quoted as a WHO definition.[11]

The programme of action (PoA) of the International Conference on Population and Development (ICPD) in Cairo in 1994 was the first among international development frameworks to address issues related to sexuality, sexual and reproductive health, and reproductive rights. The PoA defined sexual health as, dealing “with the enhancement of life and personal relations, not merely counseling and care related to reproduction and sexually transmitted diseases.19 It refers to the integration of the somatic, emotional, intellectual and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication and love.” [12]

Emerging research in the field of sexual and reproductive health (SRH) identifies a series of factors that enhance the translation of research into policy and practice.[13] These include discursive changes (creating spaces for public debate); content changes (to laws and practices); procedural changes (influencing how data on SRH are collected) and behavioral changes (through partnerships with civil society, advocacy groups and policy makers).[13]

Donald Trump’s Department of Health and Human Services issued two rules rolling back a federal regulation that employers must include birth control in health insurance plans. In doing so he is building a barrier to sexual health. Hundreds of thousands of women in the United States who access birth control without copays because of Obama's previous mandate may lose this. [14]

Childbearing and healthEdit

 
Maternal Mortality Rate worldwide, as defined by the number of maternal deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management, excluding accidental or incidental causes.[15]

Early childbearing and other behaviours can have health risks for women and their infants. Waiting until a woman is at least 18 years old before trying to have children improves maternal and child health.[16][17] If an additional child is to be conceived, it is considered healthier for the mother, as well as for the succeeding child, to wait at least 2 years after the previous birth before attempting to concep tion.[16] After a fetal fatality, it is healthier to wait at least 6 months.[16]

The WHO estimates that each year, 358 000 women die due to complications related to pregnancy and childbirth; 99% of these deaths occur within the most disadvantaged population groups living in the poorest countries of the world.[18] Most of these deaths can be avoided with improving women's access to quality care from a skilled birth attendant before, during and after pregnancy and childbirth.

A study funded by the Gates Foundation suggests that in 2008 contraceptive use prevented 272,000 maternal deaths and estimated that if every women had access to contraception, 104,000 more women would like each year.[19] South Africa’s policy guidelines promote expanding its scope to include the prevention of and planning for pregnancy. It also promotes including contraception and fertility planning in the context of HIV and the prevention of mother to child transmission of HIV.[20] The scarring caused by female genital cutting can cause complications in childbirth: those with type three may have a longer second stage of labor, have less elasticity as a result of scar tissue, and may be more likely to receive a cesarean section in places were doctors are unfamiliar with the procedure.[21]

Availability of modern contraceptionEdit

Modern contraception is often unavailable in certain parts of the world. According to the WHO, about 222 million women worldwide have an unmet need for modern contraception, and the lack of access to modern contraception is highest among the most disadvantaged population: the poor, those living in rural areas and urban slums, those living with HIV, and those who are internally displaced.[22] In developing parts of the world, the lack of access to contraception is a main cause of unintended pregnancy, which is associated with poorer reproductive outcomes.[22] According to UNFPA, access to contraceptive services for all women could prevent about one in three deaths related to pregnancy and childbirth.[23]

Female genital mutilationEdit

 
Prevalence of FGM by country, according to a 2013 UNICEF report[24]

Female genital mutilation (FGM), also known as female genital cutting or female circumcision, "comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons".[25][26] The practice is concentrated in 29 countries in Africa and the Middle East; and more than 125 million girls and women today are estimated to have been subjected to FGM.[25] FGM also takes place in immigrant communities in Western countries, such as the UK.[27]

FGM does not have any health benefits, and has negative effects on reproductive and sexual health, including severe pain, shock, hemorrhage, tetanus or sepsis (bacterial infection), urine retention, open sores in the genital region and injury to nearby genital tissue, recurrent bladder and urinary tract infections, cysts, increased risk of infertility, childbirth complications and newborn deaths. FGM procedures that seal or narrow a vaginal opening (known as type 3) lead to a need for future surgeries of cutting open in order to allow for sexual intercourse and childbirth.[25]

According to UNFPA, “FGM violates human rights principles and standards – including the principles of equality and non-discrimination on the basis of sex, the right to freedom from torture or cruel, inhuman or degrading punishment, the right to the highest attainable standard of health, the rights of the child, and the right to physical and mental integrity, and even the right to life, among others.[26]

