Marija Jevtic, Tatjana Tamas, Snezana Pantic Aksentijevic, Dragana Stojanovic:
Reproductive health in Serbia: Condition, perspectives and demographic significance
Reproductive health in Serbia: Condition, perspectives and demographic significance
Marija Jevti}
University of Novi Sad, marija.jevtic@uns.ac.rs
Tatjana Tama{
University of Novi Sad, tatjana.tamas@gmail.com
Snezana Panti} Aksentijevi}
Ministry of Health of Republic of Serbia, snezana.pantic@zdravlje.gov.rs
Dragana Stojanovi}
IPPF Serbia, dragana.stojanovic@srh.rs
Abstract
The World Health Organization defines reproductive health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, in all matters related to the reproductive system and its functions and processes. The low fertility rate in Serbia places the problems associated with reproductive health on the list of priorities of public health and indicates the need for them to be identified and systematically solved. The aim of the paper is to determine the situation in the field of reproductive health in Serbia in the past ten years and to define major topics that the Serbian professional public treated in the above-mentioned period. This review article has also covered papers from the Serbian Citation Index national base which were picked using key words related to reproductive health. We have singled out only articles that were published in the past ten years. Some of the reproductive health areas are yet to be covered, or there is not enough quality data. Gathering together experts in different fields, who are interested in reproductive health, would ensure more accurate data and enable the elaboration of concrete programs and a uniform reproductive health strategy in Serbia.
KEYWORDS: reproductive health, adolescents, abortion, contraception, reproductive rights
ANTHROPOLOGICAL NOTEBOOKS 22 (3): 47-60. ISSN 1408-032X
© Slovene Anthropological Society 2016
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Introduction
In the second half of the 20th century, there has been a rapid expansion of knowledge and technology. Their efficient use was conditioned by political and economic obstacles on the national and international levels. The mutual dependence of the global population, the overall development, and environment as well as an opportunity to adopt the appropriate macro and socio-economic principles of importance for the stable economic growth in the context of sustainable development in all countries has been recognised (United Nations 1995). At a breaking point in the history of the international co-operation, the International Conference on Population and Development was held in Cairo in 1994. This conference represents a shift in the former way of thinking from the collective to the individual level. Attention is focused on ensuring the rights of individuals and on meeting their individual needs. The conference gave birth to a new paradigm of "reproductive health", which not only represents sexuality and purely gynaecological disorders, but it also includes birth control, safe sex, and pregnancy without coercion, discrimination, or violence.
The World Health Organization (WHO) defines reproductive health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, in all matters related to the reproductive system and its functions and processes. Reproductive health, therefore, implies that people are able to have a responsible, 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 (World Health Organization).
This definition also covers the rights of men and women to be informed and to have access to safe, effective, accessible and acceptable methods of contraception according to their free choice. It also means the accessibility of the health care services that will provide a safe pregnancy and delivery to a woman and enable couples to have a healthy child (World Health Organization).
Education has been recognised as a decisive factor of importance for the demographic changes (Sircelj 2007). Without it, in developing and underdeveloped countries, it would be difficult to raise the level of wages and reach a balanced socioeconomic development. Education of girls and women is considered crucial for lowering the birth rate, as well as the reduction of their mortality and morbidity. Women's reproductive choices, especially in underdeveloped areas, depend on the process of strengthening of women which may arise only with the improvement of education, training for economic independence, and the increase of the legal and social status of women (Mayor 1994).
Women in developing countries and poor women in the cities of some industrially developed countries have the highest rates of complications of pregnancy, sexually transmitted diseases and carcinoma related to reproductive system. Inability to reach the health care services is the main reason that so many women suffer and die. The majority of the illnesses and deaths related to reproduction could be prevented and resolved by using the strategies and technologies that are accessible even in the poorest countries (Worku & Gebresilassie 2008).
The full and equal participation of women in all fields including civil, cultural, economic, political and social life, at the national, regional and international levels, and the eradication of all forms of discrimination on grounds of sex have been recognised as
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Marija Jevtic, Tatjana Tamas, Snezana Pantic Aksentijevic, Dragana Stojanovic:
Reproductive health in Serbia: Condition, perspectives and demographic significance
priority objectives of the international community since the International Conference on Population and Development in Cairo (United Nations 1995).
