Introduction

Reproductive health is defined by WHO as a state of physical, mental, and social well-being in all matters relating to the reproductive system at all stages of life. Reproductive health implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in this are the right of men and women to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, and the right to appropriate health-care services that enable women to safely go through pregnancy and childbirth.

Reproductive healthcare is defined as the collection of methods, techniques, and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, not just counselling and care related to reproduction and sexually transmitted infections.

According to the International Conference on Population and Development, reproductive health "implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. It also includes sexual health, the purpose of which is the enhancement of life and personal relationships, and not merely counselling and care related to reproductive and sexually transmitted diseases" (Cairo, 1994, paragraph 7.2).

Sexual and Reproductive Health (SRH) outcomes are important measures of the general health and social well-being of a population. The scope of Sexual and Reproductive Health (SRH) covers the entire lifespan and extends across several Public Health domains.

Health and demographic challenges

In October 2006, the Commission presented its views on the demographic challenge and the best ways for tackling it in the communication “The demographic future of Europe — from challenge to opportunity”. This communication followed a major public debate launched by the Commission, as well as discussions at the level of heads of state and government at the Hampton Court informal summit of October 2005. The Commission expressed confidence in Europe’s ability to cope with the demographic challenge and presented some key areas in which there are major opportunities for constructive policy responses with the objective, amongst others, of 'Promoting demographic renewal in Europe'. While increased fertility will not stop demographic ageing, it is important to understand the reasons for Europe's very low fertility rates. Given the difficulty of reconciling professional and private lives, women are far too often postponing childbirth or having fewer children as a result. Many young couples today are under the impression that normal pregnancy rates extend well into the late thirties and early forties. Allowing couples to have their children earlier, preferably before the age of 35, is likely to be a more effective way of dealing with infertility problems and of increasing European birth rates.

According to Eurostat, the 2008-based national population projections scenario show the population of the EU27 rising gradually from 495.4 million in 2008, reaching 520.7 million in 2035 and thereafter gradually declining to reach 505.7 million on 1st January 2060. The EU27 population is projected to become older with the median age projected to rise from 40.4 years in 2008 to 47.9 years in 2060. The young age dependency ratio for the EU27 population is projected to rise moderately to 25.0% in 2060, while the old age dependency ratio is expected to increase substantially from its current levels of 25.4% to 53.5% in 2060. Whereas in 2008 in the EU27 there are 4 persons of working age (15-64 years old) for every person aged 65 years

See Ageing characterises the demographic perspectives of the European societies – Eurostat – August 2008

Responding to the need of comparable indicators for reproductive health

In the framework of the Public Health Programme the Commission has selected the Project REPROSTAT- Reproductive Health Indicators in the European Union for funding in 2001. It is coordinated by the Universidade de Lisboa (Portugal). This project contains a final recommended minimum list of indicators that the 15 EU countries can use to monitor reproductive health. The list may also develop over time to include new indicators for issues such as erectile dysfunction, and sexual health and violence during pregnancy. For each indicator there is: operational definition, justification for selection, criteria for selection, data sources, and (when appropriate) references. The REPROSTAT list of indicators(720 KB) consists of 13 core indicators, one recommended indicator, and 4 others that need future development:

1. HIV (tested pregnant women)
2. Chlamydia prevalence
3. Teenage birth rate
4. Condom use (last high-risk intercourse)
5. Median age at 1st intercourse
6. Contraceptive use at 1st intercourse
7. Contraceptive Prevalence
8. Maternal age at 1st childbirth
9. Total fertility rate
10. Percentage of women trying to get pregnant
11. Percentage of deliveries after assisted reproductive technology (ART)
12. Induced abortions
13. Percentage of women with hysterectomy
14. Urinary incontinence
15. Hormonal therapy at menopause
16. Erectile dysfunction
17. Sexual health and wellbeing
18. Violence during pregnancy

Core indicators are defined as those essential for monitoring reproductive health and related healthcare. Regarding sexual health and sexual violence, these are areas that have been identified as important aspects of reproductive health. No definite proposal for indicators is given, but a request for future research and development.

