1 Progress, No. 63

No. 63 2003

UNDP/UNFPA/WHO/World Assisted reproduction in developing Bank Special Programme of Research, Development and countries—facing up to the issues Research Training in Human Reproduction (HRP) For millions of couples around the Attitudes to assisted reproduction are Department of Reproductive world, the inability to have children is very much influenced by the specific Health and Research, a personal tragedy. For a significant cultural and social context. Manipula- World Health Organization, proportion of them, the private agony tion of sperm, oocytes and embryos Geneva, Switzerland is compounded by a social stigma, raises numerous questions to which which can have serious and far-reach- there are no easy answers, and which Launched by the World Health ing consequences. It is not surprising often arouse strong emotions. The Organization in 1972, the UNDP/ therefore that the demand for as- article on page 5 outlines some of the UNFPA/WHO/World Bank sisted reproductive technologies ethical and legal issues surrounding Special Programme of (ART) is growing in all regions. But the use of ART, which need to be Research, Development and how can the provision of these tech- discussed openly by all involved par- Research Training in Human nologies—which are expensive and ties wherever such services are made Reproduction is a global have a success rate of less than available. programme of technical 30%—be justified in developing coun- cooperation. It promotes, tries with poorly developed health In the 25 years since the birth of the coordinates, supports, conducts, services that are still struggling with first baby resulting from in vitro ferti- and evaluates research on infectious and chronic diseases, such lization, there have been tremendous reproductive health, with as tuberculosis, malaria and HIV/ advances in scientific techniques and particular reference to the needs AIDS? medical applications of ART. But there of developing countries. are still areas where more research is In 2001, the World Health Organiza- needed. For instance, concerns have tion convened a meeting on “Medical, been expressed about the long-term Ethical and Social Aspects of As- development of the child. Experience sisted Reproduction”, to examine a in this area is, of necessity, rather INSIDE number of issues surrounding the limited, especially for the newer tech- treatment of infertility, and to learn niques, but the results so far are reas- about country and regional experi- suring. As noted in the article on page ART in developing countries— 1 a response to individual need ences with assisted reproduction. 6, however, continued vigilance is or a social priority? ...... 2 Specifically, the objectives of the needed to monitor the long-term out- meeting were (i) to review and assess comes of ART. Regional and country recent developments in ART, (ii) to perspectives ...... 3 identify unresolved issues in the field, As part of this monitoring effort, and and (iii) to provide recommendations as ART becomes available in more Ethical and legal issues ...... 5 for future research. and more countries, national and in- ternational surveillance systems as- Long-term effects of ART ...... 6 This issue of Progress looks at some sume considerable importance. The National and international of the topics that were covered at the article on page 7 describes some of surveillance of ART ...... 7 meeting, starting with an overview of the difficulties in ensuring that such the situation in developing countries, systems produce reliable and com- New publication ...... 8 where infertility rates are high and parable data. Box 3 (The Latin Ameri- private ART services are being set up can Registry of Assisted Reproduc- in response to the needs and de- tion) on page 7 describes an attempt mands of individuals. This is followed in Latin America to ensure standard- 1 Vayena E, Rowe P, Griffin PD, eds. Current practices and controversies by a series of short reports from sev- ized reporting from ART centres in a in assisted reproduction: report of a eral regions and countries on the cur- number of countries. WHO meeting. Geneva, World Health rent status of ART services. Organization, 2002. 2 Progress, No. 63 ART in developing countries— Progress a response to individual need or a social in Reproductive Health Research priority? Issued quarterly (since 1987) by There are over 186 million couples in are severely limited, where there are the UNDP/UNFPA/WHO/World developing countries alone (exclud- other pressing public health problems Bank Special Programme of ing China) today who are affected by that are not adequately addressed, Research, Development and infertility (both primary and second- and where national goals may include Research Training in Human ary). Rates of infertility vary consider- reducing fertility rates in the popula- Reproduction, Department of ably from country to country; in the tion. In addition, it is argued that