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Designing the future: promoting research in sexual and

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THE EUROPEAN MAGAZINE FOR SEXUAL AND REPRODUCTIVE HEALTH No.67 - 2008 Contents The European Magazine for Sexual and Editorial Reproductive Health By Poul F.A. Van Look 3 Utilization of research findings to improve sexual and Entre Nous is published by: reproductive health Country Policies and Systems Unit By Michael Mbizvo 4 WHO Regional Office forE urope Scherfigsvej 8 Strategic assessment of policy programme and research issues DK-2100 Copenhagen Ø related to unintended in Ukraine: lessons learned Denmark By Iryna Mogilevkina 6 Tel: (+45) 3917 1602 Fax: (+45) 3917 1818 Using research to promote maternal and child health: E-mail: [email protected] The WHO Collaborating Centre on Maternal and Child Health www.euro.who.int/entrenous at the Institute of Child Health “Burlo Garofolo” in Trieste, Chief editor By Adriano Cattaneo, Giorgio Tamburlini 8 Dr. Gunta Lazdane Unintended : the Dutch situation Editor By Cecile Wijsen 10 Dr. Lisa Avery Editorial assistant Exploring the enigma: the research component Dominique Gundelach By Sibel Bilgin, Cem Turaman 12 Layout Sputnik Reklame Aps, Denmark. Level of knowledge on emergency contraception among women www.sputnikreklame.dk requesting termination of pregnancy in the Republic of Armenia Print By Karine Arustamyan, Georgy Okoev 14 Central tryk Hobro a/s Trends in sexual behaviour among secondary-school students in Slovenia Entre Nous is funded by the United Nations By Bojana Pinter 16 Population Fund (UNFPA), New York, with the assistance of the World Health Organization Using research to help influence policy and enhance services Regional Office for , Copenhagen, By Ayse Akin 18 Denmark. Working towards better youth sex in Europe It is published three times a year. Present dis- By Angelika Heßling 20 tribution figures stand at: 3000 English, 2000 Spanish, 2000 Portuguese, 1000 Bulgarian How research on sexual and gender based violence (SGBV) can and 1500 Russian. make a difference By Els Leye, Kristien Roelens, Ines Keygnaert, [Patricia Claeys], Marleen Temmerman 22 Entre Nous is produced in: Bulgarian by the Ministry of Health in Bul- CeVEAS: Developing and using guidelines to promote SRH garia as a part of a UNFPA-funded project; By Vittorio Basevi, Dante Baronciani, Giulio Formoso, Barbara Paltrinieri, Daniela Spettoli 24 Portuguese by the General Directorate for Health, Alameda Afonso Henriques 45, Improving the reproductive health of men P-1056 Lisbon, Portugal; By Trevor G. Cooper 26 Russian by the WHO Regional Office for Europe Rigas, Komercfirma S & G; Sexual and reproductive health research training course: linking sexual Spanish by the Instituto de la Mujer, Minis- and reproductive health agendas with research methodology terio de Trabajo y Asuntos Sociales, Almagro By Robert Thomson 28 36, ES-28010 Madrid, . Farewell to Entre Nous Hungarian The Portuguese and Spanish issues are dis- By István Batár 30 tributed directly through UNFPA representa- tives and WHO regional offices to Portuguese Selected RH Publications and Spanish speaking countries in Africa and By Lisa Avery 31 South America. Material from Entre Nous may be freely trans- Entre Nous wishes to thank the following WHO Collaborating Centres for their lated into any national language and reprinted financial contribution to issue No. 67: in journals, magazines and newspapers or WHO Collaborating Centre in WHO Collaborating Centre for Sexual WHO Collaborating Centre for Re- placed on the web provided due acknowl- Education and Research in Human and Reproductive Health, Federal search and Training in Reproductive  Reproduction, Geneva Foundation Centre for Health Education (BzgA) Health, Department of and edgement is made to Entre Nous, UNFPA and for Medical Education and Research Gynecology, University Medical Centre the WHO Regional Office forE urope. (GFMER) of Ljubljana Articles appearing in Entre Nous do not necessarily reflect the views of UNFPA The Entre Nous Editorial Advisory Board or WHO. Please address enquiries to the authors of the signed articles. Dr Assia Brandrup- Jane Cottingham Ms Nell Rasmussen ­Lukanow Coordinator, Gender, Repro- Senior Consultant, Danish For information on WHO-supported activi- Senior Adviser to the Health ductive Rights, Sexual Health Centre for Research on Social ties and WHO documents, please contact Matrix Network and , Vulnerability Dr. Gunta Lazdane, Country Policies and WHO headquarters, Geneva WHO headquarters, Geneva Systems unit, officeT -316 at the address Dr Peer Sieben given above. Mr Bjarne B. Christensen Dr Helle Karro UNFPA Representative for Please order WHO publications directly from Secretary General, The Danish Professor, Head Turkey and Country Director the WHO sales agent in each country or from Association Department of Obstetrics and for Armenia, Azerbaijan and Marketing and Dissemination, WHO, Ms Vicky Claeys Georgia CH-1211, Geneva 27, Regional Director Medical Faculty Dr Robert Thomson International Planned - University of Tartu Member, Geneva Foundation ISSN: 1014-8485 hood Federation, European Estonia for Medical Education and Network, Brussels Dr Evert Ketting Research Senior Research Fellow Radboud University Nijmegen Department of Public Health ,, Paul F. A. Editorial Van Look

n 1994 the International Conference Research enables individuals to lead to be involved in technical cooperation on Population and Development healthier sexual and reproductive health for national health development. WHO Iin Cairo, Egypt, placed sexual and lives in several ways. It identifies sexual Collaborating Centres are required to reproductive health firmly on the interna- and reproductive health needs and priori- participate in the strengthening of coun- tional agenda as fundamental to the social ties within communities, it generates new try resources and national health develop- and economic development of communi- knowledge that can be used for advocacy ment via information sharing, service ties and countries. Governments from and for policy and programme formula- provision, research and training. The around the world and many international tion, it identifies and promotes best prac- European Region is fortunate to have 19 organizations, including WHO, commit- tices, and it aids with the development of of these Collaborating Centres dedicated ted to this platform. Sexual and repro- evidence-based interventions, guidelines to research in sexual and reproductive ductive health should not be difficult to and tools. Through increased utilization health. achieve, yet 18 years later the challenge of of research findings research helps to This issue of Entre Nous highlights the making sexual and reproductive health strengthen sexual and reproductive health research undertaken – and the challenges a focal part of international efforts for programmes and policies. Furthermore, experienced and successes achieved in the elimination of , illness and dis- the use of a multidisciplinary approach undertaking this research - by various ability continues to be a reality. Globally, towards research (combining economic, WHO Collaborating Centres in the Eu- each year, 210 million women suffer social, behavioural, health systems, policy, ropean Region, as well as other research from life-threatening complications of epidemiological and biomedical disci- institutions, all of which are dedicated pregnancy, just over half a million women plines) helps to ensure that key issues to advancing the state of sexual and die from pregnancy-related causes, three in sexual and reproductive health are reproductive health within their countries million infants die in the first week of understood from a variety of pertinent and across the Region. By focusing on life, at least 120 million couples have and cross-cutting perspectives. As a result, the work done by these institutions it is unmet need for contraception, 80 million scientifically well-conducted and ethically hoped that the reader will be able to gain women have unwanted or unintended sound research provides policy makers at a new appreciation for the importance of pregnancies and 340 million new cases of local, national, regional and international research in sexual and reproductive health curable sexually transmitted infections levels with the necessary knowledge to and health in general. Our hope is that (excluding HIV and other incurable viral offer quality information and services to this issue of Entre Nous will demonstrate infections) occur. individuals so that they are able to protect that research is not only about designing Recently, the ICPD goal of achieving their sexual and reproductive health and studies in a scientifically robust and ethi- universal access to reproductive health by exercise their human rights related to cally sound way, collecting and analyzing 2015 was incorporated as a second target sexuality and sexual and reproductive data and reporting findings at scientific 5B under Millennium Development health. congresses and in scholarly papers, but Goal (MDG) 5 on improving maternal Advocating for and improving sexual that research is – and must be made health. Thus, more and more countries and reproductive health has been a long- – also an integral part of health systems can be expected in the coming years to standing goal of the WHO Collaborating development through impacting on place greater emphasis on strengthen- Centres in sexual and reproductive health. individual, organizational, national and ing their sexual and reproductive health Grounded in the belief that “research in international policy levels. Only then can policies and programmes. For progress the field of health is best advanced by research claim its rightful place as a global to be made in this area, however, at assisting, coordinating and making use of public health good for the achievement of  least three ingredients will be essential, the activities of existing institutions” the better sexual and reproductive health and namely expanding the knowledge base to Organization has had the deliberate poli- well-being for individuals, communities underpin the formulation of new poli- cy, probably as long as WHO has existed, and entire populations. cies, programmes and interventions and of involving national institutions in both their pilot testing and scaling up; political the national and international research Paul F.A.Van Look, MD, PhD commitment and “courage” to tackle the promoted by the Organization. The Director barriers (political, cultural and religious) WHO Collaborating Centres form part Department of Reproductive Health that impede the provision of appropriate of an institutional collaborative network and Research WHO headquarters, Geneva, information and services for better sexual setup by the Organization in support Switzerland and reproductive health; and, last but of its programmes at all levels: country, not least, the allocation of the required intercountry, interregional and globally. human and financial resources. Research The Centres’ mandate is to provide serv- plays an integral role in all three of these ices to WHO in support of programmes aspects. that are of interest at a global level and

No.67 - 2008 Utilization of research findings to improve sexual and reproductive health

esearch serves to define the most Fig. 1 appropriate interventions or tech- Sexual and reproductive health research nologies for improving sexual and R Global National reproductive health (SRH). Research find- ings should contribute to the formulation of policies and provide the evidence base Dissemination of findings

for the development and strengthening To peers Advocacy – stakeholders and public of SRH programmes. In addition, find- ings from well-designed research should Journals Seminars Research Policy Press Research reports briefs releases reports provide the basis for: • identifying crucial issues, gaps and needs for improving SRH; • generating new knowledge regarding Development of policies and interventions developments in SRH; Practice guidelines Programme delivery strategies • developing new and improved tech- nologies, tools and guidelines; Testing of interventions • identifying and testing interventions for prevention and care strategies; Training Evaluation New research needs • improving the management and al- location of resources and; Institutionalization of evidence-based practice • advocating for change and for the of best practices for improv- are introduced into practice guidelines. stakeholders? The closer the links, the ing SRH. Findings could thus be used to inform better the communication between To ensure maximum utilization of SRH policies or programme development the interested parties and the higher research findings, researchers need to en- and strengthening. They could also serve the chances the research will be uti- gage in innovative and strategic commu- to advocate for implementation of best lized. nication and information dissemination practices. In some instances, and depend- • In relation to the research ques- approaches. For their part, policy-makers ing on the nature of the study, primary tion, what level of interaction exists and service-providers need to have a findings can be used to develop and test between the research group and the sound appreciation of how research can interventions. Successful interventions are service delivery programmes? Close contribute to the development and modi- subsequently promoted through train- interaction between these two is fication of policies and practices. A key ing. Such interventions could further be particularly important in operations obstacle to the utilization of research is integrated into health systems through research. the lack of dialogue between the various an adaptation and adoption process and • Has a technical advisory team for the stakeholders. scaled-up for wider application. At the study been established? This team SRH system level, pertinent issues, prob- guides the research planning process Pathway to implementation of lems and needs emerge or arise as part of and includes researchers and various research a dynamic process for ensuring efficiency, stakeholders.  Figure 1 presents a model for strength- effectiveness and quality of services. • Are the interventions to emerge from ening utilization of research to improve These feed back into global or national the research cost-effective? It is vital SRH. Its success depends on ensuring that research questions and priorities. to examine the cost implications of appropriate media are used (journal arti- Questions to be considered at different the interventions being proposed, cle, report, policy brief) for the target au- stages of the research-to-practice con- focusing on possible, less expensive diences (researchers, policy-makers, prac- tinuum are presented below. alternatives. titioners). The journal article is aimed at • What level of credibility does the the scientific community, whose role it is Research planning research team enjoy among its peers to ensure that the results are scientifically • How relevant is the research question and other stakeholders? The higher sound and valid. These findings are then to the priority SRH problems in the the level of credibility, the greater the converted into policy briefs and press country? The greater the relevance, likelihood of the research findings releases in order to reach policy-makers the greater the chance findings will be being communicated widely and of and the general public. Where relevant, utilized. their utilization. and once steps appropriate for policy- • What linkages and partnerships ex- • Is there interest in the research on the making have been initiated, the findings ist between the researchers and the part of the beneficiary community or Michael Utilization of research findings to improve Mbizvo sexual and reproductive health

