By Dr Sue Mann. Re-published with permission of FSRH.
Dr Sue Mann and colleagues Monica Davison and Alison Hadley provide some background to the new suite of documents on reproductive health to be published by Public Health England (PHE). The documents will define the scope of reproductive health, provide a national overview of the current status of reproductive health and, through the voices of women around the country, offer a clearer understanding of what women think about their reproductive health, the ways it affects them and the support they need. This body of work will help set a shared agenda for action across government and provide a starting point for commissioners, providers and policy makers to inform local prioritisation and planning and to improve outcomes on reproductive health across the life course.
PHE will be publishing a suite of three documents: Reproductive health is a public health issue – a consensus statement; Reproductive health is a public health issue – what the data says and Reproductive health is a public health issue – what women say. This extensive body of work defines both the scope of reproductive health and quantifies its impacts by taking stock of population reproductive health status.
The new suite of documents is grounded in the World Health Organization (WHO) definition of reproductive health, widening the scope of an area often seen in policy, commissioning and practice contexts as synonymous with contraception and abortion. In this definition reproductive health is described as:
“a state of physical, mental, and social well-being in all matters relating to the reproductive system. It addresses the reproductive processes, functions and system at all stages of life and 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” (WHO 2018)
Dr Sue Mann, PHE’s Medical Expert on Sexual & Reproductive Health
Reproductive health significantly overlaps with but is not synonymous with sexual health. Confusing terminology has not been helpful in progressing this agenda. In some contexts sexual health is seen as interchangeable with sexual and reproductive health and in others, such as the stance taken by PHE, these are considered separate but overlapping entities – sexual health, reproductive health and HIV.
Like sexual health, reproductive health is a public health issue with far reaching social and economic impacts. Stigma, embarrassment and taboos surround reproductive issues making it difficult for women to talk about them and creating a barrier to women accessing the care they need.
The impact of poor reproductive health is relevant for local authorities, clinical commissioning groups (CCGs) and wider government programmes. It is timely to consider this area through a public health lens and understand better the many influences on reproductive well-being, moving beyond the medical model of simply providing contraception and reacting to reproductive symptoms.
The starting point of PHE’s new work has been the development of a consensus statement. This is the result of extensive engagement with partners across government and the reproductive health sector, including commissioners, providers, third sector organisations and policy makers. The consensus that will be published is an agreed statement between partners that has helped define the scope of reproductive health, and a vision that is centred around a framework of “6 pillars of reproductive health”. These are key themes repeated through each document and represent the areas felt to be most important by women and the wider sector.
The data document that accompanies the consensus will provide a national overview of the current status of reproductive health. Where possible routine datasets have been analysed to create a more detailed understanding of reproductive health status. These can potentially be interrogated in the same way at local level to create a localised picture. Where there are data gaps, these have been filled by research data, drawing substantially on the National Survey of Sexual Attitudes and Lifestyles (NATSAL) as well as other large surveys.
The voices of women have shaped both the data that was collated and the analyses that were conducted for the “What do Women say” document. Focus groups were held with a total of 48 women in different parts of the country and an online survey of more than 7000 women was also carried out. These two information sources set out to try and better understand what women themselves think about their reproductive health, the ways it affects them and what sort of support might be needed.
So what will be different in these documents?
In these documents we consider preventing, preparing for and recovering from pregnancy as all part of the same pathway for women during their fertile years. Women in heterosexual relationships are likely to need contraception for much of their lives punctuated by shorter periods of needing abortion, preconception, assisted conception, maternity or postnatal care. A continuous of care approach where these needs are integrated will support better reproductive outcomes and may help women to optimise their health particularly if planning a pregnancy much earlier in the process. Another important part of reframing reproductive health is to revisit outcome measures and ensure they are fit for purpose. One example of this will be to consider how user-defined outcomes such as the London Measure of Unplanned Pregnancy can be incorporated into routine datasets, as well as identifying other outcome measures that better reflect over all reproductive well-being.
The documents also highlight some of the reproductive symptoms that are less well-addressed such as postnatal problems, heavy menstrual bleeding or menopause. These are often hidden issues, but have a significant impact on women’s home and work lives. Often the help that women tell us they need is not just about healthcare but more about providing easily accessible information to know what is “normal” as well as a supportive work environment and local support networks.
Lastly we have tried to shine a light on some of the many inequalities in both access and outcomes in reproductive health. The data confirms that the groups that already experience disadvantage are more likely to experience poorer reproductive health outcomes. The falls in cervical cytology screening are more likely to affect younger women and those from more deprived backgrounds. Use of different services for reproductive health issues vary by age or deprivation and therefore changes to service configurations differentially impact on inequalities. A number of gaps in the provision of reproductive healthcare are highlighted as are the areas where we just don’t have enough information due to the absence of routine data. For instance, it is more difficult to get a clear picture of what is happening in primary care and pharmacy despite these services offering the lion’s share of services to women.
The three documents are a starting point for commissioners, providers and policy makers at local level to localise and inform their prioritisation and planning. They will also set an agenda for action. Through the partnerships created as part of the consensus, the next steps will be action planning ensuring all partners collaborate to take this forward. This will be led by PHE together with cross-governmental partners and will be the first cross governmental action plan on reproductive health with the aim of making a significant difference to how women experience and manage their reproductive health throughout their lives.
“This will be … the first cross governmental action plan on reproductive health with the aim of making a significant difference to how women experience and manage their reproductive health throughout their lives”
Look out for the launch of the documents in the coming weeks, both in national press and on the government website. We have a companion edition of Health Matters that will be published in the same week, along with a webinar to learn more about our new approach.
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