Reproductive Health in the 21st Century: Two Steps Forward?


Sixteen years ago this month, the Journal of Nurse-Midwifery published the first of two consecutive continuing education issues devoted to the topic of “well woman gynecology.”1,2 Earlier that year, Lichtman and Papera3 published their comprehensive book on the topic, a text that was welcomed by many of us for addressing, with a midwifery focus, an aspect of care that was increasingly part of our practice. No doubt Lichtman and Papera accompanied many readers of this Journal on their journey through midwifery education as standards for midwifery practice expanded to incorporate “well woman care.”

The editorial that introduced the first continuing education issue4 ruminated on the question of whether the “overt foray” into gynecology would threaten our identity as midwives. How funny that seems now. Midwives cannot lose their identity of being “with woman.” We are the guardians of normal and natural processes, focused on participatory decision-making, whether we are in a birth room or gynecologic office. I recall a physician colleague in a family planning clinic who told me that a patient once asked her if she was a midwife. When told no, the patient commented that the reason she thought my colleague was a midwife was because she took so much time to explain everything, enabling the woman to understand and make decisions about her care. Such is our identity: with women, wherever we practice.

Another glance back in time to that 1990 continuing education issue finds Mary Franklin's article on “new” contraceptive methods.5 How distant this seems now, and how far we have come in providing options for women on the “birth control buffet.” In 1990, Plan B (Duramed Pharmaceuticals, Pomona, NY) and its predecessor Preven (Gynetics, Inc., Belle Mead, NJ) were not yet approved by the US Food and Drug Administration (FDA) or marketed as prescription products (although many of us constructed our own version of emergency contraception following the Yuzpe regimen). In August 2006, Plan B became available without a prescription to women over the age of 18.6,7 In 1990, the copper IUD (ParaGard; Duramed Pharmaceuticals) was relatively new, having been available for only 2 years in the United States. Today, it is a contraceptive mainstay, and has been joined by a hormone releasing intrauterine system.8 In 1990, the Prentif cervical cap (Cervical Cap, Ltd., Los Gatos, CA) was also new to the US market. It is no longer distributed in this country, but a resurgence of interest in cervical barrier methods has brought us FemCap (FemCap Inc., Del Mar, CA) and Lea's Shield (Yuma, Inc., Union, NJ).9 The vaginal pouch described by Franklin as awaiting more clinical trials and FDA approval has become today's female condom, although it still struggles to find its niche. The Today sponge (Allendale Pharmaceuticals, Inc., Allendale, NJ) came, went, and came back. The Norplant implant (Wyeth Pharmaceuticals, Philadelphia, PA) is no longer available but a new single rod implant has recently been approved by the FDA (Implanon; Organon USA, Inc., Roseland, NJ), and by the time this editorial appears in print, clinician training sessions in its use will have begun across the US.10 The vaginal ring and the transdermal patch, investigational methods in 1990, are now widely used by women seeking to delay pregnancy. Unfortunately, the investigational injectable contraceptives discussed in the 1990 article have not appeared, at least not in the United States, and male hormonal contraceptives and contraceptive vaccines remain a vision on the horizon.

Beyond the 1990 continuing education articles on contraceptives, newer, easier to use fertility awareness methods have been the subject of several articles in these pages over recent years.11 Transcervical sterilization has been introduced into practice, offering options to surgical procedures for women who have completed their families.12 Would we have thought in 1990 that we would have a vaccine for human papillomavirus, acknowledged as the causative agent for cervical cancer, and the promise of reducing morbidity and mortality from this disease?13

Despite the good news, there are still issues that limit or even threaten women's health. Not the least of these is a reluctance to acknowledge how critical reproductive health is to women's lives. In 1990, the term “well woman gynecology” was a deliberate contrast to typical terms used at the time such as “interconceptional” and “family planning” care. Lichtman and Papera noted in the introduction to their textbook3 that such terminology defined women by the process of conception or by their reproductive function, which these authors emphatically refused to do in their text. Why then do we choose to refer to “reproductive health” in this 21st century continuing education program?

International conferences in Cairo in 1994 and Beijing in 1995 emphasized the right of women to reproductive health. This was an acknowledgment of the reality that major disease burdens suffered by women are related to reproductive function and potential; it also acknowledges that gender predicts how societies treat (or mistreat) women. Today, reproductive health is the accepted term worldwide for a constellation of practice issues we once defined under the umbrella of well woman gynecology. Reproductive health is defined by the World Health Organization as a “state of physical, mental, and social well-being in all matters relating to the reproductive system, at all stages of life.” It implies a satisfying and safe sex life; the freedom to decide if, when, and how often to have children; the right to be informed; to have access to safe and acceptable methods of family planning; and the right to appropriate health care services. Reproductive health care includes all the methods, techniques, and services that contribute to reproductive health and well-being.14 This Journal joins other organizations in the use of this term to ensure we are all speaking a common language.

Reproductive health is the cornerstone of women's health. Pat Paluzzi's commentary in this issue15 reminds us that we cannot be guardians of women's health if we do not attend to this important aspect of their lives. Even though this is the 21st century, women are still subject to threats to their freedom to control their own reproductive lives. At the time this editorial is written, Plan B has only been made available over the counter to women age 18 and older. Many reproductive health professionals are concerned that the requirement for a prescription for adolescents under the age of 18 will leave this group vulnerable to unintended pregnancy.16 There are increasing instances of pharmacist or practitioner refusal to dispense or prescribe hormonal contraceptives as well as emergency contraception, breaching their responsibilities to women seeking care.17 Too many women lack access to needed reproductive health care and preventive screening tests.18 Maternal mortality is appallingly high in strife-torn areas of the world.19

As midwives, we must heed the call to advocacy that these issues demand. We cannot claim to be “with woman” unless we are willing to stand with women against these threats to our lives and well-being. In the words of Rabbi Hillel, a 1st century Babylonian Jewish scholar who wrote before the Christian era:

“If I am not for myself, who will be for me?

If I am for myself alone, what am I?

And if not now, when?”20