Reproductive Health and Re- worst-affected areas, over 25% of resources would be better spent on search, World Health Organiza- couples may be unable to have chil- tackling the causes of much of the tion, 1211 Geneva 27, Switzer- dren. Most of the infertility in develop- infertility—the reproductive tract in- land. For a free subscription, ing countries is attributable to dam- fections that are not diagnosed or please write to the above age caused by infections of the repro- adequately treated. address. ductive tract, notably gonorrhoea and chlamydial infection. Whatever the merits of the various Editor: Jitendra Khanna arguments, it has to be recognized Writer: Patricia A. Butler In addition to the personal grief and that couples who want children will go suffering it causes, the inability to to great lengths to have them, and have children—especially in poor that there will always be providers to © World Health Organization communities—can create broader make services available to those who 2003 problems, particularly for the woman, can pay for them. Thus, while ART is in terms of social stigma, economic still not easily accessible in develop- This newsletter is not a formal hardship, social isolation, and even ing countries—and is extremely ex- publication of the World Health violence. Various studies have found pensive—it is starting to make an Organization (WHO), and all that childless women in developing appearance. Governments in these rights are reserved by the countries are often abandoned by their countries therefore have a responsi- Organization. The document husband, subjected to violence, or bility to ensure that the services pro- may, however, be freely re- treated as servants by the husband’s vided—whether in the public or the viewed, abstracted, reproduced family. In some societies, mother- private sector—are safe and effec- or translated, in part or in whole, hood is the only way for women to tive. The majority of developing coun- but not for sale or for use in improve their status within the family tries where ART is available have not conjunction with commercial and the community. On a practical formally addressed these issues, al- purposes. level, many families in developing though some are considering or using countries depend on children for eco- approaches based on those used in The mention of specific compa- nomic survival. While many people, developed countries, including legis- nies or of certain manufacturers' therefore, would not consider infertil- lation, management guidelines, li- products does not imply that they ity a disease in itself, it can certainly censing, and reporting systems. Oth- are endorsed or recommended be said to be a social and public ers have approached WHO for ad- by the World Health Organization health issue as well as an individual vice on how to handle the introduction in preference to others of a problem. of ART. similar nature that are not mentioned. Errors and omissions It is not surprising, therefore, that The lack of appropriate guidelines excepted, the names of propri- there is a growing demand for serv- and regulations in most developing etary products are distinguished ices that can help infertile couples to countries is a serious drawback in by initial capital letters. conceive. In practice, this means efforts to improve the quality of the ART—artificial insemination, in vitro services provided. In the absence of Articles in this issue are based fertilization, gamete or zygote national legislation, health profession- on a WHO publication with intrafallopian transfer, intracytoplas- als are challenged to implement some named authors and editors (see mic sperm injection, embryo freezing form of self-regulation, giving some footnote on page 1) and do not and donation, and surrogate mother- form of recognition to practitioners necessarily reflect the views of hood (see Box 1 on page 3). The fact who are qualified to perform the pro- the World Health Organization. that these services are expensive cedures and have access to adequate and controversial has not prevented facilities. Centres should be encour- their appearance in developing coun- aged to standardize procedures and tries. equipment and to share their results and expertise in a genuine collabora- This inevitably raises questions about tive effort aimed at raising profes- whether such services are justifiable sional standards and avoiding mis- in a context where health resources use of the technologies. 3 Progress, No. 63 Regional and country perspectives