In the United states, 500-513,000 women have experienced or are at risk of female genital mutilation, also known as female genital cutting, and about 140 million worldwide have experienced this. There are multiple types of Female Genital cutting. Type one is the partial or complete removal of the clitoris, type two includes partial or total removal of the labia, type three included infibulation, or sewing together the labia, and type 4 includes all other harm for nonmedical reasons.Potential reasons for the practice: to insure virginity before marriage, as a rite of passage, as a condition of marriage, for male sexual pleasure, or out of religious duty, although it is not referenced in sacred texts. In half of the countries were this is practice, it is done to girls by the time they are five years old, and in most other it is done between the ages of 5 and 14, although adult women are sometimes cut. Additional health impacts include menstruation, STI risk increase, trauma as a result of the procedure being done forcefully, and for those with type three problems with labor, including a higher risk of an episiotomy and cesarean section. Risks to the infant such as low birth weight and trouble breathing have also been reported.[28] The World Health Organization conducted a study on the impacts of female genital cutting on the presence of anxiety/ affective disorders including PTSD. The study included 23 women who had been cut and 24 women who had not been. The women were between the ages of 15 and 40, had an average education of 11.5 years, 21% were married, 79% were single, and over 80% of the group had experienced a traumatizing event in their lifetime. Over 90% of the women who experienced female genital cutting reported feelings of intense fear, helplessness, horror, and severe pain. 78% of participants had the procedure done without explanation or done unexpectedly. 80% or the women met the criteria for and anxiety or affective disorder, with 30.4% meeting the criteria for PTSD. Only one of the uncircumcised women met the criteria for an anxiety/ affective disorder. The conclusion of the study was that female genital cutting is a likely cause of emotional disturbance and that cultural embedment does not protect against these disturbances.[29] An additional study including 66 immigrant women in the Netherlands regarding the impact genital cutting can have on mental health was conducted. The women were given four tests: the Harvard Trauma Questionnaire-30, Hopkins Symptom Checklist-25, COPE-easy, and Lowlands Acculturation Scale. The participants were between the ages of 18 and 69 with an average age of 35.5, 43% of participants were married, and 79% of participants had children. 36 of the participants had experienced type 3, 9 experienced type 2, and 21 experienced type one. The study found that ⅓ of the women were above the cut off for an affective or anxiety disorder and PTSD was indicated by 17.5 % of participant score. The study found that PTSD was more likely in those who experienced type 3, had vivid memories of the event, and who used substances to cope. It was also found that type 3, substance misuse, avoidance coping, and lock of money were associated with those who experienced depression and anxiety. [30]

Sexually transmitted infectionsEdit

 
Estimated prevalence in % of HIV among young adults (15–49) per country as of 2011.[31]

A sexually transmitted infection (STI)—formerly called sexually transmitted disease (STD) or venereal disease (VD)—is an infection that has a significant likelihood of transmission between humans by means of sexual activity. Common STIs include chlamydia, gonorrhea, herpes, HIV, hepatitis B, human papillomavirus (HPV), syphilis, and trichomoniasis.[32][33]

Sexually transmitted infections affect reproductive and sexual health, having a profound negative impact worldwide.[34] Programs aimed at preventing STIs include comprehensive sex education, STI and HIV pre- and post-test counseling, safer sex/risk-reduction counseling, condom promotion, and interventions targeted at key and vulnerable populations.[34] Having access to effective medical treatment for STIs is very important.

South Africa’s new policy addresses the needs of women at risk for HIV and who are HIV positive as well as their partners and children. The policy also promotes screening activities related to sexual health such as HIV counseling and testing as well as testing for other STIs, tuberculosis, cervical cancer, and breast cancer. [35]

Adolescent healthEdit

 
Teenage birth rate per 1,000 females aged 15–19, 2000–2009[36]

Issues affecting adolescent reproductive and sexual health are similar to those of adults, but may include additional concerns about teenage pregnancy and lack of adequate access to information and health services. Worldwide, around 16 million adolescent girls give birth every year, mostly in low- and middle-income countries.[37] The causes of teenage pregnancy are diverse. In developing countries girls are often under pressure to marry young and bear children early (see child marriage). Some adolescent girls do not know how to avoid becoming pregnant, are unable to obtain contraceptives, or are coerced into sexual activity.[37] Adolescent pregnancy, especially in developing countries, carries increased health risks, and contributes to maintaining the cycle of poverty.[38] The availability and type of sex education for teenagers varies in different parts of the world. LGBT teens may suffer additional problems if they live in places where homosexual activity is socially disapproved and/or illegal; in extreme cases there can be depression, social isolation and even suicide among LGBT youth.