industry? The greater the interest, the research is to appoint them to techni- less disruptive changes to the health greater the chance the results will be cal advisory bodies for the research system have a greater chance of being utilized. project. adopted. • To what extent does a culture of find- • Are measures taken to ensure adher- • How receptive are the staff in the ing scientific solutions to problems ence to ethical and safety standards health-care delivery system to the exist in the country? Demand for in research functioning as intended? proposed interventions? To bring evidence-based interventions and so- Incoming data must be monitored about change, staff in the health lutions are an important determinant constantly during the research proc- system need to be open to it. Keeping of utilization of research findings. ess. This ensures that: (i) researchers them informed about the research Sometimes, owing to socio-cultural are able to take timely steps to protect and its findings can help increase pressures, policy-makers may not be the study population from undesira- their receptivity to new interventions. willing to accept scientific findings. ble consequences of the intervention, • How will advocacy for change be • How feasible is the proposed research should these be detected; and (ii) managed and who will be involved? project? It is important to select re- if preliminary data already indicate Advocacy campaigns need to involve search questions that can be answered significant benefits of the interven- those best suited to undertake it with the available ethical research tion, the control group is not unethi- (stakeholders, media) and reach those methods. cally denied the intervention on the who need to be informed and con- • Have plans been made for dissemi- grounds of scientific interest. vinced (policy-makers, programme nation of research findings during • Are sound review and feedback managers, end-users). the life of the research project and mechanisms in place for the research • Is the evidence strong enough to beyond? Involving stakeholders project? These ensure that the project suggest changes (in policy, practice)? throughout the entire life of the remains on track. Recommendations that are not research project is as important as • Is local capacity-building planned for backed by solid evidence are less likely disseminating the findings after the in the research project? It is desir- to be implemented. project is completed. able to engage and train local staff in • Will resources be available and • Are the study design and methods ap- research conduct. This helps with the sustainable to make the suggested propriate and ethical? This is vital for long term goal of using research to changes? To carry the implementa- sound research results and credibility. solve public health problems. tion process through, available and • Does the research question deal with sustainable funds are required. an issue about which there is public Upon completion of research • Will researchers remain involved in sensitivity? Research on sensitive is- • Have steps been taken to ensure that the process of applying the findings? sues can be more difficult to conduct. the findings have been communicated The real test of any research is in its Opposing camps may emerge among to policy-makers and the public in the application. Researchers can learn a the policy-makers and politicians, form of policy briefs or press releases lot about their field of research by which may lead to lengthy debates in a timely manner? Policy briefs are remaining involved in the process of on the merits and demerits of the useful to inform policy-makers of the implementation of their findings. research and thwart utilization of policy recommendations that emerge findings. from the research findings. Press Finally, the tenet and principle guiding releases are designed to inform the research is to build on what already exists,  Research conduct mass media and the public about the or strengthen the evidence base on which • Is the research being conducted in research findings. decisions are made. The overriding goal accordance with the highest techni- • In preparing policy briefs and press is to improve the community’s well-being cal, scientific and ethical standards? releases, has care been taken to ensure by proposing solutions that are based on Deviation from the highest stand- that the findings are presented in the best available evidence on efficiency, ards can affect the credibility of the the local context? This is particularly efficacy and safety. researchers and the findings. important in the case of research • What actions are being taken to undertaken at the global or national Michael Mbizvo, MD ensure that progress in research work level. Findings from one setting are Coordinator/headquarters is being communicated to the stake- not always transferable to other set- Department of Reproductive Health holders, particularly the community tings. and Research WHO headquarters, Geneva, in which the research is being done? • How compatible are the research Switzerland One way to keep the community findings with the existing health [email protected] and other stakeholders interested in system? Interventions that require

No.67 - 2008 Strategic assessment of policy, programme and research issues related to in Ukraine: lessons learned

The WHO Strategic Approach to Strengthening Sexual and Reproductive Health Policies and Programmes (1) is the methodology used to identify and prioritize the needs for sexual and reproductive health (SRH) services and technologies, test the necessary inter- ventions on priority needs and apply the successful interventions at the national level. It uses a multidisciplinary approach to develop strategic decisions essential for improve- ments in selected areas of SRH.

The purpose of the strategic assess- members have come together and have involved in the SA from the start and be ment (SA) in Ukraine was to: accepted the idea of a SA, proposal devel- responsible for the SA implementation 1. identify quality of family planning opment can then be done. not only in their region of the country, and services; but at a national level as well. 2. develop sustainable programmatic Proposal development interventions to improve the quality The challenge of developing successful National workshop to develop data of SRH; proposals is not a new phenomenon. The collection instruments 3. decrease the need for abortion serv- first challenge was that of preparing a A background document character- ices; proposal in a very specific format; those izing the situation in the area of family 4. improve the quality of abortion and involved may not always be familiar with planning, unplanned pregnancies and family planning services in public and the style. abortion was prepared by the Ministry of private sectors of the country; The second challenge was that the pro- Health experts and served as useful basis 5. assist the Ministry of Health in coor- posal needed to be written in the English to identify strategic questions for the field dinating resources to strengthen these language. The required translations and work. services. back translations were time consuming. A planning workshop with involve- Due to the lack of familiarity with Eng- ment of a broad range of stakeholders This article serves to share the challenges lish in Ukraine, direct communication was held in order to identify the broad and lessons learned when conducting the between English speaking international programmatic issues and priority areas to SA in Ukraine. consultants and the SA country coordi- be assessed using the SA methodology. nator was extremely difficult. As a result Unfortunately, the background docu- First steps many comments from English speaking ment was not available to all participants In order to be successful with our SA consultants were unable to be answered of the workshop in enough time to allow numerous parties were involved from in a timely fashion and the proposal them to work with it. It is important the very beginning. Involvement of top development thus took more than a year to ensure that all involved parties have policy makers and key stakeholders is to proceed. recieved and studied the background essential in order to reach the goals of a In response to this second challenge an document before the national workshop SA. In 2004 when WHO was organizing international Russian/English speak- on preparation for the fieldwork. the workshop on the latest tools avail- ing coordinator was assigned to work At this point, two teams were created  able in improving access and quality of directly with the Ministry of Health and that adapted the tools for the field work reproductive health services, including the international consultants. This was to national needs and strategic questions those on safe abortion, Ukraine, as well extremely beneficial and would have raised in Ukraine. As the country is large as, four other countries (the Russian greatly decreased the time required for and the level of health services is similar, Federation, the Republic of Moldova, proposal development if done early on in two regions were chosen to carry out the Latvia and Lithuania) were represented by the project. field work. More diverse representation representatives of the Ministry of Health, The third challenge was deciding on of the different involved parties would professional and non-governmental the organization that would be respon- have been of benefit for the field work, as organizations (NGO). sible for the SA implementation in the health care providers were abundant in Our experience was that because a SA country. The ideal solution would have both teams and only some young people, involves multidisciplinary exercises it been to use a national NGO. However, in journalists and peer educators were was important to establish good rapport Ukraine these organizations do not exist involved. High level policy makers were in among members from the start. Failure and the next most suitable option was a the field for only a few days due to other to do so can compromise the success of local NGO. It was important to be able priorities. This influenced the ability of the planning activities. Once all team to identify a local NGO that would be the teams to develop a multidisciplinary

Strategic assessment of policy, programme and research issues related to unintended pregnancy in Ukraine: Iryna Mogi- lessons learned levkina

that enables each individual involved, whether a woman from a marginalized group or the head of the local administra- tion, to assist in the improvement of SRH in Ukraine. Willingness to change is essential in order to conduct a SA successfully and move toward system improvement. Individuals need to be assured of their anonymity and their ability to speak freely without punishment. However, it was a very interesting time that gave each of the team members the possibility to encounter diverse attitudes and practices and to discuss all that was heard or seen together in the group. Even the process of the SA itself was a capac- ity building exercise for all colleagues involved. approach and the capacity to conduct to start. This obviously created a very a SA. Luckily, we were able to help stressful situation, including concerns Conclusion overcome this challenge by incorporat- about whether or not the SA would pro- The draft report of the field work is ready ing representatives from various sectors ceed, but was solved due to great support and recommendations will be discussed (educational, economic, social and mass of the local administration, involved team during the dissemination meeting where media) into the SA teams at various sites. members and interest and attitude of the a much broader group of stakeholders Interview guides were also developed health care providers and community than those participating in the field work during the workshop. Due to different members. will be present. We all hope that these rec- levels of expertise more time could be Due to the large number of interviews ommendations will be agreed upon and allotted for development of instruments and group discussions conducted daily, will be the basis for the future action in and their pre-testing. This would allow good preparatory work was essential in Ukraine to improve the health of women better understanding of the process and ensuring the success of the SA field work. and their families. decrease difficulties of the first few days in Qualitative research methodology was the field. Similar documents from other quite new for many team members and Reference SA’s would be beneficial to have as a refer- evening discussions were interesting, but 1. WHO. The WHO Strategic Approach ence to help provide an understanding of time consuming as well. to strengthening sexual and reproduc- what the final product (interview and ob- Time management is crucial. Flexibil- tive health policies and programmes. servation instruments) should look like. ity and creativity are key. We found that Geneva:WHO; 2007 The workshop is the appropriate place splitting the teams into those responsible http://www.who.int/reproductive- to also develop the main headings and for organization and those responsible for health/strategic_approach/index.htm  structure of the final assessment report of interviewing helped facilitate the work (available in English and Russian) the field work. This would ensure that all load. individual teams are able to communicate Iryna Mogilevkina, MD, PhD effectively and collect data in a similar Field work Professor, Obstetrics, Gynaecology fashion. Our challenge was to communicate to and Perinatology those being interviewed that the goal of Donetsk State Medical University, Ukraine Preparation of field visits the SA was not to blame and find mis- [email protected] Our biggest challenge in preparing for takes, but to identify areas for improve- field work was the fact that the signing ment and gaps in the system. It may of an official document, “Prikaz”, by the require time for people in health care Ministry of Health, required for the SA, facilities to understand that this is not a happened only a week before our sched- team from the Ministry of Health with uled start date and reached the sites the international experts that is coming for day before the field work was scheduled control and punishment, but a method

No.67 - 2008 Using research to promote maternal and child health:

In 1992 the Institute of Research contributions to improve course was repeated several times in Tri- maternal and child health Child Health in Trieste, Italy, este and exported to countries of eastern During the past 15 years, the Centre has Europe and Latin America. As a follow was first designated a WHO actively contributed to research, devel- up to these courses, staff from the Centre Collaborating Centre; it has opment and implementation in several gave support to national initiatives for the fields pertinent to maternal and child development of plans for perinatal care. been re-designated since health. Several of these projects are out- The contents and methods of the course then every four years. The lined below. were more recently integrated into a sum- mer course on Public Health Approaches terms of reference agreed • Kangaroo Mother Care (KMC) to Maternal, Neonatal, Child and Ado- upon in 2004 are very simi- Originally started in 1979 by Drs. Rey and lescent Health held every year in Trieste Martinez in Bogotá, Columbia, KMC is a (www.burlo.trieste.it/?Lang=european- lar to those established in universally accepted method of care that school). The experience gained with all 1992 and include: is important for all infants, but especially these activities allowed the Centre to for preterm infants. KMC involves 3 actively contribute to the development basic principles: provision of skin to skin of the WHO European Strategy for child • Research activities for contact between the mother and baby, and adolescent health and development the development and as- exclusive breastfeeding and the provision (www.euro.who.int/childhealtdev/strat- of medical, emotional and psychological egy/20060919_1). sessment of appropriate support to the mother and infant, includ- • Essential Newborn Care (ENC) technologies and inter- ing the concept of early discharge from hospital. In resource limited settings it is Globally nearly half of all infant ventions related to WHO an effective way to help meet baby’s need are neonatal deaths, with 2/3 occurring programmes and ini- for warmth, breastfeeding, protection in the first week of life. Birth asphyxia, from infection, safety and love. After ini- infections (pneumonia, diarrhoea, sepsis, tiatives on maternal and tial experience in Maputo, Mozambique, HIV), pre-maturity and congenital child health; and the completion of a multi-centre ran- abnormalities remain the leading causes domized controlled trial (1), the Centre of neonatal mortality. As most of these • Development and field organized an international conference in causes are either preventable or treat- testing of guidelines and 1996 that gave birth to the International able ENC was developed to highlight Network on KMC. The Network meets preventative interventions that are simple, training materials on the every two years and the 7th meeting and inexpensive, available and cost effective use of appropriate tech- conference will take place in Uppsala, and that can occur at 3 various levels of Sweden, from 6 to 11 October 2008 care: home/family, the health centre and nologies and interven- (www-conference.slu.se/KMCeurope08/). the referral district hospital. In 1998 the tions related to the same On behalf of WHO, staff of the Centre Centre developed, in collaboration with developed, in collaboration with other the WHO Regional Office for Europe, a  WHO programmes and experts, a practical guide for KMC (2). manual and course on ENC (www.euro. initiatives; who.int/document/e79227.pdf). Its goal • Planning for Perinatal Care (PPC) is to review evidence and best practice • Support to the introduc- The widespread introduction of expen- for prevention of neonatal morbidity tion and implementation, sive technology has occurred in many and mortality and to help integrate these countries, often without good evidence of practices into existing health systems including evaluation, of effectiveness, appropriate training of staff, and methods of care. The course was WHO programmes, plans adequate technical support or strategic translated into Russian and Portuguese needs assessment. In order to help policy and was run in several countries of the and initiatives related to makers and decision makers identify the WHO European Region (3) and several maternal and child health. appropriate choices of technologies avail- states of Brazil. In the latter country, the able for perinatal care in their individual ENC manual was also submitted for re- settings (primarily middle income) the search on effectiveness. The work on ENC Centre organized a short course on PPC, continued along the years and included aimed at this target audience in 1997. The the collaboration with WHO in Geneva

