Integration of Sexual and Reproductive Health Services: A Health Sector Priority

Proposals for making sexual and reproductive health services both integrated and comprehensive were initially put forward by women's health advocates some 20 years ago, and in the past decade have been accepted into mainstream thinking by many governments and other stakeholders. This journal issue shows that major efforts are being made to put these proposals into practice in many countries and in many ways, despite sometimes formidable obstacles. It is the second issue of RHM to focus on sexual and reproductive health services in the context of health sector reforms.^*

Why integration?

The dictionary defines “integration” to mean inclusion, incorporation or coordination, whether fully or on an equal basis. The verb “to integrate” means to form, coordinate or blend into a functioning or unified whole; to unite one thing with another; to incorporate something into a larger unit; or to end the segregation of something.¹ All of these are descriptive of what it means to talk about sexual and reproductive health services being integrated in national health services.

Whether or not sexual and reproductive health services should be integrated, as opposed to vertical, can be debated from a range of viewpoints, drawing on an extensive academic literature. This journal issue does not enter into that debate, but takes a practical point of view. A simplified health systems definition of integration of sexual and reproductive health care in public health services is that the control of management, budgeting, funding and provision of services is situated within the Ministry of Health and its constituent decentralised levels rather than in a separate directorate with separate management and funding, such as family planning used to be. In developing countries today, this means competing for resources, staff, training and funding within the national health budget, rather than operating with separate, earmarked funding. At the services level, integration means providing more than just basic maternal and child health care and family planning.^*

The health sectors of most developing countries are currently in transition; at the same time as they are trying to implement health sector reforms they are moving from primary level maternal and child health/family planning programmes to providing a wider range of sexual and reproductive health care, deal with the AIDS epidemic and other major tropical diseases, and in some cases with famine and the ravages of war. Given the extent of change meant to be taking place and the limitations on resources, these are complicated and difficult tasks.

Integration of services

One of the main arguments in support of the integration of more sexual and reproductive health services is that it will improve women's health by encouraging greater use of services.² That is why family planning and maternal and child health (MCH) services were and still are considered highly appropriate for integration with each other: the same women need both at different moments in their reproductive lives.^*

Integrated and comprehensive care in each consultation was recently described by Pinotti et al in Brazil. They collected data on all the health problems of women attending their hospital-based clinic as the basis for determining which services to offer. Unlike the usual practice of limiting care to whatever complaint brings a patient to seek care in the first place, they screened all women for the whole range of problems they had identified and treated all the problems they found.⁴

The decision when and where to offer specific services as part of an integrated package, and to whom, must be based on epidemiological data, identified need for prevention and treatment,⁵ and priority setting in line with level of resources.⁶ Schierhout and Fonn found that integration of services seemed to work best when the target population for different services was the same.² On the other hand, if part of the point of integrated care is to broaden the population base whose reproductive and sexual health needs are being served, then services needed by different population sub-groups should be integrated and targeted appropriately as well.

Integration of sexual and reproductive health services cannot take place at primary health care level alone, but is required across all three levels of care.⁷ In a 1995 pamphlet to guide the Indian government's integrated Reproductive and Child Health Programme, Saroj Pachauri outlined a framework that consisted of two services packages—an essential services package as a starting point and a more comprehensive package as a longer-term goal. Each is divided not only according to type of service or intervention but also according to whether it is best provided at primary, secondary or tertiary level, or a combination of these.⁸ Thus, services should be coordinated in order to address the range of health needs in an efficient and effective manner and in a way that is acceptable and accessible to patients.

Skills in the provision of family planning services and antenatal and delivery care are as necessary for primary level health workers as skills for carrying out sterilisation, hysterectomy, gynaecological surgery, emergency obstetric care and treatment of breast and cervical cancer at secondary and tertiary levels. In this sense, the vision of the multi-purpose health worker carrying the weight of more and more types of service should be rejected. Instead, a broad grounding in sexual and reproductive health needs, combined with some form of specialisation, is probably required for all three care levels, starting with medical education.