The view that the provision of ART India services is inappropriate in develop- ing countries takes no account of the There is a huge stigma attached to great heterogeneity of the developing childlessness in Indian society, par- world. Countries classified as “devel- ticularly for the woman, and couples oping” vary enormously in their level who can afford to do so will go to great and pace of development, as well as lengths to obtain treatment for their It has to be recognized that in their cultural, moral and religious infertility. Anjali Widge of the Popula- couples who want children values. Some countries already have tion Council, New Delhi, reported that, will go to great lengths to the laboratory facilities and person- in 1999, there were about 60 centres have them, and that there will nel to deliver sophisticated medical offering ART in India, almost all in the always be providers to make services, as well as an emerging mid- private sector. An evaluation of the dle class that has the financial capac- few existing public sector centres is services available to those ity to pay for such services. On the currently being considered, with the who can pay for them. other hand, in a number of countries, expectation that it may lead to their strong religious opposition to ART on strengthening. There is, unfortunately, ethical grounds has meant that there no monitoring or regulation of ART has been little or no development of centres, and little discussion of the services.1 The WHO meeting on as- moral, ethical and social issues raised sisted reproduction2 heard reports on by the technologies. The first case of the current situation in a number of surrogate motherhood in the country developing regions and countries. in 1997 brought to the fore the need

Box 1. Explanation of terms

Assisted reproductive technology—any treatment or procedure that involves the in vitro handling of human oocytes and sperm or embryos for the purpose of establishing a pregnancy. Embryo donation—the transfer of an embryo resulting from an oocyte and sperm that did not originate from the recipient or her partner. Embryo transfer—procedure in which one or more embryos are placed in the uterus or fallopian tube. Gamete intrafallopian transfer—a procedure in which oocytes and sperm are transferred to the fallopian tubes. Intracytoplasmic sperm injection (ICSI)—an IVF procedure in which a single sperm is injected into an oocyte. In vitro fertilization (IVF)—fertilization of an oocyte outside the body. Preimplantation genetic diagnosis (PGD)—screening of cells from preimplantation embryos before transfer, for the detection of genetic or 1 Vayena E. et al. Assisted reproductive chromosomal disorders. technology in developing countries: why Surrogate mother—a woman who carries a pregnancy resulting from should we care? Fertility and sterility, 2002, – third-party oocytes and sperm, with the intention or agreement that the 78:13 15. offspring will be brought up by one or both of the individuals who 2 Vayena E, Rowe P, Griffin PD, eds. Cur- produced the oocytes and sperm. rent practices and controversies in as- Zygote intrafallopian transfer—a procedure in which a zygote (a ferti- sisted reproduction: report of a WHO meet- lized oocyte) is transferred to the fallopian tube. ing. Geneva, World Health Organization, 2002. 4 Progress, No. 63 for clear ethical guidelines on ART; the region. One of the stumbling- such guidelines have recently been blocks to acceptance of the tech- developed by the Indian Council of niques was the unacceptability to the Medical Research, although they have main religious groups of the involve- not yet been implemented. ment of a third party in the act of procreation. Thus, in most countries Latin America of the region nowadays, artificial in- semination using the husband’s sperm Florencia Luna, from the University is allowed, but not techniques that of Buenos Aires, Argentina, reported use gametes from outside the couple. on the situation in Latin America. Another factor delaying the establish- In Latin America, ART is gen- Stressing that the countries of the ment of ART centres was their cost. erally not provided in public region are in fact very diverse, she Most centres are in the private sector noted nevertheless the widespread and the cost to the patient is still quite hospitals, and the poor have influence of the Catholic Church, and high in relation to average income. no access to these services. the large gaps in most of the countries This has engendered a feel- between the rich and the poor. In Sub-Saharan Africa ing of discrimination and re- general, ART is not provided in public sentment. hospitals, and the poor generally have Having children is generally consid- no access to these services. This has ered the main purpose of marriage in engendered a feeling of discrimina- Africa, and the inability to have chil- tion and resentment, especially in dren remains a major cause of di- countries, such as Argentina, that have vorce. At the same time, the inci- a tradition of strong public health sys- dence of infertility in many countries tems. of the region is high, for a number of reasons. Much of the infertility is the Very few countries in the region result of genital infection, which may have legislation or formal regula- have been sexually transmitted, or Box 2. Facts about ART tions on ART. In some cases, legis- caused by traditional practices, such