Reproductive Health

1. Reproductive Health [Add Author(s)] [Add Institution(s)] [Add Date – Month day, 2011] Prepared as part of an education project of the Global Health Education Consortium and collaborating partners

2. Module overview (Delete this slide when no longer necessary) • Author note: This file provides a PowerPoint template for your module. Duplicate each of the below template forms as necessary and replace the illustrative text and figures with your own content. The template forms are: • Title page • Module goals • List of module sections • Learning objectives • Section content • Case study • Supplementary note • Thought or discussion questions • Special features (voiceovers, video clips, etc.) • Quiz (including several quiz options) • Section or Module summary • Further readings and other resources • Acknowledgements • Credits

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4. Module overview (Delete this slide when no longer necessary) • Module submission. Send draft module to Tom Hall (thall@epi.ucsf.edu) and to Glenn Nordehn (gnordehn@gmail.com) for review. Use placeholder slides, inserted immediately before the slides to which they refer, to provide instructions for the use of special eLearning features. Examples of such features are given later in this file. GHEC will initiate the review process and arrange for clarification of any questions that arise. • Processing and posting. On completion of the initial review and revision the module will be sent to an IT specialist for processing your module into the appropriate application platform and then posting on GHEC’s website.

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6. Module goals (Replace illustrative text with your own text) On completion of this module you will have a good understanding of the risks of pregnancy and delivery, the causes of maternal morbidity and mortality, and of terms used to describe maternal morbidity and mortality. The module focuses on preventive and therapeutic measures used to reduce risks and morbidity, and concludes with recommendations for improving reproductive health. Note to authors. This slide describes the overall goal for the module. It is more general than the learning objectives that follow for individual sections. Page 6

7. List of module sections (Replace template text) • Section 1, Reproductive health: Historical perspectives • Section 2, Maternal morbidity and mortality • Section 3, Major reproductive risk factors • Section 4, Sexually transmitted diseases • Section 5, Etc.

8. Learning objectives: Section 1 On completing this section you will be able to: • List the principal causes and risk factors affecting pregnancy-related morbidity and mortality. • Describe how the major risk factors affect these rates • Etc. • Etc. • Note to authors: Prefer active verbs (e.g., list, make, describe, able to…) over passive verbs (understand, know, appreciate…) whenever possible. Keep objectives short and specific. Be sure that these objectives are fully covered in the section and are addressed in the quiz. Page 8

9. Section content • Note to authors: This and additional inserted slides can be used to provide the content for Section 1

10. [Add topic title] • [Add content for this topic] • [Present details] • [Give an example] • […] Page 10

12. Case study • Note to authors: Case studies can be very useful to generate thought and discussion. You can insert them as needed. A case can be based on a real situation or hypothetical but realistic one. You could pose the case on a PowerPoint slide, ask the student to address the question, and then provide a supplementary note that reviews how the case resolved, or could resolve. Several considerations: • What actually happened? • What factors should be considered, and their relative importance? • Or how would you, the expert, approach answering the case? If you opt for this response you can acknowledge that yours is just one answer of many, that every situation is different, and that there is no perfect answer

13. Supplementary note • Note to authors : A “note” supplements the information provided on a slide. It allows the author to provide additional text, graphics , case studies, or other resources about a topic without filling the module with content likely to be of interest only to the more advanced or curious learner. This slide and the next several slides are blank pages, without special formatting. To provide a supplementary note scroll through the next several slides to see a demonstration of how to provide a note. You can then select and erase these slides or insert blank slides to provide a note. Do the following: • Prepare the slide to which you wish to append a supplementary note. • Immediately after that slide provide the note. Either draft the note text yourself or go to a source for your note, select and copy it, and then paste it into a box on an otherwise blank slide. If your note is large, paste it, select the entire note and reduce the font size so that it fits and then bring in the box margins so that the note is contained on the slide. Add pictures or graphics as desired. When GHEC converts your PowerPoint file into the module platform the note layout and font size will be formatted appropriately. If the note is very long you can also provide it in a Word file, making it clear through letter codes, A, B, C, etc., the PowerPoint slide to which it relates. • In processing the file GHEC will link the note to the appropriate slide and provide buttons for accessing the note and returning to its reference slide. The following slides give examples of what can be done.