The WHO Collaborating Centre on Maternal and Child Giorgio Adriano Health at the Institute of Child Health “Burlo Garofolo” Tamburlini Cattaneo in Trieste, Italy

a variety of other issues, from bacte- References rial meningitis to violence in children 1. Cattaneo A, Davanzo R, Worku B to the identification of near-misses for et al. Kangaroo mother care for low improved obstetric care. Along the years, birthweight infants: a randomized the Centre has shifted its focus geographi- controlled trial in different settings. cally (from Sub-Saharan Africa to eastern Acta Paediatr 1998;87:976-85 Europe) and thematically (from research, 2. WHO. Kangaroo mother care: a practi- development and training on appropriate cal guide. WHO: Geneva; 2003 technologies to development of policies 3. Uxa F, Bacci A, Mangiaterra V et and plans, focusing on inequalities and al. Essential newborn care training inequities). This latter shift in focus can activities: 8 years of experience in be better expressed by quoting a sentence Eastern European, Caucasian and that Giorgio Tamburlini and Adriano Central Asian countries. Semin Fetal Cattaneo, the two senior staff of the Cen- Neonatal Med 2006;11:58-64 tre, wrote in a letter to the Lancet: “Fo- 4. McClure EM, Carlo WA, Wright LL et cusing on health interventions alone to al. Evaluation of the educational im- reduce child mortality looks short-sighted pact of the WHO Essential Newborn and may reduce the chances of acting on Care course in Zambia. Acta Paediatr the factors that cause increased exposure 2007; 96:1135-8 for the development and testing of a new and vulnerability of children to disease, 5. Cattaneo A, Buzzetti R. Effect on rates training package (4). and ultimately lead to or to a miser- of breast feeding of training for the able life”(7). It is with this ideal in mind baby friendly hospital initiative. BMJ • Breastfeeding (BF) that the Centre looks to the future to 2001; 323:1358-62 Breastfeeding has long been recognized continue to do research on maternal and 6. European Network for Public Health as an ideal way to ensure young infants child health that can be used to advocate Nutrition: Networking Monitoring obtain the needed nutrients for healthy for better maternal and child health poli- Intervention and Training (EU- growth and development. The Centre cies and interventions, to provide training NUTNET). Infant and young child has been very active in the protection, and guidelines that improve quality of feeding: standard recommendations promotion and support of BF since in- care and to share knowledge with others for the . European ception. For instance, it carried out one of through education and dissemination Commission, Directorate for Public the few controlled trials on the effective- that can help make best practices and Health and Risk Assessment, Luxem- ness of the Baby Friendly Hospital Initial- evidence accessible to all. bourg, 2006 http://www.burlo.trieste. tive package (5). Since 2002 the Centre it/old_site/Burlo%20English%20versi coordinates EU-funded projects for the on/Activities/research_develop.htm development of a Blueprint for Action, 7. Tamburlini G, Cattaneo A. Gates’s first launched in 2004 and available grandest challenge. Lancet 2005; online (http://ec.europa.eu/health/ph_ 366:1357-8 projects/2002/promotion/promotion_  2002_18_en.htm) in many languages. The project continued with a pilot test of the Adriano Cattaneo Blueprint in eight EU countries and will Epidemiologist, Coordinator lead, by mid 2008, to the publication of a WHO CC for Maternal and Child revised and field tested Blueprint. During Health Trieste, Italy the pilot test, the Centre contributed to [email protected] the development, in 2006, of standard recommendations on infant and young child feeding (6). Giorgio Tamburlini Scientific Director Conclusion and future directions Institute for Child Health IRCCS In addition to the above main fields Burlo Garfolo Trieste, Italy of interest, the Centre has carried out [email protected] research and development activities in

No.67No.61 - 20082005

Unintended pregnancies: the Dutch situation

ike the WHO Collaborating Cen- Contraception to the Dutch population it is estimated tres, Rutgers Nisso Groep Expert A large proportion of Dutch women aged that about 67 000 (CI 46 600-96 000) LCentre on Sexuality in the Neth- 12 and 45 use contraception. Of sexu- pregnancies a year are caused by lack of erlands, has been dealing with sexual and ally active aged 12-18, nine out of contraceptive use. The reason why no reproductive health for decades. Rutgers ten girls use contraception. One in ten contraceptives were used vary widely, Nisso Groep aims to improve sexual and (11%) does not use anything to protect from religious rules to having an ambiva- reproductive health programmes by con- herself from unintended pregnancy. lent child wish. tinuously reviewing lessons learned, best There is a large repertoire of contracep- The second important cause of unin- practices and experiences that can be ad- tive methods available to young people; tended pregnancies is ineffective or faulty justed to other situations and innovative the vast majority (78%) choose the pill, use of contraceptives. Examples of this ways of working. The organization has a just over a quarter (27% ) choose to use a include forgetting one or more contra- research department that surveys aspects and one in five (20%) use both ceptive pills or improper application/re- of sexual and reproductive health and methods simultaneously (Double Dutch). moval of resulting in leakage that evaluates education programmes. An Contraceptive use of young women does or breakage. In the almost important goal of the organization is to differ from that of adult women in the one in five women (18%) is not able to facilitate talking openly about sexuality. age of 19-45. In the adult population 28% use her method of contraceptive correctly Effective sexuality education programmes of women use the contraceptive pill, 6% for six months in a row. Approximately contribute to the empowerment of choose to use condoms and 11% opt for a few thousand unintended pregnancies (young) people to make informed deci- the Double Dutch method, combining a year occur as a result of this. Between sions regarding their sexuality and sexual oral contraceptives with condoms. The contraceptive methods there are marked well-being. adults make far more use of the large differences in percentage of women fail- In the Netherlands most reproductive spectrum of methods that is available ing contraceptive use. Women using the age women who do not wish to have a to them, although the so called ‘new’ pill more often have problems using it child use contraception. We have a toler- contraceptives, like the contraceptive ring correctly; more than a quarter of them ant societal norm, accept that (young) and the contraceptive patch are not very say the have not been able to use it prop- people want to have sex, and find it popular. 13% of women have opted for erly over the last 6 months. important that they protect themselves; male or sterilization, while 7% use not only against STI’s, but also against an IUD. It is obvious that age is an impor- Morning after pill unwanted pregnancies. As a result unin- tant predictor of contraceptive choice: the When the risk of an unintended preg- tended pregnancies are rare and abortion older women are, the more likely they will nancy is high Dutch women have the rates are low. This is, in a nutshell, how choose the longer lasting or permanent possibility to purchase the morning-after the Dutch situation could be sum- alternatives. Of course, age does correlate pill, either over the counter of a pharmacy marized, and compared to most other with number of children and partner sta- or from a chemist. This is a recent op- countries this description is true. But it tus, both of which have a significant effect tion, becoming possible in January 2005, does not mean however that all is well. By on method choice (see table 1)(1,2). which has lead to a considerable increased reviewing recent research in the field of wholesale trade. Over the course of the reproductive health, this paper shows that Numbers of unintended first year sales increased by about 65%. not all Dutch women are able to, or in pregnancies 3.5% of young people (age 12-19) in 10 circumstances that allow them to, prevent Of all pregnancies, almost one third were the Netherlands report having used the unwanted pregnancies. not intended. However, when confronted morning-after pill the past year. For adult In the Netherlands two large scale with such a pregnancy almost all men and women (age 19-49) this percentage is studies on sexual behaviour and sexual women eventually say that they do want slightly lower: 2.2%. Results from a study health were recently done. Both studies to have the child. Therefore only a small among buyers of emergency contracep- had representative samples: “Sex under minority of all unintended pregnancies tives showed that buyers usually are 25” gathered data in 2005 among 4820 are unwanted pregnancies. under 25, often childless, mainly belong 12-18 year-olds (1). One year later the The risk of an unintended pregnancy is to the indigenous population, are fairly study “Sexual Health in The Netherlands eminent for women who do have sex but well educated and usually in a long-term 2006” was done with a sample of 4147 do not take action to protect themselves relationship (3). This suggests that it is adult men and women aged 19-70 years from pregnancy, for women who make not the known ‘risk-groups’ for unin- (2). These important pieces of research use of unreliable methods of contracep- tended pregnancies which are buying this have helped further our understanding of tion and for women who make mistakes product. High abortion rates are mostly the current situation in the Netherlands in use of their method of choice. When found among people of non-Dutch regarding unwanted pregnancies. the data from the surveys are extrapolated origin. Compared to women who have Cecile Wijsen

Figure 1 Table 1

Birth and abortion rate per 1000 teenagers (15-19 years af age) Use of contraception by Dutch , by age, percentages 2005-2006 12-18* 19-29 30-39 40-49 16 No contraception 9.6 22.4 30.2 40.2 Pill 51.0 40.9 25.5 17.8 12 Pill & condom 28.0 19.9 9.4 3.8

8 Condom 1.6 5.7 8.1 5.3 IUD 0.6 7.2 9.9 3.6 4 Sterilization 0.0 0.2 12.5 26.7 Other 0.9 3.7 4.4 2.6 1980 1985 1990 1992 2000 2001 2002 2003 2004 2005 2006 *Only girls who are sexually active had an abortion, morning-after pill-buy- five years. One in every ten adult women References ers use contraceptives of any type more has had at least one abortion in her life 1. De Graaf H, Meijer S, Poelman J et al. often. Though their use of contraception time (2). Abortion rates for teenagers Seks onder je 25e Seksuele gezond- is better, something has gone awry which in the eighties and nineties of the past heid van jongeren in Nederland anno results in them purchasing the morn- century were very low. At the turn of the 2005 (Sex under 25 Sexual health of ing-after pill. Morning-after pill-users century however teen abortion rates rose young people in the Netherlands anno can be subdivided into three groups: the dramatically. Partly as a result of preven- 2005) 2005. Delft: Eburon. “careless” (33%), who have not used any tive interventions targeted at teenagers in 2. Wijsen C and Zaagsma M. Zwanger- contraception and have been “surprised” the ‘riskgroups’, the teen abortion rate has schap, anticonceptie en abortus. by their sexual contact represent the first decreased and in 2006 it was only 7. 4 per (Pregnancy, contraception and abor- group. They realize only later that they 1000 (see figure 1) (4). tion) In F. Bakker en I. Vanwesen- have run a risk of pregnancy. The second beeck (Eds.), Seksuele gezondheid in group consists of women where contra- Conclusion Nederland 2006 (Sexual Health in the ception has failed (54%). They intended Research in the field of unintended preg- Netherlands 2006) Delft: Eburon; to prevent a pregnancy but most of them nancies does show that in general women 2006. pp 67-88. forgot to take one or more pills, or the in the Netherlands are able to prevent 3. Van Lee L, Picavet C and Wijsen C. condom slipped off or tore. Finally, a unintended pregnancies. When compared Emergency or precaution? Background third group of women bought the morn- with rates from other countries the Dutch and risk profiles of users of the Emer- ing-after pill as a preventive measure rates are among the lowest in the world. gency Contraceptive. Utrecht: Rutgers (10%). These women keep the morning- Still the data also indicate that there is a Nisso Groep after pill in stock at home, or take it, while considerable group of women who find 4. Van Lee L and Wijsen C. National there is actually no need for it. it difficult to prevent a pregnancy. Our Abortion Registration 2006. (Dutch) low abortion and teenage pregnancy rates Utrecht: Rutger Nisso Groep. Abortion may by no means be an excuse to think Cecile Wijsen, PhD When a women wishes to terminate an we have done what is necessary. In fact, Head of programme Reproductive unintended pregnancy she has the pos- these two recent pieces of research high- Health, 11 sibility to attend one of the countries 16 light the fact that a fairly large group of Rutgers Nisso Groep, Dutch expert abortion clinics. When she is living in the women are in need of our efforts to help centre on sexuality, Netherlands, all costs are covered by the them to be able to prevent unintended Utrecht, The Netherlands national insurance. Access to abortion pregnancies. [email protected] services is very good. Annually in the Netherlands just under 33 000 pregnan- cies are terminated. About 4500 of these are done by women who do not live in the Netherlands, but come to our country in order to have an abortion. The Dutch abortion rate is 8.6 per 1000 women aged 15-44 (4). After an increase of the abortion rate in the late nineties, the rate has remained stable for the past

No.67 - 2008 Exploring the enigma: the research component

When the Reproductive Health Programme (RHP) in Turkey started, responding to learn- ing needs and awareness raising of its target groups were principal fields of activity, in addition to gathering information needed for its own implementation. If the two target groups for information are considered as the demand and supply sides, the RHP has not only produced needed information for both, but also developed and provided necessary tools for the adequate dissemination and usage in other components of the RHP.