lation is deliberately not sought be- as female genital mutilation, or by ● About one million children have cause of a fear that it would be overly undergoing gynaecological interven- been born as a result of ART. (This restrictive, given the influence of the tions in unhygienic conditions. There number does not include babies con- Catholic Church. There appears, how- is thus a potentially large demand for ceived with artificial insemination.) ever, to be a scientific consensus that ART services. Osato Giwa-Osagie of ● Success rates in developed ART should be provided only to infer- the University of Lagos, Nigeria, and countries are generally around 25% tile, heterosexual couples, and that Godfrey Tangwa of the University of (in terms of live births per cycle) in every cryopreservation programme Yaoundé, Cameroon, gave an over- women under 34 years of age. How- should be linked to a programme of view of the situation in the English- ever, rates differ immensely between donation or adoption of embryos. and French-speaking countries of the countries, partly because of differ- These issues are, in fact, highly con- region, respectively. ences in skill levels, but principally troversial, but there is surprisingly because of differences in tech- little dialogue between the various The concepts of artificial insemina- niques. ● concerned parties. tion, in vitro fertilization and gamete The rates of spontaneous abor- donation are generally well accepted tion are heavily age-dependent, but Middle East in Africa. The first baby born in West the average is around 18% of preg- Africa as a result of IVF was delivered nancies, which is not higher than the Prevention and treatment of infertility at the Lagos University Teaching Hos- rate for spontaneous abortions in natural conceptions. are of particular significance in the pital in 1989. By 2001, there were ● Most countries today report an Middle East, because a woman’s so- eight assisted conception centres ectopic pregnancy rate of 1–2%, cial status, dignity and self-esteem carrying out IVF in sub-Saharan Af- which is not significantly higher than are closely related to her ability to rica, as well as numerous other cen- the rate in the population as a whole. have children. It might therefore be tres offering artificial insemination. In the early days of ART, higher expected that ART would have been However, the providers of these ser- rates were reported, reflecting the welcomed in the area. However, as vices currently operate in a sort of fact that most women undergoing noted by Gamal Serour of the Inter- legal and ethical vacuum, since there the procedure some years ago had national Islamic Center for Popula- is virtually no state regulation of ART. tubal damage. tion Studies and Research, Cairo, There is a need for greater inter- ● Multiple pregnancy rates vary Egypt, the techniques raise various country collaboration within the re- considerably: the USA reports a rate religious and cultural issues, and it gion, to develop regulatory ap- of 37% while the rate for Europe is was not until the mid-1980s that ART proaches that respond to the specific around 29%. centres started to be established in African context. 5 Progress, No. 63 Ethical and legal issues

The advent of IVF in the 1970s sparked zen for future use? Or should they be intense debate about the use of ART destroyed? And who has the right to and the social and legal implications make these decisions—the providers it was predicted to have. Many of the of the oocyte and sperm, the medical ethical questions raised then are still profession, or the policy-makers? debated today, and with each innova- tion in the technology a new dimen- These and similar questions are be- In many countries, questions sion is added to the debate. coming even more urgent as of parentage and legitimacy preimplantation genetic diagnosis ART—whether it is fairly simple arti- (PGD) becomes more common. Em- of children born as a result of ficial insemination or intracytoplas- bryos can now be screened in vitro for ART involving a donor are mic sperm injection—separates re- a wide range of genetic disorders, unresolved. production from sexual intercourse, and those found to be affected dis- but still involves a man and a woman. carded. PGD also makes it possible In addition, in IVF and related tech- to select the sex of the offspring. niques, fertilization takes place out- While most people would accept this side the body, which means that gam- as a way of avoiding the transmission etes and embryos are potentially avail- of serious sex-linked impairments, able for testing, manipulation and re- many would regard it as ethically un- search. For these reasons, some peo- acceptable if done simply for parental ple reject ART as intrinsically morally preference. Nevertheless, it is ac- unacceptable. Such objections are knowledged that, in some countries, typically based on either religious sex selection in this manner takes place. belief or