The components of reproductive health are quality service of family planning; promotion of safe maternity; prenatal, postnatal care, safe delivery and breastfeeding; prevention and treatment of infertility; prevention and treatment of complications of illegal abortion; services that provide legal abortion; the treatment of infections of the reproductive system, including sexually transmitted diseases; information and counselling on human sexuality, reproductive health and responsible parenthood; active opposition to harmful practice, as female genital mutilation and violence related to sexuality and reproduction (Worku & Gebresilassie 2008).
Men can also have problems with their reproductive health, mostly from sexually transmitted diseases, but the numbers and the extent of the risk are significantly higher in women. The concept of reproductive health also recognises the central importance of the equality of genders and participation of men and their responsibility (Worku & Gebresilassie 2008).
Fifteen years ago, in the Millennium Declaration, the Millennium Development Goals, represented an important framework for the development, were published; thanks to them, there has been a significant success in several areas. Their purpose was the realisation of human rights and the satisfaction ofbasic human needs. However, in certain areas, such as the health ofmothers, new-born babies and children, as well as in the field of reproductive health, satisfactory success has not been reached, especially in developing countries. The United Nations, at a summit in New York in September 2015, adopted goals of sustainable development that will define global development in the next fifteen years. The New Agenda relies on the Millennium Development Goals and is meant to finish the job started within the framework of these goals, especially to reach the most sensitive groups (United Nations 2015).
All levels of government, including local ones, should establish their priorities and adopt action plans based on the criteria of sustainable development and in accordance with the principles of public health. As sustainable development cannot be realised without a healthy population, the societies must focus on the promotion of health and the improvement of the quality of life for all categories of the population (Jevtic 2011).
Unfortunately, it is estimated that the New Agenda shall also have its shortcomings, especially because of its horizons in the area of sexual and reproductive health and rights being too narrow. The New Agenda for sexual and reproductive health which will include the entire field of these areas is needed (Starrs 2015).
The situation in Serbia
World Economic Forum's 2013 annual report ranked Serbia, according to the state in health care, to the 66th place in the world, which is 20 places worse in comparison to only three years earlier (Ringier Axel Springer 2013).
In a society in which women are uneducated, poor and politically powerless, high morbidity and mortality related to the reproductive system is common. Women are a very sensitive group, which needs adequate health care. Many years of poverty and the sense of insecurity influenced their decisions, which also affected their reproductive health.
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Together with the culture of abortion, which has been recognised in Serbia (Rasevic & Sedlecky 2011a), they influenced the negative natural increase. According to the latest data relating to 2011, the level of the birth rate is 33% below the needs of the simple reproduction of the population. This data suggests that the next generation of women will be smaller in number by one third in relation to the current one (Rasevic 2013). Research implemented in connection with abortion, contraception, and general reproductive health emphasise the importance of the knowledge of female health and their rights and how the different policies and socio-economic situation influence them.
Some indicators of reproductive health are used in Serbia for the assessment of its condition. In the domestic literature rate of total fertility, the rate of pregnancy of adolescent girls, the use of contraception methods, the structure of the use of contraception methods, the rate of total abortions, HIV infection, mortality resulting from AIDS, maternal mortality, infant mortality, and the leading causes of death in reproductive period are mostly used (Rasevic 2013). The predictive influence of personal characteristics of women, features of the environment, health and health care on the main aspects of reproductive health was also examined (Miljkovic et al. 2010).
What best characterises the measures taken in our country to improve reproductive health is the emotional evaluation of the phenomenon of insufficient births of children and the existence of prejudice among experts and politicians, who do not have sufficient knowledge in this field. The six most common fallacies identified in the surveys are: high demographic price of 1990s, poor economic conditions as the most important factor of the low birth rate, a prejudice that there were more and more non-fertile couples in Serbia, the opinion that the prohibition of abortion would solve the problem of population decline, incentives for childbirth of the fifth and higher order, and the position that it was not important that Serbia will have fewer people in 2050 than today (Rasevic 2009).