UNFPA recommends “Comprehensive sexuality education” (CSE) as it enables young people to make informed decisions about their sexuality.[39] According to the UNFPA, CSE should be taught by introducing content which is age-appropriate to the capacities of young people over a span of several years. The curriculum includes scientifically accurate information on physical development, anatomy, pregnancy, contraception and sexually transmitted infections (STIs), including HIV. It should encourage confidence and skills for communication topics include social issues around sexuality and reproduction.[39]

International Conference on Population and Development, 1994Edit

The International Conference on Population and Development (ICPD) was held in Cairo, Egypt, from 5 to 13 September 1994. Delegations from 179 States took part in negotiations to finalize a Programme of Action on population and development for the next 20 years. Some 20,000 delegates from various governments, UN agencies, NGOs, and the media gathered for a discussion of a variety of population issues, including immigration, infant mortality, birth control, family planning, and the education of women.

In the ICPD Program of Action, 'reproductive health' is defined as:

a state of complete physical, mental and social well-being and...not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed [about] and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of birth control which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.[40]

This definition of the term is also echoed in the United Nations Fourth World Conference on Women, or the so-called Beijing Declaration of 1995.[41] However, the ICPD Program of Action, even though it received the support of a large majority of UN Member States, does not enjoy the status of an international legal instrument; it is therefore not legally binding.

The Program of Action endorses a new strategy which emphasizes the numerous linkages between population and development and focuses on meeting the needs of individual women and men rather than on achieving demographic targets.[42] The ICPD achieved consensus on four qualitative and quantitative goals for the international community, the final two of which have particular relevance for reproductive health:

  • Reduction of maternal mortality: A reduction of maternal mortality rates and a narrowing of disparities in maternal mortality within countries and between geographical regions, socio-economic and ethnic groups.
  • Access to reproductive and sexual health services including family planning: Family planning counseling, pre-natal care, safe delivery and post-natal care, prevention and appropriate treatment of infertility, prevention of abortion and the management of the consequences of abortion, treatment of reproductive tract infections, sexually transmitted diseases and other reproductive health conditions; and education, counseling, as appropriate, on human sexuality, reproductive health and responsible parenthood. Services regarding HIV/AIDS, breast cancer, infertility, delivery, hormone therapy, sex reassignment therapy, and abortion should be made available. Active discouragement of female genital mutilation (FGM).

The keys to this new approach are empowering women, providing them with more choices through expanded access to education and health services, and promoting skill development and employment. The programme advocates making family planning universally available by 2015 or sooner, as part of a broadened approach to reproductive health and rights, provides estimates of the levels of national resources and international assistance that will be required, and calls on governments to make these resources available.

Millennium Development GoalsEdit

Achieving universal access to reproductive health by 2015 is one of the two targets of Goal 5 - Improving Maternal Health - of the eight Millennium Development Goals.[43] To monitor global progress towards the achievement of this target, the United Nations has agreed on the following indicators:

  • 5.3: contraceptive prevalence rate
  • 5.4: adolescent birth rate
  • 5.5: antenatal care coverage
  • 5.6: unmet need for family planning

According to the MDG Progress Report, regional statistics on all four indicators have either improved or remained stable between the years 2000 and 2005.[44] However, progress has been slow in most developing countries, particularly in Sub-saharan Africa, which remains the region with the poorest indicators for reproductive health.[45] According to the WHO in 2005 an estimated 55% of women do not have sufficient antenatal care and 24% have no access to family planning services.[45]

Reproductive health and abortionEdit

An article from the World Health Organization calls safe, legal abortion a "fundamental right of women, irrespective of where they live" and unsafe abortion a "silent pandemic".[46] The article states "ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative." It also states "access to safe abortion improves women’s health, and vice versa, as documented in Romania during the regime of President Nicolae Ceaușescu" and "legalisation of abortion on request is a necessary but insufficient step toward improving women’s health" citing that in some countries, such as India where abortion has been legal for decades, access to competent care remains restricted because of other barriers. WHO’s Global Strategy on Reproductive Health, adopted by the World Health Assembly in May 2004, noted: “As a preventable cause of maternal mortality and morbidity, unsafe abortion must be dealt with as part of the MDG on improving maternal health and other international development goals and targets." [47] The WHO's Development and Research Training in Human Reproduction (HRP), whose research concerns people's sexual and reproductive health and lives,[48] has an overall strategy to combat unsafe abortion that comprises four inter-related activities:[47]