Building on the results of the first phase, the 2004 REPROSTAT 2 - Assessing the usefulness of a comprehensive set of reproductive health indicators designed for the enlarged European Union, with particular emphasis on the reproductive health of adolescents and young adult (Phase 2) had the following aims: (i) a systematic review of factors associated with teenage pregnancy in European Union; (ii) to conduct an ad hoc youth sexual health pilot survey in four Member States, and (iii) to build a critical study about the actual feasibility of comparing the existing European SRH indicators.

The results of the systematic review show that the well-recognized factors of socioeconomic disadvantage, disrupted family structure, and low educational level and aspiration appear consistently associated with teenage pregnancy. The project also studied whether the SRH indicators are available and comparable in 8 Member States. The postponement of childbearing is continuing, even though it seems that the mean age at first childbearing seems to be diverging in the old EU Member States.

In 2006, REPROSTAT-2 conducted a sexual youth pilot survey, aimed at young people aged between 16 and 19 years old from Belgium, Czech Republic, Estonia, and Portugal. More than 47% of respondents had already had heterosexual intercourse. Mean age at first sexual intercourse ranged between 15.2 in Belgium and 16.4 in Czech Republic. The large majority of respondents used a method to avoid pregnancy at first sexual intercourse. Apparent differences related to teenage pregnancy were observed: in 2005 rates varied between 6% in Portugal and 1% in Czech Republic.

See Asking young people about sexual and reproductive behaviours: Results from Belgium, Czech Republic, Estonia and Portugal – REPROSTAT Project
See Major and Chronic diseases in the European Union - Report 2007(4 MB)

Fertility in the European Union

The Commission invites experts on demography and health in the European Observatory on Demography and the Social Situation (SSO) to investigate the literature on this issue as part of their annual work programme for 2006. First results of this work have been presented in the 2007 Demography report SEC(2007) 638 'Europe’s demographic future: facts and figures' . This report analyzes the unfavourable trends in the fertility of the European Union and it shows that since the 1970s, all Member States have experienced a decline in fertility, which is sometimes substantial and rapid. In Ireland, for instance, the TFR (Total Fertility Rate) has declined by almost 50% since the 1960s. In several of the new Member States, such as Poland, the drop was even greater than 50%. Fertility declines were less abrupt in some of the western and northern Member States. Currently, women in the EU-25 have on average 1.5 children (1.55 in the old Member States and 1.25 in the new Member States). However, despite the fertility decline in Ireland, , it still has one of the highest fertility rates in Europe, together with France and Finland, while the Czech Republic, Poland, Slovenia and Slovakia have the lowest rates. The report also analyzes the main drivers of fertility in the European Union.

The Total Fertility Rate (TFR) has been calculated by Eurostat (Statistical Office of the European Union) as the mean number of children that would be born alive to a woman during her lifetime if she were to pass through her childbearing years conforming to the fertility rates by age of a given year. It is therefore the completed fertility of a hypothetical generation, computed by adding the fertility rates by age for women in a given year (the number of women at each age is assumed to be the same). The total fertility rate is also used to indicate the replacement fertility level; in more developed countries, a rate of 2.1 is considered to be replacement level.

See Total Fertility Rate - Eurostat
See Completed Fertility – Eurostat
See Number of live births - Eurostat
See Crude Birth Rate - Eurostat

Teenage pregnancy is associated with increased risk of adverse health and social outcomes for both mothers and their babies. As data collection methods can vary between countries, comparisons between Member States must be made with caution. Eurostat has recalculated fertility rates by age, and mean age of women at childbearing, to the same definition - the age reached during the year of the event.