traditional assumptions about the nature of relationships and the Other tricky ethical questions con- role of the family. cern the practice of transferring sev- eral embryos in order to increase the Even those who accept the idea of in likelihood of pregnancy. If all the vitro fertilization as treatment for an embryos successfully implant, the infertile heterosexual couple in a sta- woman faces the prospect of a high- ble relationship might have reserva- order multiple pregnancy, with its at- tions about making such treatment tendant increased risks of obstetric available to other individuals—e.g. complications, premature birth and single women, postmenopausal disability. In some countries in these women, or homosexual couples. In- circumstances, it is common practice deed, in many countries, such people to destroy one or more of the fetuses are excluded from receiving ART serv- in order to increase the chances of ices. The objections are often based survival of the others. on preconceived ideas of what should constitute a family unit. However, the In many countries, questions of par- reality in many countries is that fami- entage and legitimacy of children born lies vary enormously in their compo- as a result of ART involving a donor sition, and there is no convincing are unresolved. Indeed, many cou- evidence that children from conven- ples who have had a child as a result tional families do significantly better of ART would prefer to keep it secret, than others. Thus the ethical basis for and may not even tell the child. restricting the availability of ART in this way is tenuous. These and many other issues raised by in vitro fertilization, and particu- The techniques themselves raise a larly by the use of donor gametes, are number of problematic issues. For aggravated by the lack of public poli- example, when embryos are formed cies to regulate ART. As a result, outside the body, what can be done individual doctors often have broad with those that are not transferred? Is administrative discretion in individual it acceptable to use them for research? care, and the more general ethical, Could they be donated to another social and legal issues are not widely infertile couple? Should they be fro- debated. As the techniques become 6 Progress, No. 63 more widely available, however, the and medical issues surrounding their questions will need to be resolved. decision to undergo ART, so that they can make truly informed choices. Lo- It is vitally important that the general cal and national patient support groups public be closely involved in all as- can play a key role in fostering dia- pects of the debate. Infertile couples logue and advocating for improved need to be aware of the social, ethical patient management.

Long-term effects of ART—the physical and psychological development of the The evidence so far indicates no difference in physical child health between children con- It is already 25 years since the first such concerns are unfounded. Par- ceived using ART and those human baby resulting from in vitro ents of children conceived by ART conceived naturally. fertilization (IVF) was born. At the appear to have good relationships time, the event was a widely publi- with their children, and there is no cized, celebrated, and controversial evidence of cognitive impairment in landmark. Since then, IVF has be- singleton children born at full term. come routine and widely accepted, Nevertheless, experience so far is and is now only one of a number of limited. Most studies have included potential treatments for infertility. only children before adolescence, and Since 1978, more than one million the quality of the studies has been babies have been born as a result of variable. Samples are often small, IVF, and it has been estimated that, in unrepresentative and poorly defined, some European countries, up to 5% and without appropriate controls. In of all births are now a result of ART. addition, for some types of ART, such as surrogacy and embryo donation, One concern that has been expressed very little is known about the children's since the early days of assisted repro- development. duction is that the children will be somehow “disadvantaged”, physically Thus, while existing knowledge does or psychologically, by the process of not give rise to specific concerns, their conception. One apparent dif- many questions remain unanswered, ference is the higher incidence of particularly in relation to the newer multiple births following IVF, and the technologies. ICSI, for example, in resulting higher proportion of preterm which a single sperm is injected di- and low-birth-weight infants. However, rectly into an egg, is a relatively re- allowing for these factors, the evi- cent technique that has provoked dence so far indicates no difference considerable debate. First used about in physical health between children 10 years ago, the technique was de- conceived using ART and those con- veloped essentially through its