Our aim is to perceive the situation of reproductive health in Serbia during the last ten years and to define major topics that were studied by professionals in the above-mentioned period.
In order to comprehensively assess the priorities and directions of action in the future, the paper is the result of a joint analysis from the perspective of the Ministry of Health, the academic community, and the non-governmental sector.
This review article has also covered papers from the Serbian Citation Index national base which were picked using key words related to reproductive health. Emphasis was placed on the analysis of the work of the profession and science in the past ten years. Having in mind that reproductive health includes both the area of medical and social sciences, we highlighted the need for a comprehensive approach to the analysis.
The interest of professional and scientific research was mostly directed to the behaviour of the young, while the remaining topics were pregnancy in adolescence, abortion, contraception, fertility, sexually transmitted diseases, in vitro fertilisation, voluntary sterilisation, and reproductive rights.
It is important to emphasise that there is the interest of experts in the field of social sciences, who deal with the research of the reproductive health and its demographic significance in Serbia.
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Reproductive health in Serbia: Condition, perspectives and demographic significance
The term adolescents means young people of the age of ten to nineteen. Due to the prolonged period of psycho-social maturing and achieving economic independence, under adolescence we often mean the period even up to 25 years of age. Most of the works in this area include respondents to this age limit. The health state of the young is primarily affected by their risky behaviour, which is defined as the new morbidity of the young (Stankovic 2006). Problems related to reproductive health represent one of the most common causes of youth morbidity, since the risky behaviour in the area of sexuality with adolescents leads to unplanned pregnancies, abortions, and sexually transmitted infections. Young people have yet to achieve their reproductive function and their reproductive health is highly significant from the individual and social aspects (Stankovic 2007). The behaviour of young people and their attitudes toward reproductive and sexual health may in the future define the demographic situation in Serbia. It was noted that adolescent girls frequently adopted models which endanger their health and do not have a sufficiently developed positive attitude toward health (Sedlecky, Markovic & Rajin 2001). Young people must also master life skills, in order to be able to recognise the risks and to avoid them, primarily to be able to resist peer-pressure (Stankovic 2002). Examination of the conduct of the young in Serbia is also possible through the Internet, which proved to be a good method not only for the collection of data but also for the education on reproductive health of the young (Rasevic & Sedlecky 2013).
Pregnancy during adolescence is a major problem not only for the girl and her further development, but also for the partner and it is also the challenge for public health. The consequences are important and have influence not only on the adolescent girl and her family, but also on the society as a whole. In Serbia in 2011, 19 girls aged 15 to 19 per 1000 of their peers gave birth to a live child. However, it should be noted that half of the adolescent pregnancies were realised by delivery, and the other half by abortion (Rasevic 2013). Reducing the registered birth rate in adolescence in Serbia represents a positive change, but the largest reduction was noted with the age of 19, while at the age of 15 and 16 the reduction was smaller. Although rarely, girls under the age of fifteen also gave birth (Stankovic & Penev 2012). Due to the lack of the maturity of the reproductive system, adolescent pregnancy is a stress for the body. Furthermore, adolescent girls delay visiting a doctor, because of which the prenatal diagnostics come late. Due to the mental immaturity of adolescent girls, their children may have poor post-natal care as well. In addition to all these problems, they are also facing socio-economic challenges. According to the study conducted in Prague, an unwanted child may suffer to maturity. It is more exposed to the risk of diseases, has a weaker average grade point in school and is overly sensitive (Rasevic 2009). To achieve the changes, it is necessary to build reproductive awareness among young people. The results of the majority of the research in our country show that adolescents do not know enough about reproductive health, which affects the increase of sexually transmitted diseases and unwanted pregnancies. Out of 292 students of the first and the fourth grades of three Belgrade secondary schools, which participated in the survey, 33.6 per cent were sexually active, without statistically significant differences among genders. In the 1st grade of secondary school every sixth adolescent is sexually active, while in the 4th grade it is on average every second one (Kisic-
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Tepavcevic, Steric, Kisic, Popovic & Pekmezovic 2010). Furthermore, only one-third of sexually active adolescents uses contraceptives consistently during sexual intercourse. A disturbing fact is also that for 3.4% of girls their first instance of sexual intercourse was not wanted (Mijatovic-Jovanovic, Ukropina, Kvrgic & Surkovic-Niciforovic 2004). The risk of pregnancy is highest during the first months after engaging in sexual intercourse. Therefore, it is necessary to emphasise the importance of sexual education of young people at the beginning of their sexual life.