See Mean age of women at childbearing - Eurostat

The UNICEF report A League Table of Teenage Births in rich nations (published in 2001) breaks down the number of births in 1998 into younger and older teenagers; it shows that in the top half of the table births to younger teenagers are a very small proportion of all teenage births. In the bottom half, however, births to 15 to 17 year-olds make up a considerably higher proportion of the overall teen birth-rate. The number of declared legal abortions for girls aged less than 15, and between 15 and 19, has increased between 1995 and 1999, although they decreased slightly between 1998 and 1999.

Infertility in the European Union: assisted reproductive technologies

The European Commission is aware of the problems related to involuntary infertility as a serious medical condition having serious negative consequences on the wellbeing of the couples concerned. Reproductive techniques such as in vitro fertilisation (IVF) play an important role in remedying involuntary infertility. It is up to Member States to determine whether such treatments are covered by social insurance and whether they are provided by public healthcare systems.

The European Society of Human Reproduction and Embryology (ESHRE) collects data on the use of assisted reproductive technology (ART) in most EU countries. The results of the Sixth European report on ART in Europe, conducted by the ESRHE, contain data since 2004 and cover all countries in Western Europe.

Data were mainly collected from existing national registers. From 29 countries, 785 clinics reported 367 066 treatment cycles including: in vitro Fertilization (IVF, 114 672), ICSI (intracytoplasmic sperm injection 167 192), frozen embryo replacement (FER, 71 997), egg donation (ED, 10 334), preimplantation genetic diagnosis/screening (PGD/PGS, 2 701), and in vitro maturation (IVM, 170). European data on intrauterine insemination using husband/partner’s semen (IUI-H) and donor semen (IUI-D) were reported from 20 countries. A total of 115 980 cycles (IUI-H, 98 388; IUI-D, 17 592) were included.

In 14 countries where all clinics reported to the IVF register, a total of 248 937 ART cycles were performed in a population of 261.6 million, corresponding to 1 095 cycles per million inhabitants. For IVF, the clinical pregnancy rates were 26.6% (per aspiration) and 30.1% (per transfer). For ICSI, the corresponding rates were 27.1% (per aspiration) and 29.8% (per transfer).

After IUI-H, the clinical pregnancy rate was 12.6% in women under 40. After IVF and ICSI, the distribution of transfer of 1, 2, 3, and 4 or more embryos were 19.2%, 55.3%, 22.1%, and 3.3%, respectively. Compared with 2003, fewer embryos were transferred, but huge differences still existed between countries.

The distribution of deliveries after IVF and ICSI combined was 77.2% (singleton), 21.7% (twins) and 1.0% (triplets), respectively. This gives a total multiple delivery rate of 22.7% compared with 23.1% in 2003 and 24.5% in 2002. After IUI-H in women below 40 years of age, 11.9% were twin and 1.3% triplet gestations.

IVF interventions in EU Member States account for 1% to 4% of all births. Information on the extent of unmet demand for treatments is not available. It is therefore not possible to estimate how many more children might be born if such treatments were more widely available. However, it is unlikely that the wider availability of assistive reproductive techniques would significantly contribute to increasing fertility rates in Europe.

See Assisted reproductive technology in Europe, 2004. Results generated from European registers by ESHRE

Other Sexual and Reproductive Health Indicators

Hormonal therapy at menopause

Hormone Replacement Therapy (HRT) is a treatment containing one or more female hormones. It replenishes diminishing oestrogen hormone levels, and is used mostly as relief for symptoms of the menopause.

The September 2007 European Commission Eurobarometer 66.2(3 MB)  français (fr) , examined two aspects of this treatment: firstly, knowledge levels amongst all women concerning HRT, and secondly, the proportion of women aged over 50 who are currently on HRT. The majority of women (58%) in the EU say that they feel they are not well informed about HRT. This comprises 30% who say they feel ‘not very well informed’ and 28% who say they think they are ‘not at all well informed’. Around 4 in 10 (39%) say that they feel they are informed on this subject, with 29% thinking they are ‘fairly well informed’ and 10% ‘very well informed’. In the previous Eurobarometer 59.0(2 MB) , December 2003, 42% said they were informed on HRT. However, because the question was worded in a different way it is difficult to make a direct comparison with the 2006 results. Given that HRT is for women going through the menopause, we would expect to see a strong variation in results when it is analysed according to the age of respondents. This certainly proves to be the case, with a particularly large jump in knowledge between the 25-39 and 40-54 age groups (29% vs. 49%).

