Hum. Reprod. Advance Access originally published online on June 3, 2006
Human Reproduction 2006 21(9):2199-2200; doi:10.1093/humrep/del172
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Monitoring reproductive health in Europe—what are the best indicators of reproductive health?
1 Department of Tropical Hygiene and Public Health, Heidelberg, Germany 2 Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands 3 Department of General Practice and Primary Care, University of Aberdeen, Aberdeen, UK 4 Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA, USA 5 Instituto de Medicina Preventiva, Lisbon Faculty of Medicine, Lisbon, Portugal and 6 Department of Obstetrics-Gynaecology, University Hospital, Gent, Belgium
7 To whom correspondence should be addressed at: Department of Epidemiology, UCLA School of Public Health, Box 951772, Los Angeles, CA 90095-1772, USA
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Setting up goals to monitor if the goals are achieved and to compare health performance over time and between regions is part of modern health care. A key part in this process is to choose the right indicators. The indicators in reproductive health should be selected on the basis of relevance and validity. They should be simple and action oriented because monitoring for the sake of monitoring alone may do more harm than good. We invite comments from the readers of Human Reproduction on a set of indicators suggested by Reprostat.
Key words: health policy/monitoring/reproductive health
The main impact of the World Health Organization’s Health for All 2000 programme was probably related to its focus upon using health indicators as health policy goals rather than productivity or cost alone. The vision was that healthcare planning would be prepared by people with expertise in public health, clinical medicine as well as economics and management. Health professionals should outline the paths to achieve these goals, and the managers should estimate how much it would cost and let the politicians make the final decisions. The hope was that the decision process would be related to health parameters and that the progress would be transparent for the taxpayers, so that achievements could be monitored.
The philosophy of this approach is still worth pursuing, but the first condition for such a planning process is to identify relevant health indicators that can be monitored over time. If we have no such indicators, we do not know whether we are on the right track; we may not even know where we are. In many European countries, there are few available reproductive health indicators that are measured routinely. We have reports on age at first childbirth, fertility and maternal mortality. However, not many other indicators of reasonable validity exist for Europe, even among European Union (EU) member states. This prevents comparisons over time or between countries.
EU has now the mandate and the financial means to change this situation, and they gave ‘Reprostat’, an ad hoc committee of clinicians and public health experts, the task to suggest a set of indicators in reproductive health (Final Technical Report, 2003
; Supplementary data file 1). This document is now available in an electronic form (Supplementary data file 1) and can also be obtained by sending an e-mail to the coordinator of the task force, Dr Miguel da Silva (mos{at}fm.ul.pt). We encourage views from all with an interest in reproductive health. The document is based on the following principles.
Indicators should ideally be simple and inexpensive to collect. They should be comparable across borders and over time. They should be action oriented as it makes little sense to provide information that is not used. Data that are not used lead to low-quality data and a waste of valuable time.
The best indicators are those for which there are clear actions to be taken when the indicator deviates from an acceptable value. These actions may be preventive measures, treatments or research.
Indicators are often wrong if they are reported without any feedback. It is difficult to take reporting seriously unless mistakes are corrected. Running a passive reporting system without feedback may even be counterproductive by creating a false sense of security. Requesting health monitoring is not something that should be taken lightly. Costs are substantial, also when they are hidden in other budgets.
Setting up an indicator system is therefore a responsibility that should be open to external criticism. When Reprostat first presented its set of indicators, we invited many health professionals from all over Europe to comment. With a new set of member states in the EU, we intend to repeat this process once more and we suggest 15 indicators that can be collected from all EU member states. When selecting these indicators, we took into consideration current availability of data. The set of proposed indicators is based either on already existing data, information that can be extracted easily from other data sources, or on data that have to be collected during surveys.
Many European countries conduct health surveys at regular intervals and have done so for many years. We suggest a few questions to be incorporated into these surveys to get comparable data, and we plan to provide the structure for de novo youth surveys for countries without a survey tradition. These surveys are now being piloted. We need data on use of contraceptive methods, age at sexual debut, knowledge about sexually transmitted diseases and actual prevalence data on the most frequent and important sexually transmitted diseases. These surveys can be repeated at intervals that fit the countries’ needs and resources.
The proposed indicators address sexual habits and the risk of sexually transmitted diseases. As part of this, we are piloting the feasibility for performing Chlamydia screening among the young. These indicators focus on the need for sexual education and other preventive measures to reduce unwanted pregnancies and induced abortions. The indicators also provide information needed to tailor preventive programmes against sexually transmitted diseases including human immunodeficiency virus (HIV). We missed the opportunity of confining HIV in its early phase of its epidemic. Now, we have to make sure the disease remains at the endemic level in Europe.
A second set of indicators address the frequency of infertility and its treatment. Infertility is common, and it seems reasonable to monitor this problem over time (Olsen and Rachootin, 2003). Although the initial results from such monitoring data will be crude, and any unexpected deviations from the current prevalence will require follow-up by specific tailored research programmes, it will be the start of understanding more fully the issues across the whole of the EU.
We have also suggested the monitoring of reproductive health treatments that affect a large segment of the general population, notably use of hormonal replacement therapy and hysterectomy.
Lastly, we have suggested that indicators should be developed to address sexual health more generally, and violence in vulnerable groups (such as pregnant women), to be incorporated into general surveys of the adult population.
The success of a monitoring system depends upon its use. It is not an easy task to implement any monitoring system, and the more complicated it is the more likely is its failure. Even simple systems, like the one we propose, need close and skilful stewardship to work. A political will to make decisions that are guided by public health goals is a precondition.
We believe comparing health indicators over time and between regions is an important and a necessary part of a quality control system in reproductive health, but a monitoring system of poor quality will do more harm than good. We encourage readers of Human Reproduction to take part in the process of developing a set of indicators for the European region by responding to this debate article.
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Final Technical Report. ( August 2003) Reprostat/indicators in the European Union.
Olsen J and Rachootin P. (2003) Monitoring fecundity over time – if we do it, then let’s do it right. Am J Epidemiol 157:89–93.
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