The need for information about the contraception, especially among adolescent girls was outlined by the nine-month long campaign 'I make love, I take care' of the Association for Reproductive Health, which was also supported by the Ministry of Health of the Republic of Serbia. In addition to the numerous appearances in the media and online consultancy, the site www.21dan.com was designed, where information on sexual and reproductive health was published. During the campaign, the Info Center received around 1,800 calls and several hundreds of SMS messages monthly from all over Serbia. The questions about reproductive health were mostly asked by the girls between 20 and 24 and by adolescent girls of 19 years of age. In this way, the new opportunities of using online service for providing information on sexual and reproductive health, which make new possibilities but also the responsibilities for both clients themselves and providers of these services, were used (Baraitser, Syred, Spencer-Hughes, Howroyd, Free & Holdsworth 2015).
Abortion is a very emotional and complex issue of importance for both individual and social plans. On the one hand, it is considered to be a safe operation, while on the other there is a fierce battle lead between the freedom of an individual's choice and the value of the life of the foetus (Klajn-Tatic 2011). The problem of the large number of abortions in our country was mentioned at the 17th Congress of Yugoslav doctors in 1935. The estimated rate of the total abortions in Serbia in 2007 was 2.76. It was two times higher than the rate of total fertility and among the highest in Europe and the world (Rasevic & Sedlecky 2011a). The real causes are difficult to identify; they can be the consequence of difficult material position, inability of finding employment, unresolved housing issues, divorce, and a lack of activities in the field of health protection of women and the promotion of reproductive health (Todorovic & Radovanovic 2006).
Another fact that is of concern is the study conducted at the Clinic for Gynaecology and Obstetrics in Novi Sad in 2008, according to which more than half of the interviewed participants (52.5%) showed acute stress disorder after abortion (Vukelic, Kapamadzija & Kondic 2010). As a legislative innovation, the law on the procedure of abortion in the health care institutions introduced the possibility (i.e. the right) of a doctor to outline his/her conscientious objection in written form, by which he or she refuses to make or to participate in a termination of pregnancy to the tenth week. However, for the cases of late abortion, it is not possible to declare the objection to conscience because they are conceived as medical assistance (Mujovic-Zornic 2009).
The only measure related to the birth control in Serbia is the liberalisation of abortion. At the same time, the availability of modern methods of family planning is relatively low, with limited marketed products, which is restricted to condoms,
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Reproductive health in Serbia: Condition, perspectives and demographic significance
oral contraceptives, and intrauterine devices, as a result of the low demand for other contraceptives within the population, which testify about the low culture of reproductive health. There is also a lack of a functional knowledge of doctors in terms of providing advice on contraception, because advice on it has not become an integral part of the curriculum of the medical professionals during the basic professional education. The network of the counselling offices for young people is not developed enough, and counselling offices exist mostly in bigger cities. Only 5% of women in the reproductive period visit the counselling office for contraception in comparison to over 90% of the pregnant women who go to the counselling office for pregnant women (Rasevic & Sedlecky 2011a). In Serbia, pregnancy is most often prevented by interrupted intercourse; in the case of failure of this method, the partners choose abortion.
According to the data of the International Planned Parenthood Federation of Serbia (IPPF Serbia), the use of methods of family planning among women in Serbia is reported only with 58.4 per cent of the population, with 40% of the entire population using traditional methods. Out of the effective contraception methods, the most commonly used is condoms (22.2%), while the use of hormonal contraceptives and intrauterine devices lags (7.2% and 5.3%) (Rasevic 2013). Health workers themselves contribute to such a bad situation. According to the survey conducted in primary health care in Belgrade, 38.7% of the health workers of different profiles have never used contraception, and more than half of the respondents (59.0%) or their partners had a deliberate abortion (Rasevic & Sedlecky 2011a). Acceptance of abortion as a serious socio-medical problem is the first step in resolving the current situation. The government and state institutions have to solve the problem of abortion primarily by supporting the use of effective contraception methods.