Of all women surveyed who were over the age of 50 at the time of interview, 6% are on HRT. This indicates a considerable decrease in the rate of treatment by HRT in recent years, as the corresponding figure for 2003 was exactly twice as high, at 12%. HRT is given more to women aged between 50 and 54 than it is to those aged 55 and over: 13% of the former group were receiving HRT, compared to 5% of the latter.

Percentage of women with Hysterectomy

Hysterectomy is a surgical procedure to remove the woman’s uterus. Other organs might also be removed if severe problems such as endometriosis or cancer appear. These organs include the cervix, the ovaries and the fallopian tubes (the passageway between the uterus and the ovaries).

According to data collected by Eurostat on discharges from hospitals, the number of hysterectomies (codes 68.3-68.7, 68.9 of the International Classification of Diseases, 9th Revision, Clinical Modification, procedure code) performed in hospitals during the year 2004 were around 339 000 in the EU27 (but note that no data from Germany was included). This represents an estimated rate of 120 women per 100 000 undergoing these procedures every year. These include total abdominal, subtotal abdominal (or supracervical), vaginal, radical abdominal, radical vaginal, and pelvic exenteration.

See Main surgical operations and procedures performed in hospitals (by ICD-9-CM) - Hysterectomies – Absolute numbers and per 100 000 of population – Eurostat(73 KB)

Chlamydia prevalence

Chlamydia is a common sexually transmitted disease (STD) caused by the bacterium Chlamydia trachomatis, which can damage a woman's reproductive organs. Even though symptoms of chlamydia are usually mild or absent, serious complications that cause irreversible damage, including infertility, can occur "silently" before a woman ever recognizes a problem. Chlamydia also can cause discharge from the penis of an infected man (US CDC Fact Sheet Definition).

According to the data disseminated by The First European Communicable Disease Epidemiological Report, 2006, from the European Centre for Disease Prevention and Control (ECDC) in 2005, 203 691 cases of Chlamydia infection were reported by 17 countries, with almost 96% of cases from (in descending order) UK, Sweden, Denmark and Norway. The highest incidence rate was reported by Iceland with 552.45 per 100 000, followed by Denmark with 441.29 per 100 000.

The estimated overall incidence of Chlamydia infection for these 17 countries was 99.39 cases per 100 000 population. 14 countries provided Chlamydia infection incidence data for the whole period. Conversely, another 10 countries did not provide data for any year during the period 1995–2004. The four remaining countries provided data ranging from one to eight years of this period. International comparisons of any condition are generally inhibited by many differences between data collection methods (especially if the country operates a strict screening programme, for example) and by the variety of patient groups targeted for surveillance of this disease, but this is particularly true for Chlamydia infection, which is not a notifiable disease in many countries. The overall trend is steadily increasing over this period.

HIV prevalence among pregnant women in Europe

The detection of HIV infection before or during pregnancy allows for the provision of appropriate care and treatment for the mother and preventive interventions to dramatically reduce the risk of mother to child HIV transmission. Accurate monitoring of HIV prevalence among women giving birth provides a valuable tool to evaluate the effectiveness of national antenatal HIV testing programmes as well as to assess the spread of the HIV epidemic in the heterosexually active population. Since the late 1980s, a variety of methods have been used to address one or both of these objectives in Europe, but the two most common methods were either seroprevalence studies (SP) based on unlinked anonymous testing (UAT) or systematic collection of the results of all diagnostic testing (DT) carried out among pregnant women.