14. Maternal mortality (Demonstration index slide for a note) • Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period. While motherhood is often a positive and fulfilling experience, for too many women it is associated with suffering, ill-health and even death. • The major direct causes of maternal morbidity and mortality include hemorrhage, infection, high blood pressure, unsafe abortion, and obstructed labor. A click on the note button takes viewer to the note Note button

15. Supplementary note to the preceding slide Every day, 1500 women die from pregnancy- or childbirth-related complications. In 2005, there were an estimated 536 000 maternal deaths worldwide. Most of these deaths occurred in developing countries, and most were avoidable. (1) Improving maternal health is one of the eight Millennium Development Goals adopted by the international community at the United Nations Millennium Summit in 2000. In Millennium Development Goal 5 (MDG5), countries have committed to reducing the maternal mortality ratio by three quarters between 1990 and 2015. However, between 1990 and 2005 the maternal mortality ratio declined by only 5%. Achieving Millennium Development Goal 5 requires accelerating progress. Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization, 2007 (http://www. who.int/reproductive-health/publications/maternal_mortality_2005/index.html, accessed 14 August 2008). Source: http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html Photo credits

16. Supplementary note to the preceding slide Source: http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html

17. Supplementary note to a preceding slide Why do mothers die? Women die from a wide range of complications in pregnancy, childbirth or the postpartum period. Most of these complications develop because of their pregnant status and some because pregnancy aggravated an existing disease. The four major killers are: severe bleeding (mostly bleeding postpartum), infections (also mostly soon after delivery), hypertensive disorders in pregnancy (eclampsia) and obstructed labour. Complications after unsafe abortion cause 13% of maternal deaths. Globally, about 80% of maternal deaths are due to these causes. Among the indirect causes (20%) of maternal death are diseases that complicate pregnancy or are aggravated by pregnancy, such as malaria, anaemia and HIV.(2) Women also die because of poor health at conception and a lack of adequate care needed for the healthy outcome of the pregnancy for themselves and their babies.

18. Supplementary note to a preceding slide Semmelweis's observations conflicted with the established scientific and medical opinions of the time. The theory of diseases was highly influenced by ideas of an imbalance of the basic "four humours" in the body, a theory known as dyscrasia, for which the main treatment was bloodlettings. Medical texts at the time emphasized that each case of disease was unique, the result of a personal imbalance, and the main difficulty of the medical profession was to establish precisely each patient's unique situation, case by case. The findings from autopsies of deceased women also showed a confusing multitude of various physical signs, which emphasised the belief that puerperal fever was not one, but many different, yet unidentified, diseases. Semmelweis's main finding — that all instances of puerperal fever could be traced back to only one single cause: lack of cleanliness — was simply unacceptable. His findings also ran against the conventional wisdom that diseases spread in the form of "bad air", also known as miasmas or vaguely as "unfavourable atmospheric-cosmic-terrestrial influences". Semmelweis's groundbreaking idea was contrary to all established medical understanding. As a result, his ideas were rejected by the medical community. Other more subtle factors may also have played a role. Some doctors, for instance, were offended at the suggestion that they should wash their hands; they felt that their social status as gentlemen was inconsistent with the idea that their hands could be unclean.[6]:9[Note 7] Specifically, Semmelweis's claims were thought to lack scientific basis, since he could offer no acceptable explanation for his findings. Such a scientific explanation was made possible only some decades later, when the germ theory of disease was developed by Louis Pasteur, Joseph Lister, and others. During 1848, Semmelweis widened the scope of his washing protocol to include all instruments coming in contact with patients in labor, and used mortality-rate time series to document his success in virtually eliminating puerperal fever from the hospital ward. Note to authors: This page provides an example of a long note associated with a picture. The font and picture can be made as small as necessary to fit on the slide. They will be enlarged as necessary on the processed note.