The fertility of the population is a topic that raises most attention in reviewing the demographic situation in Serbia. Central Serbia and Vojvodina faced the problem of low birth rate as early as the middle of the 20th century. Today, with a total fertility rate of 1.41%, the level of the birth rate in Serbia (Rasevic & Sedlecky 2011b: 259) is below the European average of 1.6 children per woman. However, there is no evidence that the situation during the 1990s affected the fertility in Serbia, because in Vojvodina in 1981 and 2002 there were identical rates of cumulative fertility registered for the 36-40 age cohort.
An attempt to attribute all problems to the poor economic situation is not the solution, as the phenomenon of low birth rate also affects more developed societies. What is common for all societies with the low rate of fertility is emancipation, insistence on the quality of personal life and the life of the child and the consumer mentality. In such a context, the freedom of an individual is greater than social responsibility and solidarity, and the needs of the future generations are not considered (Rasevic 2009).
Throughout the world, great importance for the improvement of the fertility is attached to the so-called lifestyle factors. These factors include the age of initiating a family, nutrition, body weight, physical activity, stress, smoking, use of drugs and medications, alcohol and coffee consumption, environmental conditions and the conditions of the working environment, preventive measures such as contraception, visits to the doctor, and
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other factors. If the importance of all these factors on reproductive health is perceived, by the active change of behaviour of men and women, they would be able to control their reproductive potential (Sharma, Biedenharn, Fedor & Agarwal 2013).
According to the WHO, there are an estimated 357 million new infections with one of the following four sexually transmitted infections: chlamydia, gonorrhea, syphilis and trichomoniasis, each year (2014). The incidence of diseases which are transmitted by sexual contact is growing in most of the countries in transition, due to the impoverishment of a large number of the population, the spread of prostitution and drug addiction and a lack of sexual education. In the survey conducted at the Institute for Health Protection of Students in Novi Sad, out of the total number of polled female students, 18 of them (4.53%), were cured of infections caused by Chl. trachomatis (Nikolic & Kapamadzija 2011). In 30 to 50 % of cases, pelvic inflammation disease is caused by the infection with Chl. trachomatis and N. gonorrhea. Pelvic inflammation disease is connected with the difficult morbidity and significant late consequences, including tubal infertility, ectopic pregnancy and chronic pelvic pain (Terzic & Kocijancic 2010).
In the framework of the Research of Multiple Indicators conducted in Serbia in 2010, the sexual behaviour of young people of both sexes aged between 15 and 24 was also examined. The survey showed that only half of the respondents possessed comprehensive knowledge about the ways of HIV transmission, and 41% of female respondents and 61% of male respondents had had sexual intercourse with a person who is not their permanent partner in the past 12 months. Out of them, 77% of women and 80 % of men had used a condom during the last sexual intercourse (Rasevic 2013). One of the most important reasons for the extremely high rate of incidence of sexually transmitted infections is inadequate information on them, primarily when it comes to the methods of protection. Furthermore, there is an insufficient degree of awareness of the above-mentioned symptoms of noted infections, as well as their potential complications. These data clearly indicate the need to take concrete measures for the prevention of sexually transmitted infections at the national and global level. In Serbia, two vaccines against infection with the human papillomavirus are registered, but vaccination is not required. The existence of vaccines, however, must not mean neglecting other strategies for fighting cervical cancer, above all, regular examinations (Matejic & Kesic 2013).
According to the survey performed in six institutions of primary health care of the Republic of Serbia and the Republic of Montenegro, the relevant links between recurrent vulvovaginal candidiasis and continued wearing of daily sanitary pads was found, as well as between the recurrent vulvovaginal candidiasis and predominant use of vaginal tampons during menstruation (Jankovic et al. 2010). Additional education for girls on the topic of the use of daily sanitary pads and hygienic habits is needed.