Integrating policies and programmes

An integrated health service is one that is working in tandem towards agreed health goals, a vision which advocates of health sector reforms, sector-wide approaches and sexual and reproductive health have in common. These goals are reflected in how Ministries of Health are structured at national, regional and district level, how responsibilities for different aspects of health care provision are shared out between them and how they relate to each other in a managerial and decision-making sense. Several papers in this journal issue contain organograms of particular health ministries' programmes and units, showing who is responsible for what and the connections between them. Even in the visual presentation alone, it is clear that certain programmes, services or technical responsibilities are isolated and how they might be better integrated. If such organograms focused on sexual and reproductive health services, and covered regional and district levels and private sector provision as well, they would create a comprehensive picture of what exists. This would allow for analysis of where and how to make additions, improvements and adjustments.

The need for integration of policies as well as programmes is demonstrated in a study of current policies in Tanzania related to adolescent health.^*

Excellent programmatic goals emerged—preparation for responsible parenthood; delayed age at marriage and childbearing; expanding education; reducing rural-to-urban migration of youth; education on condom use, sexuality and reproductive health issues in schools and training institutions; and information, education and counselling on family planning and provision of appropriate methods. Yet some policies said nothing specific about adolescents or their needs even when it would have been appropriate; others were inconsistent. The policy on health service user charges did not exempt adolescents from charges, while another called for services for adolescents to be free. One recognised youth as a potential but mostly unemployed labour force, while another called for exploitation of youth labour to be stopped. Sexual health education in schools was proposed in one, but out-of-school youth were not mentioned. In many cases, neither operational nor implementation strategies nor training for providers were covered, and in fact programmes were sometimes not operative due to funding and other constraints. Even the age at marriage for girls, raised in 1971, is still being widely ignored.⁹ Such an analysis helps to develop integrated goals and streamline policies. In the end, however, putting policies into practice must follow.

Integration from a health systems perspective

Many primary health care services in developing countries are in fact sexual and reproductive health services. Schierhout and Fonn found that integration of primary health care services was understood as the close physical location of different types of service and service providers to each other, or when the provider of one or more types of service at primary level also started providing other services. Most strategies for integrating primary level service delivery in the 23 studies they looked at hinged on training first-level providers for:

• referral linkages between existing service providers;

• providing two or more services together that were formerly provided separately;

• adding new or upgraded services to an existing primary level service; and

• integrating primary health care into community, family or development activities.²

They also found that the lack of a health systems approach was an important reason why integration sometimes failed. Through the lens of health sector reform, it is clear that integration must involve much more than the content of policies and type of service delivered. According to a 1996 report by a WHO Study Group, the integration of primary health care services has been linked historically to the development of district health services and implies:

• multi-purpose clinics;

• multi-purpose staff;

• programmes with multiple objectives;

• overlapping of primary, secondary and tertiary levels;

• inclusion of other sectors;

• budgeting that reflects all of these;

• information systems that track inputs, services delivered and health status;

• training courses that are generalist rather than specialised;

• supervisory visits that deal with all aspects of the service;

• mechanisms to bring together different health care providers (e.g. into health committees);

• a close relationship between health centres and the district hospital; and

• joint efforts across sectors.¹⁰

Whether and how each of these aspects of integration is taken up, as well as the many permutations possible for management, budgeting and funding, have traditionally been left by the sexual and reproductive health field to someone else. However, privatisation of health services proceeds apace, and health sector reforms have finally impinged on the consciousness of the field, not least because of the effects on existing services of sector reforms such as decentralisation. Furthermore, changes in the financing of health care, including the sector-wide approach–itself a form of integration of health sector financing–have rung alarm bells for some in the field. Now that sexual and reproductive health have been taken into Ministries of Health, it is no longer certain that services the field considers essential, including family planning, will still get priority or sufficient funding. Nor is it clear that those making such decisions are aware of why such priority should be granted. In fact, in many cases, our work inside the health system in countries has only just begun.

Some history: integration of MCH and family planning

Among the services deemed appropriate early on for delivery at primary level were maternal and child health (MCH) care. As an acronym MCH is treated almost as one service, yet in itself it is a form of integrated care. In fact, equal attention to its constituent parts could never be taken for granted. The oft-asked question “Where is the M in MCH?”¹¹ betrays the fact that the extent of attention to the pregnant, delivering and post-partum woman has not always been sufficient in many countries. Efforts to integrate family planning with MCH started as early as the mid-1970s. Yet family planning, like infant health, has often received more attention than maternal health, reflected in steadily improving contraceptive prevalence rates and declining infant mortality but continuing high maternal mortality and morbidity. In some countries, although maternal mortality has fallen due to increased contraceptive use, deaths from complications of wanted pregnancies and unsafe abortions have remained high.

