Health Dimensions of Sex and Reproduction. by Christopher J. L. Murray and Alan D. Lopez, eds. (USA: The Harvard School of Public Health for the Wold Health Organization, 1998) 580 pp, ISBN 0-674-38335-4

This textbook, Volume III of the Global Burden of Disease and Injury Series, is a substantial contribution to the global understanding of the burden of the health risks of sex and reproduction.

This book begins with definitions of reproductive health risks and includes morbidity (illness, injury and disease) as well as mortality using the DALY or disability adjusted life year, which is a measure of the burden from premature mortality and of living with disability. The book then continues to provide detailed comparative statistics on sexually transmitted diseases, maternal mortality and morbidity, as well as fetal and infant morbidity. Each chapter focuses mainly on information but is usually finished with the range responses available to prevent or treat the conditions described. The back cover contains many strong testimonials about the ground breaking importance of this book.

In the first chapter, four reproductive health programme goals are described around healthy sexuality, healthy desired family size and avoidance of ill-health, with the fourth stating: "that people should be able to exercise their sexual and reproductive rights in order to be free from violence and other harmful practices related to sexuality and reproduction (1997)".

The first three goals are well covered in the book with most the recommendations for action focusing on the health care system and education for individual behavioral change. While there is some mention of broader interventions such as improvements in income of pregnant mothers to prevent low birth weight, a healthy public policy, there is not enough balance between the macro and micro perspectives.

Given the importance of the fourth goal one might expect some emphasis on sexual violence and on the importance of power differential as a determinant. There is a chapter on "unsafe abortion and ectopic pregnancy" and the final chapter is on "Unsafe sex as a risk factor". But, these chapters are narrow in scope and this important goal and determinant under-represented. For example, the only mention of genital mutilation is with respect to a cause of obstructed labour. There is no statistics about the prevalence of this behavior, the health impacts of supervised compared with unsupervised procedures or its cultural context.

In the chapter on unsafe abortion, the authors state that "women who resort to unauthorized faculties and/or unskilled providers put their health and lives at risk" with no qualifying statement about why women might need to resort to such situations. In the final conclusions of this to avoid unsafe abortions is not addressed directly. Instead access to family planning "together with management of abortion-related complications" is proposed.

In this chapter on unsafe sex, unintended pregnancies are considered unsafe sex but the concept of forced sex or sexual violence is not covered. There is also attitudes about abortion such as "most of the morbidity and mortality from therapeutic abortions-whether medically or non-medically performed-probably occurs due to pregnancies resulting from unsafe sexual practices" which are not backed up with evidence. Sexual orientation is only discussed in the chapter on unsafe sex with the statement: "the implications on the burden of unsafe sex from those practicing homosexuality is unclear".

Perhaps because of its size and the importance of timely publication, the book appears to be poorly edited with spelling, grammar and reference mistakes.

In summary, this book has very useful information within it which hopefully will inform and implement healthy policies but overall it is disappointing in its traditional perspective. I think that the global sexual health of the population will not improved unless a clear gender and feminist perspective is applied at each stage such that gender power relationships, the importance of determinants such as education and literacy for women and central role of sexual violence as a root cause of much of the burden of sex and reproductive health are addressed. Let's hope they are in the next edition.

Fran Scott