In vitro fertilisation is the procedure of fertilisation in laboratory conditions. In the Republic of Serbia, couples are allowed a certain number of cases (two attempts) of in vitro fertilisation for free, namely at the expense of the compulsory health insurance system. Some of the cities and municipalities in Serbia make decisions on additional financing (third attempt). Private insurance in the case of the failure of the previous attempts is not yet available (Marjanski 2013).
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Marija Jevtic, Tatjana Tamas, Snezana Pantic Aksentijevic, Dragana Stojanovic:
Reproductive health in Serbia: Condition, perspectives and demographic significance
In Serbia, there is no understanding in the social and political sphere for the legalisation of voluntary sterilisation as a form of prevention of conception. Research conducted at the Narodni front Gynecology-Obstetrics Clinic in Belgrade, included 296 women who decided to have a deliberate abortion at this clinic in the period of the implementation of the research. The results of this survey showed that 58.1 per cent of women respondents not only thought that the willing sterilisation should be available in Serbia but that they themselves would undergo tubal ligation as the method of contraception. The state is obliged not only to allow its citizens the right to make individual choices in the sphere of family planning, but also to enable through legislation the spread of relevant information on all methods of contraception and to enable the availability of different contraceptive options, not only by their presence on the market but also at an affordable price (Rasevic 2002). As a surgery excluding the further possibility of fertilisation, the sterilisation rests in its basis on the right of the autonomy of a person, and it is part of the rights and freedoms guaranteed by the constitution (Mujovic-Zornic 2001).
Women with disabilities have the right to be healthy and to have equal opportunities in access to quality primary health care, which also includes regular gynaecological examinations. Thanks to the international co-operation, domestic non-governmental organisations, and Ministry of Health of the Republic of Serbia, gynaecological services for persons with disabilities (for example, the organisation Out of Circle) are provided. Furthermore, doctors and medical staff were trained to provide these individuals with services of gynecological examinations in the best manner possible.
One important indicator of the reproductive health is mortality of women during the pregnancy, at birth and in puerperium per 100,000 live births. According to the data from 2010, Serbia is in the first ten European countries that have the highest values of this indicator. According to the same report, Serbia is in a group of a dozen of countries in Europe which have the highest infant mortality rate per 1,000 live births (Rasevic 2013). Both indicators are considered important indicators of not only reproductive health but also of the state of health and health protection, as well as the level of socioeconomic development of a single population.
It is important to emphasise that the mortality rate of cervical cancer in Serbia regardless of incidence reduction remains among the highest in Europe (Knezevic 2009). By observing problem of the high incidence of cervical cancer in Serbia, the Ministry of Health in June 2006 appointed a special working group for the Prevention of Cervical Cancer whose task was to create a National Program for the Prevention of Cervical Cancer, which was adopted in 2008. Unfortunately, the results are not yet satisfactory, primarily because of the small scope of women preventively examined due to the low level of the health culture and insufficient implementation of the program of the promotion of health.
Violence against women is a significant public health problem, which has consequences for the physical, mental and reproductive health of women. A total of 35 per cent of women throughout the world has suffered physical or sexual abuse by their partners and other persons. Women who are victims of physical and sexual abuse by the partners have a series of health problems. They also have a greater risk of bearing a child with low birth weight. Therefore, it is necessary to promote equality among genders and
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organise services for the assistance of women who are victims of abuse (Low & Wong 2014). In June 2010, a Special Protocol of the Ministry of Health of the Republic of Serbia for the protection and treatment of women who are exposed to abuse was adopted. One special protocol is an instrument for the identification, recording, and documentation of gender-conditioned abuse, with the aim for health workers to become involved and react with a plan for the detection, suppression, and prevention of abuse.
Individuals consider the phenomenon of the insufficient birth rate to be given too much importance, but childbirth influences the revitalisation of the size of the population and its age structure. Delivery of children performs these two essential functions only if its level satisfies the need for at least a simple restoration of the population. The results of the analytical projections indicate that by 2050 Serbia's population will have significantly declined. 'Neglect of the importance of the age structure of the population is dangerous because the economic and social structure of the society and its functioning depend on this population structure' according to Rasevic in her survey (2009: 89). The problem of depopulation has also been characteristic for other countries in transition, which was further aggravated by emigration to the developed countries of the European Union. The lack of human resources could pose a problem for the further industrial and economic growth of Serbia for a long period to come (Tamas & Jevtic 2015).