Although basic antenatal care may be well integrated in primary health care, antenatal care alone cannot address the life-threatening aspects of pregnancy and delivery. Several decades have been lost giving minimalist training to traditional birth attendants (TBAs) without linking them into the health system for referral purposes, and TBAs should have been replaced by trained midwives decades ago. Only one antenatal visit late in pregnancy, still the norm in many places, makes attention to the control of syphilis, high blood pressure, pregnancy-related complications from anaemia and malaria, screening and treatment for RTIs and STIs, and early HIV testing and counselling, let alone prevention of mother-to-child transmission of HIV, all difficult to achieve. Yet this is what an integrated primary-level antenatal care service should look like today.

Routine antenatal care can be handled safely at primary level and provided on set days, whereas deliveries and treatment of complications cannot. Planners need to take on board the fact that emergency obstetric services cannot be pre-scheduled, and ensure that deliveries can be attended and referrals for complications made 24 hours a day. Furthermore, these costs need to be integrated into the maternity care package, which is often not the case.

Despite its worthiness, integration of MCH + FP services began to get a bad name among first-level providers in developing countries by the 1980s, because the same number of health care workers, based in the same facilities, were expected to provide double the services with little or no increase in resources or training. Although clinics and staff were made “multi-purpose” in a variety of ways, there was still a need for additional staff, space, commodities and resources, as well as additional training and skills development for health workers and managers. In the absence of these, added services only stretch an already overstretched system further.¹² In fact, wherever MCH–FP services have not been able to meet women's needs, and poor quality of care stops women from wanting to attend, reproductive health outcomes have not improved. In other words, reproductive health on the cheap doesn't work.

“The concept that integration will cut down costs is in itself fallacious … [though] ‘low cost’ can be obtained by just increasing the denominators. Serving large segments of the population is expensive, and drugs and training can be prohibitive.” ¹³

Now, as funding for dedicated family planning services is no longer growing to meet still-increasing demand, due to funding ceilings and the shifting of funds elsewhere, some experts are saying that family planning would have been better off not being integrated but kept as a vertical programme (George Zeidenstein, personal communication, November 2002). It is difficult to know whether this is true or not, especially given the growing list of priority health problems and demands for funding. Nonetheless, if restrictions on funding make family planning into yet another women's health service on the cheap, as maternal health care has always been, family planning will certainly not continue to be the success story it is today.

The influence of HIV/AIDS on integrated service delivery

The rapid spread of HIV and AIDS from the mid-1980s highlighted high and contributory rates of untreated sexually transmitted infections (STIs) as well. These are in fact two closely interconnected but far from identical epidemics, and policy on how and where to integrate attention to them requires better analysis and greater breadth of vision. At primary health care level, it was proposed to add STI/HIV prevention activities to MCH–FP services, and a number of papers have been published in the past few years which analyse the advantages and disadvantage of this form of integration in depth.^{5 12 14 15 16 17 18} As logical and valuable as integration of STI prevention with MCH–FP would be, particularly for reducing the number of women with untreated STIs who present because they are experiencing fertility problems, it is far from a sufficient response.

Firstly, STI/HIV prevention in MCH–FP settings will reach only one group of women and may only consist of risk assessment, education for risk reduction and condom promotion. Widespread deaths from untreated AIDS, political leadership in mobilising action and education, and the practice of safer sex will eventually reduce the prevalence of HIV infection, as is thought to have occurred in Uganda. But screening and treatment for STIs is also crucial for lowering the incidence of both STIs and HIV infection.¹⁹ In many settings, however, the population of women requiring STI treatment may be different from the population for whom MCH–FP is traditionally provided. As argued earlier, this is not an argument against this form of integration per se, though others suggest it might be,¹⁵ as long as the right sub-populations of women are targeted. But STI control would not be covered sufficiently with MCH–FP. On the contrary, STI screening and treatment should also be provided in services addressing men's sexual health, services used by sex workers and their clients, and services targeting adolescents and any other vulnerable populations at high risk of STIs.