19. Supplementary note -- Example of extensive text Author note: You can copy/paste and reduce font size to put text in a slide. It will later be converted by GHEC into a supplementary note During 1848–1849 some 70 000 troops from the Habsburg-ruled Austrian Empire thwarted the Hungarian independence movement, executed or imprisoned its leaders and in the process destroyed parts of Pest. It seems likely that Semmelweis, upon arriving from the Habsburg Vienna in 1850, was not warmly welcomed in Pest. On May 20, 1851 Semmelweis took the relatively insignificant, unpaid, honorary head physician position of the obstetric ward of Pest's small St. Rochus Hospital. He held that position for six years, until June 1857.[4]:107[6]:68 Childbed fever was rampant at the clinic; at a visit in 1850, just after returning to Pest, Semmelweis found one fresh corpse, another patient in severe agony, and four others seriously ill with the disease. After taking over in 1851, Semmelweis virtually eliminated the disease. During 1851–1855 only 8 patients died from childbed fever out of 933 births (0.85%).[4]:106–108 Despite the impressive results, Semmelweis's ideas were not accepted by the other obstetricians in Budapest.[6]:69 The professor of obstetrics at the University of Pest, Ede Flórián Birly, never adopted Semmelweis's methods. He continued to believe that puerperal fever was due to uncleanliness of the bowel.[4]:24* Therefore, extensive purges was the preferred treatment. After Birly died in 1854, Semmelweis applied for the position. So did Carl Braun — Semmelweis's nemesis and successor as Johann Klein's assistant in Vienna — and Braun received more votes from his Hungarian colleagues than Semmelweis did. Semmelweis was eventually appointed in 1855, but only because the Viennese authorities overruled the wishes of the Hungarians, as Braun did not speak Hungarian. As professor of obstetrics, Semmelweis instituted chlorine washings at the University of Pest maternity clinic. Once again, the results were impressive.[6]:69 Semmelweis turned down an offer in 1857 to become professor of obstetrics at the University of Zurich.[4]:56 The same year, Semmelweis married Mária Weidenhoffer (1837–1910), nineteen years his younger and the daughter of a successful merchant in Pest. They had five children: a son who died shortly after birth, a daughter who died at the age of 4 months, another son who committed suicide at age 23 (possibly due to gambling debts), another daughter who would remain unmarried, and a third daughter who would have children of her own.[6]:70 One of the first to respond to Semmelweis's 1848 communications was James Young Simpson who wrote a stinging letter. Simpson surmised that the English obstetrical literature must be totally unknown in Vienna, otherwise Semmelweis would have known that the English have long regarded childbed fever as contagious and would have employed chlorine washings to protect against it.[4]:174 Semmelweis's views were much more favorably received in England than on the continent, but he was more often cited than understood. The English consistently regarded Semmelweis as having supported their theory of contagion. A typical example was W. Tyler Smith, who claimed that Semmelweis "made out very conclusively" that "miasms derived from the dissecting room will excite puerperal disease."[4]:176*[11]:504 In 1856, Semmelweis's assistant József Fleischer reported the successful results of handwashings at St. Rochus and Pest maternity institutions in the Viennese Medical Weekly (Wiener Medizinische Wochenschrift).[6]:69 The editor remarked sarcastically that it was time people stopped being misled about the theory of chlorine washings.