Research: In depth and ad-hoc discoveries its data are of qualitative nature and its last 20 years. A direct implication of this Fifteen data collection activities have universe is limited to 3 provinces. The is a rapid decrease in the size of “urban- been conducted under the RHP, with a validity of comparing their data should ized” young families, and a considerable total budget of approximately € 4 mil- be considered carefully due to both the increase of families. As a lion (1). These activities were planned time gaps and the comparability of their result of this development, vertiginous to cover specific information needs of sampling universes: the quality and differences are observed between the the Ministry of Health (MoH) for RHP incidence of antenatal care, skilled birth regions concerning the use of family intervention areas. Three out of fifteen attendance rates and other characteristics planning methods or maternal mortality are especially important for policy-level differ between NMMS and TDHS. rates; while the former is still far lower in decision-making and are discussed in this Overall, the socio-economic status of the East versus the West, the latter in the article: Turkish Demographic and Health the woman’s family is the main independ- Northeast is double the Turkish aver- Survey 2003 (TDHS), National Maternal ent variable that explains the determi- age (2, 4). When it comes to the Mortality Study (NMMS), and Health nants and patterns of service use and West-urban, by decreasing itself two-fold, Seeking Behaviour Study (HSBS). morbidity-mortality related risk factors. versus the East-rural, is now equal to The TDHS started in 1968, later to be- It also correlates with risk of unwanted European rates (2). The need for quality come the only data source for monitoring pregnancy, use of free of charge prenatal sexual and reproductive health services the health level of the population and the care and with skilled birth attendance, is rapidly increasing, together with the quality of healthcare services, is conduct- again free of charge. Strikingly, maternal increase of service-demanding families in ed at 5-year intervals. The last DHS was mortality appears to be correlated to the speedy modern metropolitan areas. conducted in 2003 and supported by the caesarean sections (C/S); one out of every Whereas service coverage and accessibility RHP. Despite its usefulness in providing two dead mothers had undergone C/S. are still priority issues in the traditional necessary data to estimate most of the re- This method is known to be the preferred East, its urban areas are now ruralized, as productive health indicators, TDHS fails delivery method of high socio-economic a result of migration. to estimate maternal mortality levels and level families in the West and the country answers most of the “what’s” but not the average of caesareans is slightly above Other knowledge generating activi- “how’s”. Therefore, in addition to mother 20% (2). When the woman has access to ties: potential data sources for local and child health data provided by TDHS, healthcare, the quality of care received health management 12 the NMM Study, which provides data on and the communication skills of the In order to provide the needed informa- maternal mortality, and the HSBS which, service providers do not always meet her tion for both the RHP and the Provincial together with the others, provides data expectations. Only a negative past experi- Health Directorates, working groups on risk factors related to maternal deaths, ence in the neighbourhood may be a (youth, management, safe motherhood/ were required. source of worry for the pregnant woman emergency obstetrical care, family plan- (3). ning, STI’s, training, community service Mutually complementing findings organizations) conducted eleven various Findings of the 3 studies comple- Effects of information gathering activities.The ment each other. While the “what’s” Another main independent variable, information generated has been useful are answered by the TDHS, the HSBS caused by recent economic transition, is mostly to determine the needs of both complements results on the “how’s”. The the high internal migration rate, which target groups and health care facilities. (2) and the maternal is a huge issue affecting the population The approach of consensus build- mortality rate (4) perfectly correlate distribution of Turkey. Large numbers of ing meetings is especially important for geographically. The HSBS is not always people have moved from rural to urban Turkey and the stakeholders (decision comparable to the 2 other studies since areas and from the East to the West in the makers, provincial managers, service pro- `s Sibel Bilgin Cem Exploring the enigma: the research component Turaman

Box 1

Programme information These activities should be maintained tion areas. Sustainability has been ensured Active behaviour of the population influenc- through public-civil sector collaboration. through institutionalisation of in-service ing health service utilization includes delay Even though mainstream media are not trainings and equipping the training and in health seeking behaviour mostly due to much involved, the local media have proved service facilities. On the other hand, the Min- shortage of the family’s resources. Passive to be a potential “conspirator” ready to pro- istry of Health has started the preparation behaviour seems to be not even being vide important inputs, as shown by the RHP. of service standards implementation in the aware of the need when it is present or not Programme information areas of , pre/, haem- orrhage, delivery and , in taking a decision when danger signs appear. While the passive behaviour on the service order to ensure and sustain standardized Programme response provision side involves ineffective care (due quality of care under the RHP. The “Database to lack of knowledge, capacity and equip- Education is a basic variable in deciding of Mother Deaths” is now implemented ment), the active behaviour manifests itself on service use, but the CSO contribution to nation-wide. Maternal deaths are described as indifference to clients and communica- adult awareness raising is still limited and in this data-base in line with both ICD-10 tion failure. pilot-sized. Its impact should be extended classification and the three-delay model through inter-sectoral collaboration. The Programme response described by the WHO (5). IEC/BCC activities planned under the RHP Considerable numbers of service providers were unnecessarily delayed and thus the have been trained under the RHP, training expected achievements have fallen short. subjects reflecting the RHP’s main interven-

viders and clients) should be encouraged one hundred percent reliable. Further- References to further use such participative informa- more, decision makers will always need 1. http://epos.eusrhp.org tion generation methods. The integra- data of qualitative nature complementing 2. Hacettepe University Institute of tion of consensus building meetings into the quantitative data generated by future Population Studies. Turkey Demo- the healthcare management training, TDHS’s. The social science profession graphic and Health Survey, 2003. An- implemented under the RHP, has been should concentrate its efforts on using a kara: Hacettepe University Institute beneficial and should be integrated into variety of qualitative research methods of Population Studies, Ministry of future trainings for managers. and widespread use of their results. Health, Maternal Child Health/Family Planning, European Union; 2004. What is next? Epilogue 3. Conseil Santé, Sofreco and Eduser. In sum, the information produced under The RHP gathered a considerable amount Health Seeking Behaviour Study, Eu- the RHP has been useful mainly to define of data on various fields of SRH to define ropaid/121387/C/SV/TR. MoH MCH/ the two-winged bottlenecks of health its priorities. The knowledge thus gener- FP GD and Delegation of European care: one is the active or passive behav- ated has been shared widely in collabo- Commission to Turkey, Ankara 2007. iours fed by the values and attitudes of ration with other result areas of RHP, 4. Icon-Institut Public Sector GmbH, the population, and the other is the active mainly with decision makers, managers, Hacettepe University Institute of or passive effects of service provision (see service providers, clients and the general Population Studies, and BNB Con- Box-1). public. The information generation ap- sulting. National Maternal Mortality proaches will be useful for monitoring Study, 2005. MoH MCH/FP GD and Future data gathering activities and improving the SRH care service and Delegation of European Commission While interventions in the social factors policy development in Turkey. to Turkey, Ankara 2006. 13 need a longer-term and broader strategy 5. WHO. Beyond the numbers: reviewing of awareness raising and behavioural maternal deaths and complications to change than the duration the RHP of- make pregnancy safer. Geneva: WHO; fers, improving the level of skills and the 2004. attitudes of service providers could be achieved in the short term. What type of data will be required in Cem Turaman, MD the future to help the improvement of Consultant, Public Health Expert primary and SRH healthcare services and [email protected] for the development and orientation of policies towards the national strategic Sibel Bilgin, MD targets? Data generated exclusively by re- Officer of theT urkish Ministry of search will always be needed even if rou- Health, Mother and Child Health/ tine data collection systems would prove Family Planning General Directorate

No.67 - 2008 Level of knowledge on Emergency Con- traception among women requesting termination of pregnancy

The Research Center of Maternal and Child Health Protection in Yerevan, Armenia has been a WHO Collaborating Centre on Human Reproduction since 1985. Contraception is one of the main areas for research and collaboration at the Centre. In 2005 this project, examining knowledge of emergency contraception among women requesting termina- tion of pregnancy, was identified as a priority topic for research in sexual and reproduc- tive health.

Rationale face to face, in a private setting. Inclusion and 13.1% had 3 children). Unwanted pregnancy is a major medi- criteria for the selection were the follow- More than half of all abortion patients cal, social and public health problem. ing: requesting an abortion on demand (51.2%) did not use any contraceptive Since induced abortion became legalized and agreeing to the interview. method before the current pregnancy. in Armenia in 1955, it has become the The maximum age of the patients was 48.8% of women were using contracep- most common method of childbearing 45, the minimum 17. The majority of tive methods at the time they became regulation in our country. Even after abortion patients (77.3%) were between pregnant: 43% were using withdrawal, launching 77 family planning centres the ages of 20-35. 47.6% of patients had 29.2% were using condoms, 24.4% were in 1997 the situation has changed only university education, 34.5% had high using the rhythm/calendar method slightly. According to the data of the 2005 school education (10 grades) and 17.8% and 2.4% were using spermicides. One Demographic and Health Survey (1), 37% had secondary professional school educa- would expect that the preferable types of of women have had at least one abor- tion (14 grades).The greatest proportion contraception were traditional methods tion. The average number of abortions of abortion patients (90.5%) lived in (withdrawal and rhythm/calendar) and among women who have ever had an urban areas and only 9.5% lived in rural condoms. Our data shows that traditional abortion was 2.6. Only 53.1% of women areas. Women who live in rural areas methods were used by 68.3% of abor- use contraception, and the majority of usually have the opportunity to undergo tion patients whereas modern methods them (33.6%) use traditional methods abortion in the same region they live in; (mainly condom) were used by 31.6% of of contraception. Withdrawal is the most thus they prefer to have the abortion in them. widespread method of contraception, that region as opposed to traveling to The majority of abortion patients whereas 19.5% of women use mod- Yerevan to have the procedure performed (76.2%) were of the opinion that it is ern methods of contraception. 52% of there. This is felt to be due to the follow- better to prevent unwanted pregnancy by women requesting termination of preg- ing reasons: not all regions of Armenia using contraceptives. 15.5% of patients nancy use some method of contraception. are located closely in distance to Yerevan, had no opinion on this matter. Thus our This means that pregnancy among these it is more convenient to have the abor- data support that the majority of abor- women is the result of contraception tion performed in the same village than tion patients theoretically realize that failure. Emergency contraceptives (EC) to travel to Yerevan, and termination of contraception is better than abortion, but are methods that can prevent unwanted pregnancy in Yerevan will require addi- in practice they do not use contraception 14 pregnancies if administered within 120 tional expenses, such as for traveling, ac- consistently or effectively. hours after intercourse(1-5). There are commodation and sick leave from work. Only 8.3% of all abortion patients no official data about the use of EC in This is probably the reason for having believed that abortion was a better choice. Armenia. Thus the aim of this study was only a small number of rural inhabitants The reasons for considering abortion a to determine the knowledge and use of in our sample. better choice than contraception were EC in the group of women requesting Overall, the majority of abortion the following (more than one answer termination of pregnancy. patients (91.7%) were married and most was possible): abortion is safer (100%), of them have had only one sexual partner. abortion is a short procedure (100%) and Methods and Results Only 3.5% of abortion patients have had abortion is painless (85.5%). This data Voluntary and anonymous questioning more than one sexual partner. again supports that abortion patients of 840 abortion patients aged 17-45 was If one looks at the number of children have incomplete and overall incorrect in- conducted at the Research Center of Ma- of abortion patients, the picture is as formation about the danger and possible ternal and Child Health Protection dur- follows: 15.5% had no children, 31% had complications of abortion. ing May 2006-April 2007. Interviews with only one child and more than half had 2 The greater proportion of abortion patients were conducted confidentially, or more children (40.4% had 2 children patients (59.5%) expressed their inten- Karine Georgy in the Republ ic of Armenia Arusta- Okoev myan

tion to use contraceptive methods after mentioned regular as an References their current abortion: 44% opted for indication for EC (again more than one 1. National Statistic Service (Armenia), the condom, 20% preferred the IUD, answer was possible). Ministry of Health (Armenia) and 18% preferred contraceptive pills, 10% ORC Macro. Armenia Demographic decided on rhythm/calendar method, 4% Conclusion and Recommendations and Health Survey 2005.Calverton: on withdrawal, 4% on sterilization and Based on our research and the analysis of National Statistical Service, Ministry 2% chose spermicides. Only 4% could the results the following conclusions and of Health and ORC Macro; 2006. not decide on future use of contracep- recommendations can be made about the 2. Bastianelli C, Farris M, Benagiano tive method. A high proportion of all situation in Armenia regarding EC. G. Emergency contraception. Eur abortion patients (70.3%) appreciated the J Contracept Reprod Health Care. protection offered by the contraceptive 1. There is a gap between theoretical 2008;13(1):9-16. method. 53.1% stated that contraceptives knowledge and practical implementa- 3. von Hertzen H, Piaggio G, Ding J have no negative effect on health. Only tion of contraceptives among abor- et al. Low dose mifepristone and 9.3% of the patients had no opinion on tion patients. two regimens of levonorgestrel for this matter (again more than one answer 2. The knowledge and experience in the emergency contraception: a WHO was possible). proper use of contraception methods multicentre randomized trial. Lancet It was observed, that a great propor- are insufficient – a fact that suggests 2002; 360:1803-10. tion of abortion patients (70.2%) had no we need to pay closer attention to the 4. WHO. Medical eligibility criteria information on EC and only 29.8% of educational aspects of this problem. for contraceptive use. Third edition. abortion patients had heard about EC. Our data also supports that there Geneva: WHO; 2004. We performed an evaluation based on the is a great need for health education 5. WHO. Selected practice recommenda- responses received from abortion patients among women. tions for contraceptive use. Second relating the source of their information 3. Wide health educational campaigns edition. Geneva:WHO; 2005. on EC. 54.4% of abortion patients who through the use of TV, Radio and had information on EC received that mass media could greatly improve the information from books and 31.8% from “scarce informational situation” of Georgy Okoev friends. Only 18.2% mentioned their the population on proper and effec- Director, WHO Collaborating Centre health providers as a source of informa- tive use of EC as a means of avoiding on Human Reproduction, tion on EC. 68% of abortion patients, unwanted pregnancies. Research Centre of Maternal and Child who had received information on EC, 4. We should intensify our health Health Protection, Yerevan, Republic believed that they had enough knowledge education efforts to let our patients of Armenia on EC, although during the interview know more about EC, its effectiveness [email protected] it became evident that their knowledge and efficiency, as well as, EC’s role in could not be assessed as complete. Some preserving women’s health through Karine Arustamyan study participants, who considered their considerably decreasing the number Deputy Director on Research, knowledge on EC as complete, men- of unwanted pregnancies. Head of Non Surgical Gynecologic tioned withdrawal (8%), rhythm/calendar 5. We need to greatly improve our Department, method (12%) and spermicides (16%) educational efforts in the field of EC Research Centre of Maternal and 15 as methods of EC. 12 patients even men- and provide our patients with proper Child Health Protection, tioned vaginal douching as an appropri- and accurate information, since only Yerevan, Republic of Armenia [email protected]) ate EC method. 18.2% of health providers were listed The majority of abortion patients as sources of information. (48%), who had information on EC, mentioned damage of the condom as an indication for EC use. Other indications for EC use included: unprotected inter- course (36%), (28%), unplanned intercourse (24%) and missed contracep- tive pills (16%). Some patients (4%), who mentioned that they had information on EC, could not mention any indications for EC use. Another 4% of patients even

No.67 - 2008 Trends in sexual behaviour among secondary- school students in Slovenia

As a WHO Collaborating Centre part of our mandate has been to perform research on sexual behaviour among students in Slovenia. Pregnancy rates among adolescents in Slovenia declined from 61/1000 women aged 15-19 years in 1981 (delivery rate 37/1000, abortion rate 24/1000) to 12/1000 in 2006 (delivery rate 5/1000, abortion rate 7/1000) (1). Our representative studies in 1996 (2) and 2004 (3) revealed interesting changes in sexual behaviour and contraceptive use that occurred among secondary- school students in Slovenia in between.