Secondly, as regards condom provision, it is worth pointing out that unmet condom need in Africa was recently estimated in one study to be 1.9 billion condoms per year, and in another as high as 13 billion per year.²⁰ To meet this need, once increases in manufacturing capacity can be resolved, male and female condom promotion should be integrated across all sexual and reproductive health services using multiple strategies. Providing condoms to women seeking MCH and family planning services is an excellent idea, for purposes of both family planning and prevention of STIs, and should already have been happening for years, but again it is only one of many ways in which condom promotion should be taking place.

The coordination of multiple condom promotion strategies in many countries is made more difficult because separate funding exists for condoms intended for contraceptive use, which are distributed by family planning services, and condoms intended to prevent STIs and HIV transmission, which are distributed through STI services (mostly used by sex workers and men), HIV testing and counselling services and condom social marketing campaigns. With this division, condom promotion is currently targeted at married couples for contraception on the one hand, and groups such as truckers, sex workers and their clients for STI/HIV prophylaxis on the other. Why is this problematic? Condoms are considered less effective than other contraceptives by family planning professionals, who rarely promote them as a first option anymore. Yet condoms are universally recognised as the most effective method for preventing sexual transmission of infection. This leads to contradictory and confusing messages from the point of view of potential users. Not surprisingly, “dual protection”—unlike “safer sex”—remains a lesser known and little promoted concept. Marriage is not a natural prophylactic against STI/HIV, however, and many women who sell sex need contraception. Furthermore, dual protection against unwanted pregnancy and infection is appropriate for adolescents having more than one partner.²¹ Dual protection is not needed by everyone for whom condoms are appropriate, and that includes many adolescents, but where it is needed, integrated condom funding, distribution, provision and promotion also make sense.

Thirdly, what works for women will not work for men. Men needing STI care are not willing to attend MCH–FP clinics, which are staffed and attended mainly by women, especially pregnant and nursing women and babies. Men need to be taken into account in their own right, not only for STI care but also for condom promotion, family planning information and infertility treatment, with services provided at times and in premises that men will attend, e.g. in separate facilities (another room, across the corridor, on the next floor, across the street), separate clinic days/hours and by separate staff.²² This is not at all outside the notion of an integrated approach, but requires staffing and programming with gender issues explicitly in mind.

Similarly, syndromic management of STIs has been shown to be more effective for men than for women because most women are asymptomatic.⁶ Hence, different STI treatment protocols need to be developed for men and for women, based on prevalence data in the catchment area concerned.¹⁶ Availability of drugs and laboratory facilities are also crucial, as are the other central pillars of successful STI service delivery–partner notification and treatment and condom promotion.^{17 18}

Fourthly, although not all reproductive tract infections in women are sexually transmitted, the need for attention to RTIs which are not sexually transmitted is often sidelined. This is a crucial distinction, however, as the population of women needing treatment for endogenous and iatrogenic RTIs may be different from (or overlap) the population needing STI treatment.^*

Fifthly, the need for HIV/AIDS care must not be collapsed into or tacked onto the need for STI care, as highly specific needs are raised by the HIV/AIDS epidemic. There is no cure for HIV infection but there is both antiretroviral treatment and treatment for opportunistic infections. Specialist services are needed for HIV/AIDS, especially where antiretroviral treatment is available, and few would question their necessity. On the other hand, HIV is above all a bloodborne and sexually transmitted disease and its interconnections with other aspects of sexual and reproductive health are close. Any combination of MCH, FP and STI services for women in high HIV prevalence areas should certainly be doing voluntary HIV testing and counselling on a routine basis, as long as some form of antiretroviral treatment is available.²⁴ A strong case can be made, however, that antenatal clinics and primary level MCH–FP services in most low-income developing countries cannot take responsibility for other HIV-related care unless they are greatly strengthened, making referral the preferred form of integrated care. Indeed a district hospital may be better able to sustain STI and HIV-related treatment services than a rural health post or any other primary level facility.¹²

Lastly, the private sector is highly involved in providing STI treatment, not least because of the lack of public sector services. Unfortunately, quality of screening and choice of treatment are often poor in the private sector too. For example, a recent study of private sector care for STIs in one sub-Saharan African country found that knowledge of recent developments in syndromic management and effectiveness of drugs was poor, and less than half of prescriptions were effective. Furthermore, for most syndromes, uninsured patients were offered significantly cheaper and less convenient antibiotic regimens, and effective regimens were significantly more expensive than ineffective ones.²⁵