clini- ceived naturally. cal application in humans, and expe- riences in animal studies are very The psychological development of limited and possibly not relevant to children born as a result of ART has humans. ICSI is used essentially in also received considerable attention. the treatment of male infertility, and It has, for instance, been suggested concerns have been raised about the that the stress associated with the potential use of abnormal sperm, the experience of infertility and its treat- bypassing of the usual process of ment may result in parenting difficul- natural selection, and the possibility ties when a child is eventually born. of damaging the egg or embryo, all of Or that the parents may be overpro- which may produce changes in ge- tective, or have unrealistic expecta- netic material. While the evidence on tions either of their children or of the short-term health of ICSI offspring

1 themselves as parents. is reassuring, the WHO meeting noted Golombok S. Parenting and the psycho- that further research was needed on a logical development of the child in ART A recent review of research on variety of aspects, and recommended families. In: Vayena E et al. eds., Current practices and controversies in assisted parenting and the psychological de- that the risk of congenital malforma- 1 reproduction. Geneva, World Health Or- velopment of children concluded that, tions in such children should continue ganization, 2002. from the evidence available so far, to be monitored. 7 Progress, No. 63 National and international surveillance of ART

Concerns about the safety and effi- ectopic pregnancies, and deliveries cacy of ART have led a number of relative to started cycles, ovum pick- countries to set up monitoring or sur- up rates and embryo transfers. One veillance schemes to provide infor- area of considerable confusion is the mation for policy-makers, health care definitions used for the various statis- professionals and consumers. How- tics reported. For instance, in report- ever, there is significant variation ing success rates, different numera- Concerns about the safety between countries in both the quan- tors and denominators have been and efficacy of ART have led tity and the quality of the data avail- used. The numerator may be the a number of countries to set able, as well as in the definitions number of pregnancies or the number used. of live births. But even once that up monitoring or surveillance decision is made, questions arise as schemes to provide informa- At the national level, there are two to how to define pregnancy—whether tion for policy-makers, health basic options for collecting data. The as the presence of a gestational sac care professionals and con- first is to ask each clinic in the country or a positive pregnancy test. The con- sumers. to prepare an annual report covering cept of live birth is reasonably straight- items specified by the national regis- tration body. This is the approach used in Scandinavian countries, for example. The second option is to Box 3. collect data for each cycle individu- ally, preferably in a direct system, The Latin American Registry of Assisted where details are reported before the Reproduction outcome of the treatment is known. This system is more complicated and ART is available in almost all the countries of Latin America, mostly in private expensive, but provides more reli- institutions. However, because of the lack of national regulatory bodies and a general able data, and is used in Germany reluctance to deal with controversial issues, in the early days very little was known and the United Kingdom, among oth- about the number and type of procedures performed in each country. ers. Ideally, national data should be In 1990, a multinational registry of assisted reproduction (Registro Latinamericano de published once a year. Reproducción Asistida) was initiated, with three objectives:

There are currently four regional bod- 1. to create an educational tool that would allow consumers to evaluate the costs and ies, which collect the national reports benefits of ART procedures; 2. to develop a comprehensive regional database to serve as an external reference and produce their own annual re- for each centre's self-evaluation; gional reports. These bodies cover 3. to develop a robust database that could be used for epidemiological research. Australia and New Zealand, Canada and the USA, Europe and Latin The registry currently covers 93 centres in 11 countries, and collects the following America (see Box 3). Regional bod- information: ies are currently being formed in ● number of initiated cycles, follicular aspirations and transfer cycles; South-East Asia. At global level, the ● pregnancy, delivery and live-birth rates by follicular aspiration and by transfer International Working Group for Reg- cycles; isters on Assisted Reproduction is a ● pregnancy, implantation and multiple gestation rates according to the age of the task force under the International