Results abortion statistics, where the decline in graders and 4% of 3rd graders practiced In the 2004 study, 2380 secondary-school abortion rates in the same period was withdrawal and 1% (both grades) used students were enrolled: 1285 1st grade obvious in 17-19 years old adolescents, other methods. 1% (both grades) used students (average age: 15.4 ± 0.7 years) but not in 15-16-year old adolescents, emergency contraception and 8% of 1st and 1095 3rd grade students (average age where, on the contrary, a slight increase graders and 7% of 3rd graders used no 17.4 ± 0.7 years). The study revealed that of abortion rates was seen in the last method at all. 88% of 1st graders and 92% of 3rd grad- years (3). This clearly shows that our A comparison of the contraceptive use ers had experienced falling in love; 66% adolescents, regarding early sexual debut, at the last among 3rd of 1st graders and 82% of 3rd graders had are not empowered enough to cope with graders, aged 17 years, between 1996 and been on a date; 76% of 1st graders and the responsibility and consequences of in 2004 showed a marked increase in pill 87% of 3rd graders had been kissing; 62% early sexual debut. Early sexual debut and use, and a marked decrease in unprotect- of 1st graders and 78% of 3rd graders had unwanted pregnancies could be a reflec- ed intercouse (use of no methods) and in experienced caressing; and 36% of 1st tion of the lack of knowledge and skills condom use (Figure 2). graders and 61% of 3rd graders had tried regarding sexual behaviour and contra- Despite the increased early sexual petting. Almost one quarter (23%) of 1st ceptive use; unfortunately, activity among Slovenian secondary- graders (24% of boys and 21% of girls) is not available or mandatory either in school students, the increased use of and 53 % of 3rd graders (52% of boys primary or in secondary-schools in Slov- reliable contraception is noticeable. In and 54% of girls) had experienced sexual enia. However, in the last decade, teachers 1996 14% of sexually active 17-year-old intercourse. and gynaecologists have put much effort students were using the pill and in 2004 A comparison between the results of into integrating sex education into the 32%. The main reason for the increased the studies on sexual activity of second- school curriculum. Unfortunately, the pill use among adolescents in Slovenia ary-school students (3rd graders, aged issue has not yet been recognized to be of is, in our opinion, the rising awareness, 17 years) carried out in 1996 and in 2004 national importance or priority. increasing knowledge and a changed at- showed that some changes in intimate Regarding contraceptive use our study titude of gynaecologists towards the pill, communication regarding sexual behav- revealed that at the first sexual intercourse which is reflected in changing practice of iour had occurred in between. In 1996 the 74% of 1st graders and 76% of 3rd grad- pill prescription to adolescents. The pill students’ first fell in love, then went on ers used a condom; 6% of 1st graders and is covered by the general health insurance 16 a date, later started kissing and caress- 7% of 3rd graders used the pill; 4% of for all insured women and the contracep- ing; petting was the next step, and sexual 1st graders and 2% of 3rd graders used tive service is accessible through out- intercourse the last (2). In 2004 they a double method (condom and the pill); patient gynaecology clinics. In addition, kissed before they went on a date and on 3% of 1st graders and 4% of 3rd graders gynaecologists have been involved in in- that date they already started caressing; practiced withdrawal; and 2% of both tensified promotion of contraceptive use also petting and sexual intercourse started grades used other methods. 1% (both in journals and other lay public media. earlier (Figure 1). grades) used emergency contraception It is also very important that the per- We observed an increase in the (EC) and 9% of 1st graders and 8% of centage of students practicing sex without percentage of sexually active students: 3rd graders used no method at all. At use of any contraceptive decreased from in 1996 38% were sexually active and in the last sexual intercourse, 65% of 1st 19% to 7%. Concomitantly, the use of 2004 53%. The age at which one half of graders and 50% of 3rd graders used a a condom at the last sexual intercourse Slovenian students experienced the first condom; 11% of 1st graders and 32% of decreased from 60% in 1996 to 50% in sexual intercourse decreased from 18.5 3rd graders used the pill; 6% of 1st grad- 2004. Additionally, the study revealed a years to 17 years. This decline in age at ers and 4% of 3rd graders used a double very low use of the double method among sexual debut is reflected in the national method (condom and the pill); 3% of 1st secondary-school students in Slovenia; Bojana Pinter

Figure 1: Experience in intimate relationships, 17-year old secondary-school students. References Comparison between representative studies on sexual behaviour of secondary-school 1. Inštitut za varovanje zdravja Republike students in Slovenia in 1996 and 2004. Slovenije. Informacijski sistem sprem- ljanja fetalnih smrti v Sloveniji 2006. 1996 2004 100 Ljubljana: Inštitut za varovanje zdravja

90 94 92 Republike Slovenije, 2007 (Institute of 87 Public Health of the Republic of Slovenia. 80 82 80 78 70 National Information System of Slov- 70 69 enia Concerning Fetal Deaths in 2006. 60 81 50 53 Ljubljana: Institute of Public Health of

40 43 the Republic of Slovenia; 2007). 38 30 2. Pinter B, Tomori M. Sexual behaviour of secondary-school students in Slov- 20 enia. Eur J Contracept Reprod Health 10 Care 2000; 5:71-6. 0 being in love dating kissing caressing petting sex.inter. 3. Barbara Mihevc Ponikvar. Splavi (fetalne smrti). Ljubljana: Inštitut za varovanje zdravja, 2006 (Abortions – Fe- Figure 2: Contraceptive use among sexually active secondary-school students aged tal Deaths. Ljubljana: Institute of Public 17 years at the last sexual intercourse. Comparison between representative studies on sexual behaviour of secondary-school students in Slovenia in 1996 and 2004. Health of the Republic of Slovenia, 2006). Accessed on 17 January 2008 at: http://www.ivz.si/index.php?akcija=nov 1996 2004 70 ica&n=1049) Legend: 4. Pinter B, Čeh F, Pretnar-Darovec A, 60 EC – emergency contraception 60 Vrtačnik-Bokal E, Vogler A, Drobnič S. O 50 50 vama: varna izbira za odgovorno spol-

40 nost. Didaktično metodični priročnik za učitelje. Ljubljana: Schering, Podružnica 30 32 za Slovenijo, 2004 (About You Two: Safe Decision on Responsible Sexuality. 20 19 Didactic and Methodological Manual for 14 10 Teachers. Ljubljana: Schering, Office for 7 0 4 4 4 1 1 1 1 1 1 Slovenia; 2004). 0 condom pills double method withdrawal periodic abst. EC other no method 5. Pinter B, Čeh F, Pretnar-Darovec A, Vrtačnik-Bokal E, Vogler A, Drobnič S. only 4% in 2004. Indeed, the low condom by The National Educational Institute of O vama : varna izbira za odgovorno use and low double method use observed Slovenia and has, until now, been financed spolnost. Brošura za mladostnike. point to the necessity of more vigorous with the support from a pharmaceuti- Ljubljana: Schering, Podružnica za promotion of these two methods in Slov- cal company. This year the printing costs Slovenijo, 2004 (About You Two: Safe 17 enia. Such a promotion could be easily will be partially covered by The National Decision on Responsible Sexuality. Book- reached by introducing sex education to Educational Institute of Slovenia. We hope let for Adolescents. Ljubljana: Schering, primary and secondary schools. that in the near future the necessity of long- Office for Slovenia; 2004). term and comprehensive sex education Conclusion will finally be recognized by the Ministry Bojana Pinter, MD, PhD With the aim to fill the gaps, to some of School and Sport and the Ministry of Assistant Professor extent, in the systemic lack of sex educa- Health. Until such time we will continue Department of Obstetrics and Gynaecology tion the gynaecologists from our WHO to prioritize and advocate for research in WHO Collaborating Centre for Re- Collaborating Centre, in 2004, published sexual and reproductive health of adoles- search and Training in Reproductive a handbook for teachers (4) on sex educa- cent populations in Slovenia, especially in Health tion and a booklet (5) for adolescents. the area of sex education. University Medical Centre Ljubljana These tools have since been distributed Ljubljana, Slovenia every year to all 1st grade students in [email protected] Slovenia for free. The project was endorsed

No.61No.67 - - 2005 2008 Using research to help influence policy and enhance services

The Hacettepe Public Health Department was first designated in 1978 as a WHO Collaborating Center (CC) for Family Planning. This designation has been renewed several times, most recently in 2004. Thus, it is perhaps one of the oldest CC in the European Region which collaborates with the WHO headquarters in Geneva, and with the WHO Regional Office for Europe in Copenhagen, in research and training activities for the development and assessment of appropriate technologies and guidelines related to the WHO programmes and initiatives on sexual and reproductive health (SRH), in- cluding family planning.

The scope of work of the CC has the CC uses research results as a means to expanded its perspectives and capaci- inform policy makers about the current ties since its first designation. Originally situation and advocate for improvements started as a CC solely for family plan- in SRH. The usual strategy of the CC ning, over the years it has developed a is to move from research to practice, so more comprehensive approach to SRH. that based on the research results, the Currently, within the field of SRH, the CC CC designs and implements interven- focuses on research training and support tion programmes and follow-up of those activities across a broad range of topics: programmes specific to the topic, region sexually transmitted infections, youth and context of Turkey. friendly health services and adolescent The CC also carries out activities on SRH, services, abortions, advocacy for change in policy to remove maternal mortality, contraception and the barriers and improve the provision many topics related to gender and health, and quality of SRH services. Research such as integration of gender perspective results in the forms of publications, into SRH policies, identification of gender kick-off meetings, expert meetings, and sensitive health indicators and identifica- dissemination meetings are widely shared tion and prevention of gender discrimi- for advocacy purposes. Last but not least, nation in SRH. Mechanisms have been the CC functions as a local, national and established for efficient and close collabo- international reference center and con- ration in training and research activities ducts consultancy activities with different on SRH and family planning with local, bodies to increase capacities mutually. national and international health agencies 18 (WHO, UNFPA, Population Council, Impact AVSC, JHPIEGO, Gynuity), institutions So far the CC has carried out sev- and non-governmental organizations to eral projects that have made significant achieve its goals and to use the resources impact on a national basis. Some of the effectively. examples are presented briefly below.