The lack of inexpensive means of diagnosing STIs and RTIs is a major barrier; those who have no symptoms will not come forward and those who cannot afford expensive drugs will look elsewhere for cheaper, often ineffective ones. This is a good place to highlight the use of self-medication, traditional practitioners, pharmacists and a wide range of private sector providers, qualified and unqualified, for many sexual and reproductive health problems, from STIs to induced abortion to obstetric complications. These providers and non-formal aspects of national health systems need to be better mapped, including any differences in how they are used by women vs. men. Oversight and regulation by governments of private service providers should be part of broader plans for how to integrate private and public sector provision and ensure that public health services do not remain limited and, at worst, become irrelevant except for the very poor.

Making integrated services more comprehensive

Broadening the list of currently available services, methods and procedures means more population groups and their needs can be covered, though it also increases costs. In this sense, there is a difference between integrated services and comprehensive ones. Greater choice is not just a rights or a market issue; it contributes to public health goals. However, quite a few service elements are still excluded from integrated MCH–FP programmes. Some of these include:

• fertility awareness education, especially for young people;

• breastfeeding education and support, including for replacement feeding for HIV positive women;

• family planning services for older single, widowed and divorced/separated women and men, sex workers and their clients, and other marginalised groups;

• services catering specifically for young people, including family planning, STI education and treatment, sexuality education, and life skills, and help coping with stress and depression;

• safe abortion services (including both medical and surgical methods);

• post-partum and post-abortion care that includes contraceptive services;^{26 27}

• female sterilisation and vasectomy.

Forging effective links between contraceptive services (including emergency contraception), abortion and post-abortion care is also an important aspect of integrated care. The population of women requiring abortion services is a subset of those requiring contraception. Early medical abortion, which is simple to administer, does not require a gynaecologist, surgery, anaesthesia or a bed in a ward. Hence, family planning services rather than surgical abortion facilities may be the best place to offer it, in spite of the ideological barrier to considering this that will be raised in many quarters.

It is to be regretted that in the name of compromise, the fallacious and damaging statement that “abortion can in no way be treated as a method of family planning” was allowed into the Programme of Action of the International Conference on Population and Development in 1994. While abortion is certainly not a method of contraception, it most definitely is a method of family planning, which like MCH has long been understood as a set of inter-dependent practices:

“Family planning [is] the group of practices which help individuals or couples to attain certain family-related objectives: to avoid unwanted births; to bring about wanted births; to regulate the interval between pregnancies; to control the time at which births occur in relation to the ages of the parents; and to determine the ultimate number of children in the family in a planned and voluntary fashion.” ²⁸

A number of other essential sexual and reproductive health services have also been given short shrift in priority-setting exercises in many developing countries, in spite of the significant burden of morbidity and mortality they cause. Among the most important of these are infertility; cervical, breast and other cancers of the reproductive tract; problems of menstruation and menopause; and the sexual and reproductive health consequences of gender-related violence and war. Integrating each of these will have its own particular requirements as well.

Has there been progress in the past decade?

A recent multi-country study attempted to determine whether countries who have tried to integrate reproductive health services are succeeding, at least partially, and whether indicators have been improving over time or not. The study was carried out in 49 developing countries. Some 10–25 experts per country were asked 81 questions about capacity of health centres and district hospitals to provide services, access to services in urban and rural areas, and care received. An unorthodox method of evaluation was used: services were rated by participants on a scale of 0–100. The services asked about included family planning, antenatal and delivery care, emergency obstetric care, neonatal care, immunisations, control of STIs, and HIV testing and counselling. Data were not shown on a per country basis, only mean scores for all countries. Variation between countries was substantial. Overall, the likelihood that a typical service was adequate was 56%. Rural areas fared worse than urban areas on almost all questions asked and the weakness of implementation was reflected in poor scores for resources. National ratings ranged from 70 to 89 for Jamaica, Dominican Republic, Peru, Iran, China, Viet Nam, West Bank and Gaza Strip, Egypt and South Africa. They were extremely weak, ranging from 10 to 29, for Yemen, Pakistan, Nepal and Ethiopia. The other 36 countries fell in between. Importantly, there were indications that services had improved by about 10 points per country in the three years from 1994, implying that overall, progress may be taking place but not very quickly.²⁹