  • to collate, synthesize and generate scientifically sound evidence on unsafe abortion prevalence and practices;
  • to develop improved technologies and implement interventions to make abortion safer;
  • to translate evidence into norms, tools and guidelines;
  • and to assist in the development of programmes and policies that reduce unsafe abortion and improve access to safe abortion and high quality post-abortion care

During and after the ICPD, some interested parties attempted to interpret the term ‘reproductive health’ in the sense that it implies abortion as a means of family planning or, indeed, a right to abortion. These interpretations, however, do not reflect the consensus reached at the Conference. For the European Union, where legislation on abortion is certainly less restrictive than elsewhere, the Council Presidency has clearly stated that the Council’s commitment to promote ‘reproductive health’ did not include the promotion of abortion.[49] Likewise, the European Commission, in response to a question from a member of the European Parliament, clarified:

The term ‘reproductive health’ was defined by the United Nations (UN) in 1994 at the Cairo International Conference on Population and Development. All Member States of the Union endorsed the Programme of Action adopted at Cairo. The Union has never adopted an alternative definition of ‘reproductive health’ to that given in the Programme of Action, which makes no reference to abortion.[50]

With regard to the US, only a few days prior to the Cairo Conference, the head of the US delegation, Vice President Al Gore, had stated for the record:

Let us get a false issue off the table: the US does not seek to establish a new international right to abortion, and we do not believe that abortion should be encouraged as a method of family planning.[51]

Some years later, the position of the US administration in this debate was reconfirmed by US Ambassador to the UN, Ellen Sauerbrey, when she stated at a meeting of the UN Commission on the Status of Women that:

Nongovernmental organizations are attempting to assert that Beijing in some way creates or contributes to the creation of an internationally recognized fundamental right to abortion.[52]
There is no fundamental right to abortion. And yet it keeps coming up largely driven by NGOs trying to hijack the term and trying to make it into a definition.[53]

Contraception prevents 112 million abortions per year by UN estimates.[54] Abortion is declining in all age groups. [55]

By regionEdit

AfricaEdit

HIV/AIDS in Africa is a major public health problem. Sub-Saharan Africa is the worst affected world region for prevalence of HIV, especially among young women. 90% of the children in the world living with HIV are in sub-Saharan Africa.[56]

In most African countries, the total fertility rate is very high,[57] often due to lack of access to contraception and family planning, and practices such as forced and child marriage. Niger, Angola, Mali, Burundi and Somalia have very high fertility rates.

The updated contraceptive guidelines in South Africa attempt to improve access by providing special service delivery and access considerations for sex workers, lesbian, gay, bisexual, transgender and intersex individuals, migrants, men, adolescents, women who are perimenopausal, have a disability, or chronic condition. They also aim to increase access to long acting contraceptive methods, particularly the copper IUD, and the introductions of single rod progestogen implant and combined oestrogen and progestogen injectables. The copper IUD has been provided significantly less frequently than other contraceptive methods but signs of an increase in most provinces were reported. The most frequently provided method was injectable progesterone, which the article acknowledged was not ideal and emphasised condom use with this method because it can can increase the risk of HIV: The product made up 49% of South Africa’s contraceptive use and up to 90% in some provinces.[58]

Tanzanian provider perspectives address the obstacles to consistent contraceptive use in their communities. It was found that the capability of dispensaries to service patients was determined by inconsistent reproductive goals, low educational attainment, misconceptions about the side effects of contraceptives, and social factors such as gender dynamics, spousal dynamics, economic conditions, religious norms, cultural norms, and constraints in supply chains. A provider referenced and example of propaganda spread about the side effects of contraception: "There are influential people, for example elders and religious leaders. They normally convince people that condoms contain some microorganisms and contraceptive pills cause cancer". Another said that women often had pressure from their spouse or family that caused them to use birth control secretly or to discontinue use, and that women frequently preferred undetectable methods for this reason. Access was also hindered as a result of a lack in properly trained medical personnel: "Shortage of the medical attendant...is a challenge, we are not able to attend to a big number of clients, also we do not have enough education which makes us unable to provide women with the methods they want". The majority of medical centers were staffed by people without medical training and few doctors and nurses, despite federal regulations, due to lack of resources. One center had only one person who was able to insert and remove implants, and without her they were unable to service people who wanted an implant inserted or removed. Another dispensary that carried two methods of birth control shared that they sometimes run out of both materials at the same time. Constraints in supply chains sometimes cause dispensaries to run out of contraceptive materials Providers also claimed that more male involvement and education would be helpful.[59]