Research Activities Unsafe abortion and family plan- The CC mainly conducts research on ning services priority SRH topics, many of which In order to prevent maternal deaths due were mentioned above. The CC employs to unsafe abortion and increase family research strategically as an instrument to planning practices in Turkey, a series of draw attention of relevant parties (such operational research were carried out as the community, service providers, ad- by the CC with the collaboration of the ministrators and decision makers) to the WHO Health Research Programme. significant SRH issues in Turkey. Thus, Based on the results, the old population Hacettepe University Medical Faculty Department of Public Health, World Health Ayse Organization Collaborating Centre for Research and Training in the Service Aspects Akin of Reproductive Health and Family Planning

planning law was changed and non-physi- hanced the quality of services in Turkey. Regional Advisory Panel cians were authorized to insert intrauter- This project also provided the basis for Meeting in Turkey ine devices (IUD), abortion was legalized training skills curriculum development in and general practitioners were authorized several of the medical schools. ligation and injectable and implantable to terminate pregnancies. The impact of contraceptives in Turkey have resulted in this change and new law was very signifi- Understanding SRH of adolescents their introduction into the national fam- cant; the prevalence of IUD use doubled The WHO Health Research Programme ily planning programmes and availability in 5 years, maternal mortalities due to collaborative study on “The Influential to the Turkish population. unsafe abortion almost disappeared and Factors of Sexual and Reproductive a substantial decrease in unmet needs Health of Adolescents/Young People in Conclusion in family planning occured. Despite this Turkey” has been a pioneer in under- It has been the Hacettepe CC experi- success, the unmet need for abortion standing the SRH situation of adolescents ence that through their research, work services is still high in Turkey. Thus, the and young people in Turkey. The research and knowledge of national needs and CC has been actively involved in research showed that young people do not have the local situation, the WHO CC’s can which demonstrates the acceptabillity and sufficient knowledge of SRH and a great impact significantly on the national SRH safety of medical abortion. Two major majority had never used any SRH serv- policies and practices. Given this impact studies, carried out in collaboration with ices, either from the university or from at the country level, if they are used more the Gynuity Health Project, have been outside service units. It also provided effectively CC’s can and will contribute very encouraging. These result have been important insight into the worlds of the to the global and regional SRH objec- analysed and shared with the Ministry young people in Turkey and the kinds of tives as well. However, to increase their of Health to help move forward with the services that they wish for themselves. effectiveness more communications and required policy changes and action. Based on the results of this study, a collaborations are needed across various model “Youth Friendly SRH Services” was disciplines, sectors and organizations. Improving medical education in developed at the medico-social centres of 19 SRH the universities. At present this model is With the collaboration of the JHPIEGO present in 13 universities in Turkey which Prof. Dr. Ayse Akin the project “Strengthening Undergradu- increased the overall utilization of the Head of the WHO Collaborating ate Family Planning Education in Medical University Health Centres by the students. Centre, Turkey Schools in Turkey” was carried out. This [email protected] project was revolutionary in Turkey from Promoting new technologies for several aspects; by allowing pre-gradua- fertility regulation tion certification of medical students, the Presently and in the past, the CC has been burden on the Ministry of Health (which a pioneer in introducing new technolo- had limited resources) to train service gies for fertility regulation in Turkey. Ini- providers has decreased; and the stand- tial studies on efficacy and safety of man- ardization of all service procedures, use of ual vacuum aspiration as an atraumatic a humanistic approach and integration of technique for pregnancy termination, STI screening and prevention greatly en- the mini-laparotomy technique for tubal

No.61No.67 -- 20052008 Working towards better youth sex education in Europe

ermany’s Federal Centre for include local conversation and discus- boys and 75% of girls had had some sex Health Education (BZgA) has sion opportunities and the provision of education from their . The situa- Gbeen a WHO Collaborating training for those with contact to young tion is quite different among young peo- Centre for Sexual and Reproductive people, such as school and kindergarten ple with a migration background. Of this Health since 2003. Within this field, teachers, social workers and parents. This group as a whole, only 41% of girls and BZgA supports the WHO programme to promotes curriculum development at 33% of boys said that sex or pregnancy intensify co-operation with the countries school and university level, as well as, the were even mentioned at home. Amongst of central and eastern Europe. The first out-of-school sphere. Turkish adolescents, these figures are one- phase of collaboration between the WHO The sex-education measures and media third lower overall. Important reference and BZgA focuses on young people. In- are scientifically based from the outset. people for all adolescents are friends of creasing mobility through the opening of Key concepts of sex education take into the same sex, and siblings. Sex educa- national frontiers makes young people a account gender, education and social tion at home among all young people is particularly important target group in re- situation, lifestyle, and dependent on the level of education. gional and national strategies for improv- cultural background. ing sexual and reproductive health. In Sex education in schools: this context the BZgA, together with the The scientific foundation study: widespread and well-received WHO Regional Office for Europe, held an youth sexuality School lessons are the source of knowl- international conference on the subject A central study in the field of sex educa- edge on sex and contraception most of “Sex education for Young People in a tion in the Federal Republic of Germany frequently named by boys, and second- Multicultural Europe” in November 2006. is the representative survey of youth most frequently by girls. Teachers are of Its aim was the promotion of learning sexuality (3). For the past 25 years, this above-average importance in particular processes, networking and co-operation study has been analysing the attitudes and for young people with a migration back- in the European Region. Three main behaviours of German 14–17-year-olds ground, who can only talk to their parents topics were considered: multiculturalism, of both sexes (n = 2500) studying, among on sexual matters to a limited degree. In the implementation of life-competence other things, sex education in the family the Federal Republic of Germany, nine approaches in sex education, and quality and at school, forms of sexual contact, out of ten boys and girls come into con- management (1). knowledge of contraceptive methods tact with sex education at school between and their contraceptive behaviour. The the ages of 14 and 17. Sex education: most recent survey, carried out in 2005, a national responsibility additionally included young people with Inadequate information on sexual In the Federal Republic of Germany, sex a migration background (n = 674). The matters education and family planning are seen results of the study show clear trends, In general, girls and boys from migrant as national responsibilities. Sex educa- point to deficits in sex education, indicate families feel less well informed than tion in schools is legally regulated at the how certain media and people can be young people with a German back- federal-state level, and is implemented in used to access the young people, sketch ground, especially in the following areas schools of all types. In 1992 the Preg- their sexual and contraceptive behaviour, of knowledge: the female body, contra- nant Women and Family Assistance Law analyse their knowledge and use of BZgA ception, tenderness and love. requested BZgA prepare and disseminate sex-education materials, and describe 20 sex-education and family-planning media areas of inadequate knowledge. The find- First sexual intercourse and measures on a nationwide basis. The ings of the study are analysed with respect 12% of girls and 10% of boys have sexual BZgA develops quality-assured concepts to the media and measures of the BZgA, intercourse for the first time at the age of and target-group-specific media and and the results of continuous feedback 14 or earlier. Overall, 39% of all German measures on sex education with the goal will also be incorporated into the design girls and 33% of all German boys be- of preventing unplanned and unwanted of the next representative survey, due to tween the ages of 14 and 17 report having pregnancy (2). In the process it works be held in 2009. had sexual intercourse at least once. closely together with the federal state and By comparison, a total of 26% of other co-operation partners (specialist Selected results of the 2005 survey: girls and 44% of boys with a migration associations, NGOs and academic institu- sex education at home and in the background report experience of sexual tions). In addition to providing other family intercourse between the ages of 14-17. services the BZgA develops and promotes In 1980 according to the survey, less than 14-17 year old girls of Muslim back- print media, internet services and audio- half of German boys received any sex ground are far more reticent than others visual media in the field of sex education education at home, and of those who had, with sexual contacts of any kind. Among for 14–17-year-olds and young adults. only a quarter received any more than a these girls, the argument “I don’t think Other personal communication services one time conversation. In 2005 65% of sex before is right” is the reason Angelika Heßling

most often given (60%) alongside the fear Figure 1 Contraceptive behaviour: first intercourse intercourse time. Trend: Girls of their parents’ reaction. As a rule, they No contraceptive Condom The pill Chemical contraceptive Other No contraceptive Condom The pill Chemical contraceptive Other first have sexual intercourse with a steady 1980 20 32 18 21 17 1980 20 32 18 21 17 partner. This is also true of German girls, 1994 9 63 27 3 13 German boys, and girls with a migration 1994 9 63 27 3 13 1996 13 61 31 2 7 background. In the case of boys with a 1996 13 61 31 2 7 1998 11 68 31 2 6 migration background more than one- 1998 11 68 31 2 6 third knew the with whom they first 2001 12 63 33 1 6 2001 12 63 33 1 6 had sexual intercourse fleetingly, or not 2005 9 71 35 2 5 2005 9 71 35 2 5 % at all. This has an unfavourable effect on 0 20 40 60 80 0 20 40 60 80 0 20 40 60 80 0 20 40 60 80 0 20 40 60 80 % 0 20 40 60 80 0 20 40 60 80 0 20 40 60 80 0 20 40 60 80 0 20 40 60 80 their contraceptive behaviour.

Figure 2 Contraceptive behaviour: first intercourse intercourse time. Trend: Boys Contraception for first intercourse: condom is option number one No contraceptive Condom The pill Chemical contraceptive Other (Figures 1 and 2) No contraceptive Condom The pill Chemical contraceptive Other 1980 29 28 11 16 20 1980 29 28 11 16 20 The great majority of German youth be- 1994 15 56 25 2 9 have very responsibly when they first have 1994 15 56 25 2 9 1996 12 66 26 3 8 sexual intercourse: 71% of girls and 66% 1996 12 66 26 3 8 1998 16 55 31 0 12 of boys said a condom was used and 35% 1998 16 55 31 0 12 and 37% said the pill was used (instead 2001 15 65 26 1 11 2001 15 65 26 1 11 of, or additionally). 2005 15 66 37 2 4 2005 15 66 37 2 4 % In 1980 32% of girls and 28% of boys 0 20 40 60 80 0 20 40 60 80 0 20 40 60 80 0 20 40 60 80 0 20 40 60 80 % said a condom was used the first time 0 20 40 60 80 0 20 40 60 80 0 20 40 60 80 0 20 40 60 80 0 20 40 60 80 they had intercourse. By 2005 condom ity at home by using the internet at school ments. Such questions need to relate to use had more than doubled. In the con- and in internet cafés. Girls with a migra- not only the expectations of the different text of AIDS prevention and sex educa- tion background do not manage this to target groups, but also the differentiated tion campaigns the number of those the same extent. access routes and methods. using no contraception at first sexual intercourse has halved since 1980; it is Conclusions References now 9% of girls and 15% of boys. The study shows a clear relationship 1. BZgA/WHO Conference on Youth Sex Young people with a migration back- between sex-education at home and re- Education in a Multicultural Europe, ground are much more likely to not use sponsible contraceptive behaviour. Young Cologne, November 2006 contraception, or to use unsafe methods, people with a migration background have Country Papers on Youth Sex Educa- when they first have intercourse. 34% of certain obvious deficits when it comes tion in Europe. Available at order@ boys and 19% of girls with a migration to sex and contraceptive education at bzga.de. background used no contraception the home. There is thus a need to find other 2. General Concept for Sex Education of the first time they had intercourse. access routes for these youth. Alternative BZgA in cooperation with the Federal routes for all youth include: sex education States Use of media in school (which in Germany has a high Concept Sex Education for Youths. Avail- 21 In order to analyse and improve the compensatory value), the internet (an im- able at [email protected] young people’s access to sex-education portant medium for young people where 3. Youth Sexuality – Representative Survey media, the study asked particular ques- sex education is concerned according to of 14 to 17-Year-Olds and their Parents tions about their media-use behaviour. the survey) and doctors and counselling 2006 in “Representative Surveys Research In general it appears that girls prefer centres (also often accepted by young and Practice of Sex Education and Fam- print media, while boys favour audio- people as sources of information). ily Planning BZgA, 2006”. visual media. The results also show that Migration represents a particular chal- the popularity of the internet as a sex- lenge for those working in both sex edu- Angelika Heßling education medium is not dependent on cation and family-planning. The growth BZgA, Cologne, Germany nationality. of immigrant populations in many EU WHO Collaborating Centre for For young people with a migration Member States requires ongoing consid- Sexual and Reproductive Health [email protected] background there is, however, not much eration in research and practice. Research chance of using the internet at home. in and development of sex-education Older boys with a migration background measures in future needs to include mi- compensate for the non-existent possibil- gration-sensitive questions and require-

No.67No.61 - - 2008 2005

How research on sexual and gender based violence (SGBV) can make a difference

n 2007 staff from the International from the first EC-Daphne Programme on • the lack of strong partnerships Centre for Reproductive Health Violence against Women and Children. between different levels: policy level, I(ICRH), a WHO Collaborating The project led to practical recommen- research and community level; Centre, gathered in Belgium to discuss dations for European policy makers on • the inaccurate knowledge on the the impact of research on policy mak- the eradication of FGM in Europe with magnitude of the problem and; ing, and how to bridge the gap between regard to legislation, education and • the limited funding available. research and policy. This research is based prevention, and health issues. ICRH on the principle that research needs to also implemented several other projects IPV and role of health care workers be applied and operational. The ICRH between 2000- 2007 including: in Belgium: input for the develop- research unit is a multidisciplinary team 1. the development of frameworks for ment of national guidelines on prevention of violence among preg- of scientific collaborators who are actively training of health professionals and nant women involved in research, services delivery and guidelines for the care of women with training in the field of SGBV. FGM in the EU; In 2004 the Belgian National Organiza- 2. a research agenda with priorities for tion of Family Physicians developed a The objectives of ICRH include: research on FGM in Europe; consensus document on the role of the • to conduct multi-disciplinary 3. the foundation of the European Net- family physician in detecting and dealing research into SGBV, focusing on work for the Prevention of Harmful with IPV. This consensus is a good and vulnerable groups, within the broader Traditional Practices, in particular practical tool; however there are no rec- context of SRH and rights; FGM (EuroNet-FGM, 2002) and; ommendations about pregnant women • to enhance national and international 4. an in-depth study on the implemen- and IPV. awareness raising and sensitization on tation of laws regarding FGM in the ICRH and the Department of Obstet- SGBV; EU (2004, 2007). rics and Gyneacology at Ghent University • to contribute to the development of The impact of this research resulted in the conducted 2 studies in the area of IPV. policies, guidelines and tools aimed at following milestones: The first one was a cross-sectional survey the prevention of SGBV and quality 1. The expert meeting in the European study among pregnant women attending aid for victims; Parliament to develop a Joint Agenda antenatal care (2). The other study was a • to train stakeholders involved in for Action (2001). This Agenda was Knowledge Attitude Practice study among prevention of and response to SGBV; presented to the EC, European Parlia- gynaecologists to identify potential bar- • to support concrete interventions in ment and UN bodies. That same year, riers to IPV screening in a context where the field aimed at prevention and aid; ICRH also contributed to the so- no guidelines are in place (3). • to build partnerships with research called “Valencia Report” and ‘Resolu- These studies yielded the first data on institutions, international agencies, tion on FGM’ adopted in September IPV in pregnancy in Belgium. The most public authorities and non-govern- 2001. striking observation was that women mental organizations in the field of 2. The creation of EuroNet-FGM; This rarely disclose abuse to the health care SGBV. European-wide network connects 32 worker, unless directly asked about it. member organizations (mostly NGOs Routine screening was found to be largely Case Studies and community based organizations) acceptable to the women surveyed, while To illustrate the impact and challenges of working on the prevention of FGM in one of the main barriers against screening 22 our research on policies regarding SGBV, more than 13 EU countries. for gynaecologists was the fear of offend- this paper highlights 3 case studies of our 3. Invitation of ICRH to expert group ing patients. work: female genital mutilation (FGM) meetings for developing a national With these specific Belgian data, ICRH among migrant women in Europe, plan of action to prevent FGM in is involved in development of professional intimate partner violence (IPV) among Belgium. guidelines for Obstetricians-Gynaecolo- pregnant women in Belgium and SGBV These projects played an important role gists in Belgium, especially for violence in against refugees in Europe. in placing FGM on the national and pregnancy. The development of screening international agenda. However, critical tools and formal referral systems will be FGM: impact on policy making in issues with regard to the elimination of part of this professional guideline. Europe (1) FGM in Europe remain: For over a decade ICRH has assessed the • the apparent lack of coordination Prevention of SGBV against refu- magnitude of FGM among migrant wom- between the different EC budget lines gees in Europe: the importance of a en living in Europe. The kick-off project that finance research and interven- participatory approach in research to policy development occurred in 1998, when the European tions on FGM; Commission (EC) requested data on the • the lack of an integrated EU policy A recent study used a community-based problem of FGM in Europe, with funds agenda on FGM (1); participatory research approach to Marleen [Patricia Ines Kristien Els Temmer- Claeys] Keygnaert Roelens Leye man