The contribution of this journal issue

Many of the papers in this journal issue take a health systems approach to the integrated delivery of sexual and reproductive health services. They map at least some of what is available, mostly in the public sector, and assess the operation of integrated systems, programmes and services. One shows how long it takes, working at local level in a poor community, to build an integrated service step by step. Several focus on the effects of decentralisation on services. One shows the pitfalls of imposing a top-heavy framework for programme planners and managers to implement. One outlines what an innovative curriculum for medical education in sexual and reproductive health care should consist of. One describes how advocates of gender equity were able to influence the development of equitable health sector policies but not their implementation. Many identify a range of barriers to integration, some of which could be resolved by better communication, better division of responsibilities, improved programming, development of managerial skills and better flows of commodities and resources. Others discuss the integration of specific services, such as post-abortion care, emergency contraception and female condoms, the integration of contraceptive services into STI clinics for women sex workers, and the elements of an integrated programme for adolescents. Another reminds us that continuing adherence to traditional beliefs and practices is still contributing to maternal deaths, and that neglect of the perspectives of birthing women will continue to get in the way of their seeking life-saving care. One assesses one of the best resourced sexual and reproductive health programmes in the world. Most illustrate the near-insurmountable obstacle presented by lack of adequate resources.

Figure 1 Bamako, Mali, 1970

Future perspectives

Future assessments need to cover the entire health system, both public and private, and address the role of government in ensuring that the two are working together, delivering quality of care, and are accessible, affordable and accountable. Costings of integrated sexual and reproductive health services packages, from basic to comprehensive, are urgently needed if priority setting is to include them in a realistic manner. Governments are considered to have ultimate responsibility for the oversight and financing of services and the education, training and working conditions of health workers. But the crucial and sometimes counter-productive role of external funding and loans, particularly when donors and lenders are unwilling to work together or to ensure that funding is coordinated and in line with national policies and programming, has also surfaced in these papers and deserves more attention. Until and unless these agencies are willing to work together and allow governments to take the lead, wasted resources and missed opportunities will characterise health systems and programme management in low-income countries, and governments will remain disempowered.

It is a complicated task to manage a health system and make it work well, especially with a limited and fragmented resource base. The papers in this journal issue show that many countries are working hard to provide integrated sexual and reproductive health services and need more skilled people, time, money and autonomy to succeed. They also invite recognition of the destabilising and destructive effect of major shifts and changes by international and national stakeholders in policies, priorities and financing often orchestrated without the participation of those who will be affected, which occur with depressing regularity. We must be vigilant to prevent this happening to the past three decades of hard work for sexual and reproductive health.

Acknowledgements

Particular thanks to Michael Reich, Director, Harvard Center for Population and Development Studies, for intellectual and office space for research on this subject, which will also result in a longer paper. Thanks also to participants of the Center's Brown Bag meeting on 26 November 2002 for helpful comments. TK Sundari Ravindran and Marianne Haslegrave gave insightful comments on previous drafts; Louisiana Lush, Sharon Fonn and Jane Cottingham made helpful suggestions; Scott Gordon provided several key references.

Notes

1. See also Reproductive Health Matters 10(19), November 2002 on the theme of “Health sector reforms: implications for sexual and reproductive health services”.

* Additional services include those for sexually transmitted diseases, HIV/AIDS, infertility, abortion, cancers of the reproductive tract, essential obstetric care, problems of menopause such as hysterectomy and uterine prolapse, and menstrual disorders.

* For example, a 1995 Moroccan study found that: “1) MCH service use causes increased contraceptive usage, 2) contact with contraceptive service providers leads to use of MCH services, and 3) women who use MCH services are predisposed to accept FP services.”³

* These included the 1990 National Health Policy, 1992 National Population Policy, 1994 Health Sector Reform Policy, 1994 National Policy Guidelines and Standards for Family Planning Services Delivery and Training, 1995 National Youth Development Policy, 1996 Community Development Policy, National Policy on HIV, AIDS and STDs (undated), and 1997–2001 Strategy for Reproductive Health and Child Survival.⁹

* RTIs include endogenous infections resulting from the overgrowth of organisms normally present in the vagina and iatrogenic infections resulting from the entry of micro-organisms into the reproductive tract through invasive medical and other procedures, i.e. infection from unsafe abortion or delivery practices, retained products of conception or re-used menstrual cloths.²³