[4]:24[12]:536 In 1858 Semmelweis finally published his own account of his work in an essay entitled, "The Etiology of Childbed Fever".[Note 9] Two years later he published a second essay, "The Difference in Opinion between Myself and the English Physicians regarding Childbed Fever".[Note 10] In 1861, Semmelweis finally published his main work Die Ätiologie, der Begriff und die Prophylaxis des Kindbettfiebers (German for The Etiology, Concept and Prophylaxis of Childbed Fever). In his 1861 book, Semmelweis lamented the slow adoption of his ideas: "Most medical lecture halls continue to resound with lectures on epidemic childbed fever and with discourses against my theories. […] The medical literature for the last twelve years continues to swell with reports of puerperal epidemics, and in 1854 in Vienna, the birthplace of my theory, 400 maternity patients died from childbed fever. In published medical works my teachings are either ignored or attacked. The medical faculty at Würzburg awarded a prize to a monograph written in 1859 in which my teachings were rejected".[4]:169[Note 11] In Berlin, the professor of obstetrics, Joseph Hermann Schmidt, approved of obstetrical students having ready access to morgues in which they could spend time while waiting for the labor process.[4]:34[14]:501 In a textbook, Carl Braun, Semmelweis's successor as assistant in the first clinic, identified 30 causes of childbed fever; only the 28th of these was cadaverous infection. Other causes included conception and pregnancy, uremia, pressure exerted on adjacent organs by the shrinking uterus, emotional traumata, mistakes in diet, chilling, and atmospheric epidemic influences.[15][Note 12] The impact of Braun's views are clearly visible in the rising mortality rates in the 1850s. Ede Flórián Birly, Semmelweis's predecessor as Professor of Obstetrics at the University of Pest, never accepted Semmelweis's teachings; he continued to believe that puerperal fever was due to uncleanliness of the bowel.[4]:4* August Breisky, an obstetrician in Prague, rejected Semmelweis's book as "naive" and he referred to it as "the Koran of puerperal theology". Breisky objected that Semmelweis had not proved that puerperal fever and pyemia are identical, and he insisted that other factors beyond decaying organic matter certainly had to be included in the etiology of the disease.[4]:41[16]:1 Carl Edvard Marius Levy, head of the Copenhagen maternity hospital and an outspoken critic of Semmelweis's ideas, had reservations concerning the unspecific nature of cadaverous particles and that the supposed quantities were unreasonably small. "If Dr. Semmelweis had limited his opinion regarding infections from corpses to puerperal corpses, I would have been less disposed to denial than I am. […] And, with due respect for the cleanliness of the Viennese students, it seems improbable that enough infective matter or vapor could be secluded around the fingernails to kill a patient."[4]:180–181[17] In fact, Robert Koch later used precisely this fact to prove that various infecting materials contained living organisms which could reproduce in the human body, i.e. since the poison could be neither chemical nor physical in operation, it must be biological.[4]:183* At a conference of German physicians and natural scientists, most of the speakers rejected his doctrine, including the celebrated Rudolf Virchow, who was a scientist of the highest authority of his time. Virchow’s great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time.[13] It has been contended that Semmelweis could have had an even greater impact if he had managed to communicate his findings more effectively and avoid antagonising the medical establishment, even given the opposition from entrenched viewpoints.[18]