develop a prevention tool and formu- ers, respondents and a large community researchers and NGOs and community late recommendations to prevent SGBV advisory board and focuses on knowledge based organizations. Expectations from against refugees, asylum seekers and transfer, awareness raising and network- both sides have to be defined from the undocumented migrants in Europe. ing in nine languages. In addition policy, beginning. From arrival on European territory structural and service recommendations Finally, research needs to acquire onwards, young female and male refugees, were formulated and presented to a Eu- insight and skills on how policies are de- asylum seekers and undocumented ropean and national policy makers panel veloped. There is a need for an increased migrants are extremely vulnerable to at the EU Seminar “Hidden Violence is a communication between researchers and several types of SGBV. This was one of Silent Rape”, held February 14-15, 2008 policy makers. Innovative, additional the conclusions drawn from the research in Ghent, Belgium. In the mean time measures are needed to provide incentives project “Prevention of SGBV against refu- EN-HERA! “the European Network for for academic staff to communicate and gees in Europe: a participatory approach”, the Promotion of Sexual and Reproduc- collaborate with policy makers. that has been conducted in Belgium, the tive Health & Rights of Refugees and Netherlands and the UK. The aim of the Asylum-Seekers in Europe and beyond” References project was twofold: develop a prevention was founded and is now developing 1. Powell RA, Leye E, Jayakody A et al. tool which can be used by refugees and frameworks of good practices in policy Female genital mutilation, asylum asylum seekers and raise awareness on development and service delivery of SRH seekers and refugees: the need for an this topic through participatory research. for refugees and asylum seekers from a integrated European Union agenda. The research was conducted in close part- participatory approach. Health Policy 2004;70:151-162 nership with 23 community researchers 2. Roelens K, Verstraelen H, Van Eg- and a community advisory board. Recommendations and challenges mond K et al. Disclosure and health- According to the 223 respondents To improve the impact of research on seeking behaviour following intimate participating in the research (refugees, policies, stakeholders need to be carefully partner violence before and during asylum seekers and undocumented identified and involved from the begin- pregnancy in Flanders, Belgium: A migrants from , Afghanistan, the ning. However, it is not always easy to survey surveillance study. Eur J Obst former USSR, Somalia and from Roma achieve this within the limited time avail- Gyn R B 2008; 137(1):37-42. and Kurdish origin), prevention of SGBV able to complete the research. In order 3. Roelens K, Verstraelen H, Van Eg- against refugees, asylum seekers and to have an impact at a specific level, the mond K et al. A knowledge, attitudes, undocumented migrants in Europe can research needs to respond to an expressed and practice survey among obste- be done at 3 levels. On the personal level need, for example by policy makers, as trician-gynaecologists on intimate prevention should focus on behavioural was the case with the research on FGM, or partner violence in Flanders, Belgium. change and on the enhancement of by the communities, as was demonstrated BMC Public Health 2006; 6:238. social capital. On the socially interac- by the participatory research project on 4. Digital version available on www.icrh. tive level, prevention should focus on SGBV among refugees. Challenges that org the enhancement of social capital and remain here are the need to develop joint the access to health care and services. agenda’s for action and the need for a On the societal level, prevention should thorough situation analysis before start- Els Leye,PhD primarily enhance general knowledge of ing the research project. Kristien Roelens, MD, OB/GYN sexual health and awareness of SGBV risk To have an impact at a broader policy Ines Keygnaert, PhD –fellow 23 and preventive factors. Furthermore, the level research should be methodologically [Prof. Patricia Claeys], MD, MPH, PhD overall legislative framework should be sound; credibility and visibility of the Prof. Marleen Temmerman, MD, adapted in order to be more preventive, researcher or the research institution is MPH, OB/GYN, PhD and finally, the system of residence status needed. Correspondance contact Ines. Keyg- and rights should be changed in order to Communicating research results to a [email protected] enhance the refugees, asylum seekers and broad public is another challenge; often undocumented migrants’ possibilities to neither time nor budget are available to enjoy rights and to participate actively in disseminate the results at a larger scale. the host society. The utmost majority of Researchers should define and include a respondents were willing to participate in dissemination strategy in the budget from prevention of SGBV against refugees, asy- the start of the research, in order to dis- lum seekers and undocumented migrants seminate results and broaden the impact in Europe. of their findings. A prevention tool (4) was developed in The impact at community level can be collaboration with community research- improved through collaboration between

No.67 - 2008 CeVEAS: Developing and using guidelines to promote Sexual and reproductive health

Last February the National courses for nurses, midwives, physicians The difficulties in implementing scientific and other health professionals. Examples guidelines are a well known problem, Health Service Centre for of this collaborative work include the and in the last ten years it has been at the the Evaluation of Effective- provision of methodological support centre of the scientific debate. In fact, very to the revision of the “WHO Standards often moving from the best evidence to a ness of Health Care (Ce- on Maternal and Neonatal Care”(1) the better clinical practice is not easy; resist- VEAS) in Modena, Italy, was contribution of reviewing evidence to ance is common and different strategies update the Health Evidence Network on to overcome barriers to change need to be designated a WHO Collabo- effectiveness of antenatal care (2) and re- explored. rating Centre (WHO CC) for viewing and grading the existing evidence The implementation methodology for the WHO Guidelines on Prevention of adopted by CeVEAS, based on broad Evidence Based Research Postpartum Haemorrhage (3) using the scientific literature, includes the follow- Synthesis and Guideline GRADE methodology (4, 5). ing: the specification and analysis of the barriers and facilitators, the choice of Development in Reproduc- Evidence based guideline develop- specific interventions needed to remove tive Health. ment: GRADE methodology or overcome barriers and/or to include One of the pivotal roles of the Collaborat- the facilitating factors identified, and the As the name suggests, the CeVEAS will ing Centre is to provide methodological evaluation of the results. contribute to WHO activities by produc- support in the development of recom- As an example of implementation, ing and disseminating the best available mendations based on systematic review in 2005-2006, using the elements of evidence on effective interventions to of the evidence. This aspect of CeVEAS’ the above described framework, our increase and protect women’s sexual and role was emphasized in 2007 via the col- institution developed an implementation reproductive health, with particular focus laboration with the working group for the model for the guidelines for breastfeeding on women in the reproductive age group. definition of the minimal criteria for the promotion in Italy. The project was car- The new WHO CC will focus on: production of guidelines at WHO to up- ried on by a group of health professionals • collection and synthesis of the best date the “WHO Handbook for guideline from Local Health Authorities of Emilia- evidence from scientific literature for development”. Romagna region and from experts of the development of guidelines; Such methodological support will in- CeVEAS, within a programme supported • development of models to facilitate clude facing the challenge of introducing by the Emilia-Romagna Regional Health the implementation of the guidelines GRADE methodology to the development Authority (7). in clinical practice, taking into con- of guidelines for reproductive health Briefly, the project provided 3 tools (at sideration the different local settings; (GRADE methodology has been already the moment available only in Italian) to • developing tools for sharing evidence adopted by WHO for guidelines on other health professionals: based knowledge with health profes- issues). Dr Quazi Monirul Islam, Direc- 1. a manual with the recommendations sionals, women and communities; tor of the WHO Department of Making on breastfeeding promotion based on • supporting the drug evaluations Pregnancy Safer, has recently underlined the best available evidence; for WHO Essential List, the importance of adopting a rigorous 2. software (HEAVyBASE) for collecting including specific drugs of interest in evidence based process for the produc- and analysing data of exclusive breast- 24 reproductive health. tion of the guideline on Prevention of feeding rates within the local context. Postpartum Haemorrhage (6). A careful analysis of the local context A collaboration dating back a few Briefly, GRADE methodology uses a is essential for identifying barriers years systematic evaluation of the methodo- and facilitators and for selecting the Since the year 2000, CeVEAS has been logical quality of the evidence and an most appropriate recommendations working together with the WHO on estimate of the balance between benefits to be implemented in the local con- projects concerning maternal and neo- and harms of the health interventions as- text; natal care. Specific collaborations with sessed. This then helps authors of guide- 3. a second type of software, (PRIMA), both the WHO headquarters in Geneva lines and protocols (researcher, clinician that included a list of possible solu- and the WHO Regional Office for Europe or policy maker) to base recommenda- tions that may be used (for every (Making Pregnancy Safer, Reproductive tions on evidence that has been rigorously recommendation there is a list of Health and Research, Health Evidence assessed. possible barriers and hypothetical Network) have aimed at facilitating the solutions) to help guide the produc- development of practice guidelines and How to implement a set of recom- tion of the local implementation plan. protocols and at organizing training mendations

National Health Services Centre for the Evaluation of Effectiveness of Health Case (Ceveas), WHO Collaborating Centre for Evidence Based Research Synthises and Guideline Development in Reproductive Health

By using this specific type of framework, ing and curricula. A similar activity was Grading evidence and recommenda- it was and is easier to define a local imple- developed in 2007 in Georgia with Tbilisi tions. Health Res Policy Syst. 2006; mentation plan for breastfeeding promo- University. This partnership has been suc- 4:21 tion in the Emilia- Romagna region. It cessful in helping to improve sexual and 5. GRADE Working Group website. is possible to apply this implementation reproductive health, especially maternal URL: http://www.gradeworking- model to other topics (such as caesarean and newborn health, through integration group.org/index.htm section rate reduction) and also to other of evidence based guidelines into clinical 6. Making Pregnancy Safer. A newsletter languages (it could easily be translated work . of worldwide activity. WHO. April into English). 2007. Issue 4. Conclusion 7. Allattamento al seno. Strumenti per Knowledge transfer project It is our belief that sound methodologi- facilitare il cambiamento delle pratiche A communication project of knowledge cal assessment and evaluation of new or assistenziali. Bologna: Regione Emilia sharing is also being implemented. The exisiting research, data and best practice Romagna, 2005. URL: http://www. idea is based on the creation of a weekly is essential to the development of good saperidoc.it/str_5.html on-line newsletter which includes the evidence based guidelines, knowledge summary of new relevant and valid transfer and implementation of guide- papers on reproductive health. The news- lines. By striving to share and produce the Vittorio Basevi letter will be published on the website of best available evidence on women’s health MD, PhD, Obstetrics and Gynaecol- SaPeRiDoc (http://www.saperidoc.it), an the Collaborating Centre, and its work, ogy “evidence based” website developed with allows health professionals to access in- Dante Baronciani the support of Emilia-Romagna region. struments and information to establish a MD, Neonatology The website is written in Italian language better communication with their patients Simona Di Mario, MD, MPH, Pediat- for health professionals working in the and to improve the overall quality of rics field of women’s and infants’ health. The the care provided. In addition, this same website, operative since 2001, provides a information can provide policy makers Giulio Formoso summary of updated evidence; every day with the tools and the knowledge needed MPharm, MPH, Epidemiology about 2000 single users “surf” SaPeRiDoc. to choose priorities and to increase the ef- Gianfranco Gori, MD, Obstetrics and By June 2008 the SaPeRiDoc website will fectiveness of the organization within the Gynaecology also have an English forum dedicated to health sector they are working in. the newsletter available on the website. Barbara Paltrinieri In addition, there are web pages and References MSC, PhD, Science Communication Expert leaflets addressing women’s and com- 1. Department of Making Pregnancy munities’ information needs. These sites Safer, WHO. Standards for Mater- Daniela Spettoli contain the same information given to nal and Neonatal Care. Geneva: MD, Obstetrics and Gynaecology professionals but with a different lan- WHO:,2006. URL: http://www.who. Nicola Magrini, MD, Clinical pharma- guage and editorial format. int/making_pregnancy_safer/publica- cist, Director tions/standards/en/index.html Correspondance contact v.basevi@ Training courses in evidence based 2. Health Evidence Network, WHO. ausl.mo.it maternal health What is the effectiveness of antena- 25 As previously done, CeVEAS will con- tal care? (Supplement). Geneva: tinue to collaborate with specific WHO WHO; 2005. URL: http://www.euro. training courses in eastern European and who.int/HEN/Syntheses/antenatal- African countries for midwives, physi- supp/20051219_11 cians and obstetricians on data collec- 3. Department of Making Pregnancy tion, basic epidemiology and evidence Safer, WHO. WHO Recommenda- based information retrieval, and to tions for the Prevention of Postpar- promote research relevant for low and tum Haemorrhage. Geneva: WHO; middle income countries. CeVEAS will 2007. URL: http://whqlibdoc.who. also support the development of col- int/hq/2007/WHO_MPS_07.06_eng. laboration with Universities in eastern pdf European countries to include contents 4. Schünemann HJ, Fretheim A, Oxman of the effective perinatal care of Making AD. Improving the use of research Pregnancy Safer in pre-service train- evidence in guideline development:

No.67 - 2008 Improving the reproductive health of men WHO Collaborating Centre for Male Reproduction: The Institute of Reproductive of the University of Münster, Münster, Germany

The Institute of (IRM) in Münster is the only WHO Collaborating Centre for Male Reproduction and it broadcasts its research information to wider audiences by way of publications and presentations at international scientific meetings. Currently, far more attention is given to women’s reproductive health than that of men, but several gender main- streaming policies and the increasingly large population of ageing men have prompted a positive attitude towards male reproductive health.