See alsoEdit

ReferencesEdit

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  2. ^ International technical guidance on sexuality education: an evidence-informed approach (PDF). Paris: UNESCO. 2018. p. 22. ISBN 978-92-3-100259-5. 
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  9. ^ "Doctors' Refusal to Perform Abortions Divides Croatia :: Balkan Insight". Balkaninsight.com. Retrieved 14 November 2017. 
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  14. ^ https://www.nytimes.com/2017/10/06/us/politics/trump-contraception-birth-control.html
  15. ^ Country Comparison: Maternal Mortality Rate in The CIA World Factbook. Date of Information: 2010
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  21. ^ https://www.womenshealth.gov/a-z-topics/female-genital-cutting
  22. ^ a b http://apps.who.int/iris/bitstream/10665/102539/1/9789241506748_eng.pdf?ua=1
  23. ^ "Family planning — UNFPA — United Nations Population Fund". Retrieved 13 December 2016. 
  24. ^ "Prevalence of FGM/C". UNICEF. Archived from the original on 15 July 2015. Retrieved 18 August 2014. 
  25. ^ a b c "Female genital mutilation". WHO. February 2014. Retrieved 14 May 2015. 
  26. ^ a b "Female genital mutilation". UNFPA. 
  27. ^ "Female genital mutilation". UK National Health Service. 
  28. ^ https://www.womenshealth.gov/a-z-topics/female-genital-cutting
  29. ^ http://www.who.int/reproductivehealth/topics/fgm/mental_problems_and_fgm/en/
  30. ^ Knipscheer J, Vloeberghs E, van der Kwaak A, van den Muijsenbergh M (2015). "Mental health problems associated with female genital mutilation". BJPsych Bull. 39: 273–7. doi:10.1192/pb.bp.114.047944. PMC 4706216 . PMID 26755984. 
  31. ^ "AIDSinfo". UNAIDS. Retrieved 4 March 2013. 
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  33. ^ "Sexually transmitted diseases". UK National Health Service. </
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  39. ^ a b "UNFPA Operational Guidance for Comprehensive Sexuality Education: A Focus on Human Rights and Gender" (PDF). UNFPA. 
  40. ^ ICPD Programme of Action, paragraph 7.2.
  41. ^ The United Nations Fourth World Conference on Women
  42. ^ ICPD. "ICPD Program of Action". Retrieved 2009-02-04. 
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  48. ^ "World Health Organization". Retrieved 13 December 2016. 
  49. ^ European Parliament, 4 December 2003: Oral Question (H-0794/03) for Question Time at the part-session in December 2003 pursuant to Rule 43 of the Rules of Procedure by Dana Scallon to the Council. In the written record of that session, one reads: Posselt (PPE-DE): "Does the term ‘reproductive health’ include the promotion of abortion, yes or no?" - Antonione, Council: "No."
  50. ^ European Parliament, 24 October 2002: Question no 86 by Dana Scallon (H-0670/02)
  51. ^ Jyoti Shankar Singh, Creating a New Consensus on Population (London: Earthscan, 1998), 60
  52. ^ Lederer, AP/San Francisco Chronicle, 1 March 2005
  53. ^ Leopold, Reuters, 28 February 2005
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  55. ^ https://www.nytimes.com/2017/10/06/us/politics/trump-contraception-birth-control.html
  56. ^ http://www.afro.who.int/health-topics/hivaids
  57. ^ https://www.cia.gov/library/publications/the-world-factbook/rankorder/2127rank.html
  58. ^ https://www.jstor.org/stable/43288351?Search=yes&resultItemClick=true&searchText=contraception&searchUri=%2Faction%2FdoBasicSearch%3Fpage%3D2%26amp%3Bacc%3Don%26amp%3Bwc%3Don%26amp%3Bfc%3Doff%26amp%3Brefreqid%3Dsearch%253Ab6bccbb1acbd4658559709e8fc8d2f57%26amp%3BQuery%3Dcontraception%26amp%3Bgroup%3Dnone&refreqid=search%3A48f7569abff3be368c7cc7f286b92658&seq=1#page_scan_tab_contents
  59. ^ https://www.jstor.org/stable/24877606?Search=yes&resultItemClick=true&searchText=Sexual&searchText=health&searchUri=%2Ftopic%2Freproductive-health%2F%3Fsi%3D1%26amp%3Bso%3Dnew%26amp%3Btopic%3Dreproductive-health%26amp%3BQuery%3DSexual%2Bhealth&seq=7#page_scan_tab_contents

External linksEdit