Currently, the discussion of interested parties on reproductive health in Serbia, according to the IPPF Serbia, is proceeding from the two initial premises: very low birth rate which prevents biological reproduction of the nation and the very high number of abortions at the annual level, which endangers the health of women and contributes to the low birth rate. Unfortunately, these premises have not yet been quite clarified, when reproductive health and respective rights are debated: the birth rate in Serbia is below the European average, but it is not extremely low, while the expressed phenomenon of demographic aging that affects Serbia is most likely a combination of several factors, for which migratory trends are probably more important than birth rate (the departure of the population in the reproductive age, the return of the population which moved out of it). Likewise, a high number of abortions at the annual level is an indicator of which for now there are only estimates that range from twenty to one hundred and fifty thousand thanks to the lack of a good record of data related to the provision of these services, especially in the private sector where the services are often not recorded either fiscally or factually. As a rule, abortion (either in the private or in public sector) is not followed by counselling before or after the intervention, which along with its availability seems to be a method of family planning in the number of cases, which is not inconsiderable.
According to WHO, a good system of public health also includes the health of migrants. A fast and efficient response to the coming of large groups of people from abroad may be complex, require many resources, and disturb social order when host countries are not entirely prepared. Women refugees and migrants are faced with special challenges, particularly in terms of complications related to pregnancy and delivery, sexual and reproductive health, and violence (Jakab 2015). As a result of cooperation between the Ministry of Health and the Office of the United Nations Population Fund (UNFPA) in Serbia, gynaecological tables and ultrasound devices have been provided as an aid for health centers in Presevo, Dimitrovgrad,
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Reproductive health in Serbia: Condition, perspectives and demographic significance
Bosilegrad, Sid, Vranje, and Belgrade (UNFPA donation). The Ministry of Health of the Republic of Serbia has also made a step towards improving care for reproductive health at the time of the passage of migrants and asylum seekers through the Republic of Serbia and while staying in centres for accommodation of asylum seekers by initiating procurement of mobile gynaecological clinic and mobile large gynaecological and paediatric clinics.
The civilian sector in Serbia, not only in the field of reproductive health, via the public sector, generally is represented as a potential provider of services, primarily in education and counselling, which reflects the role that the civil sector had in the project of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), but also the general perception of nongovernmental organisations as places where there are motivated human resources, but not a significant corps of knowledge and expertise. IPPF Serbia represents the International Planned Parenthood Federation, and as a part of the largest world network which deals with reproductive health and sexual rights, it can also offer knowledge and expertise. The federation began 1952 and today has member federations in 152 states, with services provided in more than 170 states. As the largest world organisation dealing with this topic and a partner of agencies of the United Nations and other development agencies and organisations, IPPF possesses a great amount of expertise related to the provision of reproductive health services , and also for the creation of public policies based on human rights which are providing fair and healthy life for the population and the groups within it such as women, girls, youngsters and boys, members of sexual minorities, etc. IPPF Serbia follows the international processes of importance for this topic and seeks to help the authorities of the Republic of Serbia in the fulfilment of commitments taken by the ratification of different international agreements, conventions, and declarations, by providing education, expertise, and examples of good practice. One example of co-operation is the public hearings in the National Assembly of the Republic of Serbia with the topic of reproductive health in which IPPF Serbia participates together with the Ministry of Health. Public hearings are an opportunity for the wider participation of citizens and civil society representatives in the debates and discussions. Participation of representatives of civil society in the public hearings puts the greater emphasis on the needs and opinions of ordinary citizens, strengthens trust in the parliament and the government, and institutions through bringing their work closer to citizens this process (Orlovic 2007).
Conclusion
On the basis of the presented image of the reproductive health in Serbia, it can be concluded that from the conference in Cairo until today, no satisfactory developments related to reproductive health have been achieved. Only the stabilisation of certain indicators was achieved, but at an undesirable level. The only exception is the decrease in the mortality rate of acquired immunodeficiency syndrome. The decision-makers in Serbia must be aware of the current situation because the implementation of the previous measures has no significant effect.