20. Thought or discussion questions • Note to authors: These can be very useful and may be used at multiple locations. Two varieties: • Thought question: This is a “stop and think” question that invites the learner, before proceeding to the next slide, to think about the question and perhaps provide a short answer. For example: “Before going to the next slide take one minute to write down words or terms that indicate the kinds of factors a donor organization will want to consider when responding to a request for funding support by a potential recipient.” • Discussion question: This can be a more general question, especially suitable for use when the module has been assigned prior to a class.

21. Special features • Note to authors: We hope authors will make use of some of the special features allowed in PowerPoint and the following sections illustrate several of them. • Voiceovers • Video and YouTube clips • Hotlinks to other resources • If you would like to use one or another of such features but need assistance please let us know.

22. Audio voiceover • This slide describes, and the following slide demonstrates, an audio voiceover. You’ll need a microphone (low cost) plugged into your computer. • Click on the loudspeaker and hear brief text. • Voiceovers allow you to comment or expand on a slide and, in the process, ‘humanize’ your presence to the learner. Clicking on the loudspeaker initiates the recording. • Both the 2003 and 2007 versions of PowerPoint allow voiceovers though the procedures are somewhat different. Review the instructions and experiment a bit until you master the technique. If you encounter problems we may be able to help.

23. Box 1 Five common shortcomings of health-care delivery Inverse care. People with the most means – whose needs for health care are often less – consume the most care, whereas those with the least means and greatest health problems consume the least10. Public spending on health services most often benefits the rich more than the poor11 in high- and low income countries alike12,13. Impoverishing care. Wherever people lack social protection and payment for care is largely out-of-pocket at the point of service, they can be confronted with catastrophic expenses. Over 100 million people annually fall into poverty because they have to pay for health care14. Fragmented and fragmenting care. The excessive specialization of health-care providers and the narrow focus of many disease control programmes discourage a holistic approach to the individuals and the families they deal with and do not appreciate the need for continuity in care15. Health services for poor and marginalized groups are often highly fragmented and severely under-resourced16, while development aid often adds to the fragmentation17. Unsafe care. Poor system design that is unable to ensure safety and hygiene standards leads to high rates of hospital-acquired infections, along with medication errors and other avoidable adverse effects that are an underestimated cause of death and ill-health18. Misdirected care. Resource allocation clusters around curative services at great cost, neglecting the potential of primary prevention and health promotion to prevent up to 70% of the disease burden19,20. At the same time, the health sector lacks the expertise to mitigate the adverse effects on health from other sectors and make the Demonstration voiceover; click on the loud speaker The sound reproduction in this example is not good. It was done on the microphone of a laptop. If you can’t get good reproduction then either don’t use a voiceover or ask your university’s IT staff for help.

24. Quiz, format options – Author note The next slides demonstrate six types of question options that you can use as “pop ups” or as section and final quizzes. Please provide your questions on individual slides inserted in the location where you want the questions to appear. For each question indicate the desired option style if not readily apparent. Indicate which answer(s) are correct, and provide short feedback answers that you want to appear when a student’s response is not correct. Do not be concerned with formatting; we will handle that at the time of assembling your module.

25. Quiz, format option 1 How many women die each year due to pregnancy-related conditions? a. abc -- incorrect; correct answer is…. b. def -- incorrect; correct answer is…. c. ghi -- correct d. jkl -- incorrect; correct answer is…. e. mno -- incorrect; correct answer is….

26. Quiz, format option 2 Which two of the following answers are major risk factors for pregnancy-related morbidity? a. abc -- incorrect; correct answers are…. b. def -- incorrect; correct answers are…. c. ghi -- correct d. jkl -- incorrect; correct answers are…. e. mno -- correct

27. Quiz, format option 3 Which word or phrase best fills in the blank? _________ would be the most effective single measure to reduce maternal morbidity due to hemorrhage? a. abc -- incorrect; correct answer is…. b. def -- incorrect; correct answer is…. c. ghi -- incorrect; correct answer is…. d. jkl -- incorrect; correct answer is…. e. mno -- correct

28. Quiz, format option 4Match each item on the left with the appropriate line on the right • Abc • Def • Ghi • Jkl • Mno • Pqr • 123 • 456 • 789 • 987 • 654 • 321 Note: Be sure to indicate which items are linked

29. Quiz option 5 – ranking Rank the below answers starting from most important to least important • Abc • Def • Ghi • Jkl • Mno • Pqr Note: Be sure to show the correct ranking

30. Quiz option 6 – true/falseIndicate whether each answer is true or false. (When response is incorrect a brief explanation as to why it is incorrect should be provided) • Abc [true] • Def [false] • Ghi [false] • Jkl [true] • Mno [true] • Pqr [false]

31. Quiz • Now we invite you to take the module quiz and test your recent learning. • This module quiz includes: • [Add a brief reference to the respective module quiz. How many questions, the type and scope of questions, and any other information and instruction for the students.] • After completing your quiz, come back for the summary of this module presentation.

32. Summary • [Add content to your summary slide(s) ] • [State what has been learned and if appropriate, ways to apply the learning ] • [Make sure you cover the most important points in your module objectives…] Page 32

33. Further readings & other resources • Note to authors: Provide a listing, briefly annotated if useful, of additional resources relevant to the module’s topic. Especially useful are recent journal reviews and good online material • Source abc • Source def • Source ghi • Source, etc. Page 33

34. Acknowledgments • Note to authors: This slide is for acknowledging help received from persons and organizations that were especially useful in preparating the module. Named authors will not be listed on the “Credits” slide Page 34

35. Credits [for named authors; you can include contact information if desired] [Add author 1 information] [Add author 2 information] [Add … ]

36. End of module [Reserved for GHEC notes and acknowledgment of donor organizations]