According to the data collected by the EuroHIV network, funded by the European Commission, in Europe the prevalence of HIV among pregnant women remains low (<0.5%); increasing numbers of cases of HIV infection reported in women of child-bearing age are reflected in an increasing HIV prevalence among pregnant women, most notably in Estonia (0.48% in 2002) and Ukraine (0.34% in 2004); important pockets of higher HIV prevalence among pregnant women have been reported in major urban areas.

See HIV prevalence surveys and results of diagnostic testing among pregnant women, 1999-2004 – EuroHIV(198 KB)

See HIV/AIDS Surveillance in Europe 2006, No. 72 - EuroHIV

Declared legal abortions

According to data collected by Eurostat on declared legal abortions, approximately 1.5 million abortions were declared in the EU in 2002 (last year for which the figures are representative). From which 157 000 correspond to young girls between 15 and 19 years and 4 000 to girls under 15 years.

See Declared legal abortions by age – Eurostat(75 KB)
See Abortion legislation in Europe - IPPF European Network – January 2007

Other EU health reproductive or related projects

• As a continuity of the REPROSTAT Projects, the Commission has selected for funding in 2007 a project for a European Report The state of Reproductive Health and Fertility in the European Union coordinated by the Universidade de Lisboa (Portugal). This report will be the first to collect Sexual and Reproductive Health (SRH) and policy data in all the Member States, identifying major disparities and inequalities in SRH among the 27 MS, testing standardised methods of data collection, information exchange and reporting on SRH within EU, and advocating for the importance of regular monitoring of SRH at the EU level.
• Endometriosis is a condition where tissue similar to the lining of the uterus is also found elsewhere in the body, mainly in the abdominal cavity. The tissue responds to a woman’s hormonal cycle. This abnormal tissue can give rise to nodules, cysts in the ovaries and adhesions, resulting in inflammation, pain and infertility. Endometriosis is a condition affecting 14 million EU women. The average time to diagnosis is 8 years and it's a condition that contributes to infertility (It is estimated that 30-40% of women with endometriosis are infertile) and has an untold impact on quality of life as well as an important economic impact on the EU. The Commission is supporting a project, lead by the National Endometriosis Society UK, selected for funding in 2006, to create a European Network on Endometriosis (ENE). Its main objectives are: (1) To create a new European Endometriosis Support Alliance (EESA) to coordinate and provide comprehensive support and training to the sectors associated with the condition; (2) An Internet based Endometriosis Community Gateway (ECG) that will provide the focal point for all individuals and groups requiring information and support; (3) A comprehensive pan-European epidemiological study of over 10 000 women with endometriosis in order to develop a research-based information and support base from which to inform new treatment techniques, training programmes for health professionals, and appropriate information materials.
  
  See web site of the European Network on Endometriosis (ENE) Project
• Urinary Incontinence (UI) is a prevalent, bothersome and costly condition affecting primarily women. Incontinence does not present dramatically, nor is it lethal, but it deeply impacts women’s quality of life. The issue of UI has been well documented and there are national and international networks focusing on the condition, but there is a lack of systematic, reliable and consistent data particularly with regards to certain sections of the female population. Urinary Incontinence is one of the SRH indicators retained by the REPROSTAT Project. For this reason the European Commission selected for funding in 2007 the project Surveillance System: Occurrence of Urinary Incontinence in Women as a Consequence of Inefficient or Inappropriate Obstetric Care coordinated by the Azienda USL Ferrara (Italy). This action proposes setting up a surveillance system to monitor the occurrence of UI incontinence in women in the EU as a consequence of inefficient or inappropriate obstetric care. The proposed action foresees three distinct outcomes: (1) Compilation of available info/data; (2) Forum for dialogue synergies; and (3) Feasibility Study for a surveillance system.
• See also WHO Reproductive Health and Research
• See also Reproductive Health – CDC United States