The strategy for reproductive health is still being discussed at the initiative level. In addition to several announcements to plan its drafting, there is no concrete action plan at present. Nevertheless, there is much room for improvement of cooperation of the public and the civil society sectors in this area of reproductive health, which should be used in order to achieve the desired goals in.
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The lack of systematic and integrated education on the topic of reproductive health and sexual rights is one of the likely reasons for the low culture and bad practices of the population in this area. The state itself does not yet have a clearly demonstrated vision of the manner in which it wants to solve this problem.
Inadequate knowledge and prejudices that respondents show in research in the field of reproductive health underscore the need for the continuing education of the groups of all ages. Education for reproductive health is a long process and must begin at the earliest age, and it must include health care institutions, media, schools, and counselling for young people. The lack of knowledge of the current generations and overwhelming inadequate information may be corrected through integrated programs for reproductive health. With the adoption of adequate positions on reproductive health, not is the reproductive potential of the population is improved, but prevention and healthy lifestyle also become priorities.
The education of journalists, their commitment, and determination to deal with the topic of reproductive health as well as the editorial policy and the commitment of the media to address this issue in the correct way are of particular significance for the promotion of the reproductive health of the population.
It is necessary to encourage research in the field of reproductive health because it gives better insight into the measures to be implemented. Some reproductive health areas are yet to be covered, or there is not enough quality data that would enable the elaboration of concrete programs and uniform strategy. Gathering experts in different fields, who are interested in reproductive health and the right to its implementation, would not only enable the development of their skills, but also the implementation of the research which would ensure more accurate data on the problems related to reproductive health in Serbia.
A comprehensive assessment of the scientific foundation, which refers to the most important factors (fertility in the future, mortality, migration, and education) is clearly to be related to the reproductive health. The experience of other countries cannot be reproduced, but it may be significant, together with the already existing predictions, for issuing decisions in the field of reproductive health that are of particular importance for Serbia (Basten, Sobotka & Zeman 2014).
Acknowledgements
This paper was produced within the graduate study programme at the Medical Faculty of the Unversity of Novi Sad; the course Basic principles in public health approach; Prof. Marija Jevtic as supervisor and Tatjana Tamas as PhD student.
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Povzetek
Svetovna zdravstvena organizacija opredeljuje reproduktivno zdravje kot stanje popolnega telesnega, duševnega in socialnega blagostanja in ne zgolj kot stanje odsotnosti bolezni ali nemoči, v vseh pogledih, ki se nanašajo na reproduktivni sistem, njegove funkcije in procese. Fenomen nezadostnega števila rojstev v Srbiji probleme, povezane z reproduktivnim zdravjem, postavlja na prednostno listo javnega zdravja in opozarja na potrebo, da se le-ti prepoznajo in sistemsko rešijo. Cilj dela je razumevanje položaja na področju reproduktivnega zdravja v Srbiji v zadnjih desetih letih in določanje glavnih tem, s katerimi se je ukvarjala naša strokovna javnost v navedenem obdobju. Delo zajema tudi pregled člankov iz Srbskega nacionalnega indeksa citatov, dobljenih z iskanjem ključnih besed, vezanih za reproduktivno zdravje. Predstavljena so dela, ki so objavljena v zadnjih desetih letih. Posamezna področja reproduktivnega zdravja še vedno niso dovolj zastopana ali pa zanje ne obstajajo dovolj kakovostni podatki. Srečanje raziskovalcev iz različnih področij, ki jih zanima reproduktivno zdravje, bi zagotovilo dobivanje natančnejših podatkov in omogočilo izdelavo konkretnih programov in enotne strategije reproduktivnega zdravja v Srbiji.
KLJUČNE BESEDE: reproduktivno zdravje, adolescenti, abortus, kontracepcija, reproduktivne pravice
CORRESPONDENCE: TATJANA TAMAŠ, Hadzi Ruvimova 56, 21000 Novi Sad, Serbia. E-mail: tatjana.tamas@gmail.com.
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