woman, number of transferred embryos and stage of development at time of Federation of Fertility Societies transfer; ● (IFFS), and has so far produced five outcome of clinical pregnancies, i.e. abortion, ectopic pregnancy, stillbirth, live birth, neonatal death; world reports, the most recent in 2001. ● gestational age at delivery, birth weight, major malformations, and cytogenetic analysis of abortion material. Ideally, each country should report the results of direct treatment (e.g. The centres provide their data to the registry using a standard software. Results are pregnancy rates), pregnancy out- reported and published as summaries for Latin America as a whole, and results of come, child development and side- individual clinics are not disclosed. Over the years, the registry has served as an educational instrument for the centres performing ART. Its activities have also effects of treatment for the women. expanded to include continuous education and multinational research. Most registries today deal with only the first category, covering the pro- The activities of the ART community in Latin America are described on the web site portion of pregnancies, abortions, . 8 Progress, No. 63 forward, but simply measuring live Ovarian hyperstimulation and trans- births does not give any indication of fer of more than one embryo have a the health status of the infant. higher success rate but also a higher risk of multiple pregnancy. As for the denominator, this is compli- cated by the fact that ART is not a The reporting of outcome of delivery single procedure carried out at a par- is generally much more difficult to ticular point in time. It is rather a cycle organize at national level. Thus, moni- of treatment, beginning typically with toring of birth outcome is usually done ovarian stimulation, ovum retrieval, by individual clinics. One exception is fertilization, and embryo transfer. A the Scandinavian countries, where Success rate is greatly influ- cycle may be discontinued at any of national birth registers can be cross- enced by the selection of cli- these steps, for clinical reasons, be- linked to specific ART registers, al- cause of medical complications, or lowing the compilation of complete ents—rates are higher in simply because the couple decides to information. younger women—and by the withdraw from treatment. Rates have procedure used. been reported relative to the number Follow-up of the child through adoles- of transfers or the number of cycles cence to adulthood is also needed to commenced, which obviously give monitor physical, mental and psycho- very different success rates. social development. Data collection in this case is even more cumber- Even a standardized way of present- some, and is generally only done for ing results can be misleading, if used small samples of individuals. Reports to compare the performance of differ- in this category are still scarce, and ent centres. Success rate is greatly more information is urgently needed influenced by the selection of cli- if the long-term safety of the various ents—rates are higher in younger ART procedures is to be unequivo- women—and by the procedure used. cally demonstrated.

New Publication

Towards adulthood: ume covers a wide range of issues, exploring the sexual and including: factors that undermine ado- lescents’ ability to make informed reproductive health of sexual and reproductive choices; the adolescents in South Asia social context and health conse- quences of early marriage and child- Edited by: Sarah Bott, Shireen bearing; the sexual behaviour and Jejeebhoy; Iqbal Shah and Chander Puri attitudes of adolescents before mar- 2003, vii + 244 pages ISBN 92 4 156250 1 riage; sexual coercion against young people; the extent to which adoles- This publication provides a compre- cents take measures to protect them- hensive overview of the socio-demo- selves from unwanted pregnancy and graphic and sexual and reproductive sexually transmitted infections; abor- health situation of adolescents in tion among married and unmarried South Asia, including available evi- adolescents; the physiological, be- dence about the health risks and chal- havioural and social risk factors sur- lenges that young people face in South rounding STIs/HIV among adoles- Asian countries. The chapters in this cents; communication between ado- volume are detailed summaries of lescents and adults; and the extent to papers and panel discussions from which family relationships can be To request a copy of the above an international conference entitled dominated by fear and violence. publication please write to: “Adolescent Reproductive Health: Documentation Centre Drawing on the extensive and diverse RHR, World Health Organization, Evidence and Programme Implica- evidence presented, wide-ranging 1211 Geneva 27, Switzerland tions for South Asia”, held in Novem- policy and programme recommenda- e-mail: [email protected] ber 2000 in Mumbai, India. The vol- tions are suggested.