Two main reproductive issues concerning thus share the contraceptive burden with the male partner represent two sides of their partners. one coin: fertility and . Whereas fertile men generally do not approach in- Activities fertility clinics (except perhaps as semen These problems set the stage for the donors before vasectomy), infertile men activities of the WHO Collaborating Cen- provide a wide spectrum of diseases (of tre for Male Reproduction in Münster. the testes, the epididymides, the accessory These are related to male health issues, sexual glands) that can be studied. How- or , the equivalent for men of ever, providing a therapy is less assuring, gynaecology for women. Andrology deals as ~30 % of men are classified as having with male reproductive function and dys- idiopathic infertility (of no known cause) function; the institute is a referral centre (1). This is frustrating for both the couple for male infertility and hypogonadism wishing to have a child naturally, and the around Germany and its’ clinical staff doctor who can offer only assisted repro- deal with the male partners of infertile ductive technologies (ART) that bypass couples. Once a female factor has been the problem and do not cure the patient. excluded, the cause of infertility in the It is also a challenge for the andrologist to male is sought. Investigation primarily determine the cause of the infertility and involves assessing semen quality and then suggest a rationale therapy. blood hormones. Related basic research The problems associated with over- carried out at the WHO Collaborating population can reduce the quality of life Centre examines ways of improving the of men, women and children the world diagnostic aspects of semen analysis and over, since they often promote disease assessing testicular function, as well as, 26 and hunger in cramped and unsanitary performing clinical trials on hormonal conditions. Voluntary population control, male contraceptives. by means of family planning, can help re- On the diagnostic front, the IRM has duce problems to all, especially to mother compared methods for measuring semen and child, and sensible family planning volume and developed new methods is an acceptable way for partners to show for quantifying low sperm numbers and responsibility to their neighbourhood sperm cell precursors in semen: impor- and other inhabitants of their ecosystem. tant criteria for assessing the fertility Although the brunt of this task cur- potential of a man. The institute has been rently falls on women, for whom female involved in the production of the fifth methods are widespread, several methods edition of the WHO laboratory hand- rely on the male partner’s participation book on semen analysis (2), which should and there is evidence that, given a real op- be the “gold standard” for andrology portunity, men within stable relationships laboratories worldwide. It is also involved would use a “male pill” (or injection) and in the generation, for the first time, of Trevor G. Cooper

true reference limits for the parameters monkeys and men. The pull-out of major References of human semen. They are based on a pharmaceutical companies previously reference group of men whose partners supporting our research in this area will 1. Nieschlag E. Classification of andro- became pregnant within 12 months or be a severe blow unless public funding logical disorders. In: Andrology. Male less, and are being compiled from data can be attracted to it. Other contracep- reproductive health and dysfunction. submitted from competent laboratories tive-directed studies examine the product Eds Nieschlag E & Behre HM, Berlin: using WHO-recommended methods of of the testes: spermatozoa themselves. Springer; 2000. pp. 83-87. analysis. Such values are thus analogous The osmotic challenges that face sperm 2. WHO. WHO laboratory manual for to clinical reference values of serum vari- in the female tract are only now being ap- the examination and processing of hu- ables and can be used in the same way. preciated and spermatozoa must regulate man semen. Fifth edition, in prepara- The IRM runs an external quality control their volume or fail to penetrate cervical tion. Geneva : WHO; 2008. programme for semen analysis in Ger- mucus. We have demonstrated differences 3. Cooper TG, Hellenkemper B, Ni- many, the results of which have shown an in the ability of sperm from fertile men eschlag E. External quality control for improvement in agreement in assessment and patients attending the institute to semen analysis in Germany. J Reprod- between participating laboratories (3). regulate volume; this test may become a uct Med Endocrinol 2007; 4: 331-335. Studies of the pituitary peptide hor- novel diagnostic test of sperm function. mones (LH, FSH) that regulate sperm Although tragic for the couple them- production in the testis have revealed selves, information on the cause of male Dr. Trevor G. Cooper different forms of these genes in infertile infertility could be used in the design of Muenster Collaborative Centre men, indicating a possible genetic cause contraceptives for men. For example, if Institute of Reproductive Medicine of infertility. Other studies have shown the cause of failed volume regulation in [email protected] that the action of androgens in a man some patients is discovered, mimicking depends not only on the steroid levels in the failed osmoregulatory state may be of his blood but the structure of the andro- contraceptive potential. gen receptor, which binds the hormone and initiates virilisation; another genetic Conclusions cause of male infertility. Not only does It is our goal at the IRM, through our diagnosis benefit from such observations, ongoing research activities, to continue but the possibility is also raised of tailor- to address issues that are of importance ing the hormonal therapy to a particular to male sexual and reproductive health. patient, depending on the phenotype of By continuing to focus on issues such as his androgen receptor. On the long-term fertility and infertility, quality assurance therapeutic side, ambitious studies are of semen analysis and male contracep- in progress on the isolation and survival tion, the IRM is helping to contribute to of spermatogonial stem cells in novel the overall well being of not only men culture conditions and after transplanta- and their sexual and reproductive health, tion. These could eventually provide a but also that of their partners and society reserve of germ cells for men with severe at large. 27 testicular damage, or juvenile cancer patients whose testes have been damaged by chemo- or radio-therapy, who may wish to father children after their disease has been cured. One approach to develop a male con- traceptive is to follow the same principle as that of the female pill – steroidal feed- back inhibition of the hypothalamus and pituitary. Interestingly, our research has shown that addition of female hormones (progestins) to the main ingredient of such a male pill, the male hormone testosterone, improves efficacy in both

No.67 - 2008 Sexual and reproductive health research training course: linking sexual and reproductive health agendas with research methodology

Would it help your youth health service to find out if internet and mobile phone use significantly affected the sexual behaviour of adolescents in Switzerland, or Mauritius, and assess how they might evolve in your own country? Or maybe the nurses and midwives in the maternity hospital are coming to you with their concerns about future complications that could be linked to the appearance of cases of female genital mutilation in immigrant populations? Research in sexual and reproductive health (SRH) conducted with sound research methodology can help provide the answers to such questions.

The first joint training initiative between around 1500 Swiss francs while costs for the Geneva Foundation for Medeval living modestly in Geneva can be around Education and Research (GFMER) and 3500 Swiss francs for the duration of the the Department of Reproductive Health course. and Research at the WHO dates back to The five week course on research meth- 1991, with an early focus on European odology is held in the English language at countries in transition. It was formally WHO headquarters and in Geneva Uni- established in 2002. Since 2005 the course versity Medical Faculty. Both institutions also covers the area of sexual health. Our support participants who are carefully current priorities include strengthen- selected health professionals involved ing the integration of sexual health and in research, as well as, providing the reproductive health, making research lecturers. A scientific committee with ad- training more widely available in resource ditional membership from UNFPA, and constrained institutions, making research research collaborators at the Universities findings available to media professionals of Bern and Lausanne, select participants and in developing high quality e-learning based on their ability in research method- tools for clinical specializations. ology and scientific writing. Candidates’ The interaction between the interna- initial research proposals are used to tional research community and pro- assess the ability to identify and address gramme managers working on contra- research priorities and become future ception, fertility or gender and sexuality trainers; indeed the course sees itself as and the promotion of equitable human providing capacity building in research 28 relationships is a fundamental preoccupa- techniques and their application to most tion of the GFMER. recent pressing needs, particularly in For this reason, GFMER aims to flag public health and reproductive health in key issues from the contemporary global global development. SRH research agendas in the objectives GFMER works in collaboration with of its training on research methodology. a private foundation at the University The full range of courses featured is at of Geneva in emerging fields in sexual http://www.gfmer.ch/300_MedicalEduca- health: the definitions of healthy sexuali- tion_En.htm and course files are freely ties; portrayals of conventional sexuality available. Application forms for the 2009 and of sexual minorities, youth, ageing course can also be downloaded. Inciden- and inter-generational relationships; tally, if you are considering attending, gender-based violence; sex selection; you or your institution will be pleased economic influences on sexual behav- to know that the course is immensely iour; sexual violence and abuse; religion, good value for money, tuition costing culture and spirituality; and sex and Sexual and reproductive health research training course: Robert Thomson linking sexual and reproductive health agendas with research methodology

Main objectives Common course • to promote health through medical • research methodology (2 weeks) education and research that can be – Study design, statistics, epidemiology, critical appraisal, research applied by developing countries, and synthesis, strategies for data analysis, ethics and human rights in countries in economic transition clinical research, Internet and Medline • Common topics in reproductive health / sexual health (1 week) Terms of Reference – Sexual and reproductive health work at WHO • to provide postgraduate training in – STIs, HIV/AIDS, family planning, infertility, genetics, environment research methodology in reproduc- and reproduction, sexual function and dysfunction tive and sexual health. • to develop & conduct research & Reproductive health parallel week: research synthesis activities. pathophysiological principles, gynecologic endocrinology, meno- • to assist partner institutions in the pause, genital infections/STIs cancer, obstetrics conduct of postgraduate medical Sexual health parallel week: education programmes. concepts, methods in sexual health research, sexual identity disorders, • to collaborate with the WHO on , STIs/HIV and sexuality, violence, child abuse, e-learning activities as well as on FGM, rights and ethics in sexual health research the conduct of short postgraduate courses in epidemiology. Exams (last week) • to provide expertise to the WHO • to obtain certificate, participants have to pass an exam, consisting of: or to centres of the WHO’s network – a scientific paper (defined as preparing a protocol for a research requesting collaboration in research, project, a grant proposal, a systematic review) research training or clinical aspects in – a 15 minutes oral presentation on the scientific paper and reproduction. – a multiple choice questionnaire

ethnicity. As a result of this collaboration, and psychological models of sex and four hundred or so past participants and initial funding was made available from gender are presented in the course. They the development agencies and public 2005, along with a small number of study complement a global epidemiological health bodies which support the course. grants, to launch a sexual health track review of sexually transmitted infections, Thus, by promoting good research alongside a reproductive health track pregnancy and delivery, dysfunctions and design and methodology and encourag- creating the SRH research methodology genital practices. ing knowledge sharing and best practice, course. GFMER training is also delivered to GFMER is able to ensure that both new The course enhances participants’ skills staff of supporting institutions on devel- and past generations of researchers, pro- not just in carrying out research but com- opmental tasks in adolescence and the grammers, clinicians and policy makers municating on these issues accurately, supportive role of peer education, the ef- are able to help research in SRH move with clarity, comprehensiveness and fects of abstinence-only programmes and forward in a positive direction. appropriate interpretation to the wider management of risk-taking. There is also public health and development commu- close involvement in the Partnership for 29 nities. A key part of the course examina- Maternal, Newborn & Child Health, the Robert Thomson, tion consists of developing and defending Campaigns to End Fistulae and Female Member, Geneva Foundation for the research proposal. The presentation of Genital Mutilation, the Y-Peer network Medical Education and Research a proposal is in fact a skill closely related and the Art for Health exhibition. [email protected] to resource mobilization and many par- We encourage all participants to be ticipants appreciate the training in com- aware of and share knowledge of current munication that is a feature of the session. trends in research on a range of clinical Few courses so actively facilitate and public health issues by publishing in networking between health professionals the online journal http://www.reproduc- working on SRH from across the different tive-health-journal.com/home/, or simply regions of the world. Overviews of devel- by opening their own “member page” on opmental, behavioural and clinical issues gfmer.ch and uploading their very crea- in human sexuality, reproductive health, tive research proposals. This open access as well as, key concepts in bio-medical approach is of immense importance to

No.67 - 2008 István Farewell to Entre Nous Batár Hungarian

t is well known that Entre Nous was gynaecologists). The nurses formed the launched by Miss Wadad Haddad, the greatest part of the readers; according to Ifirst Regional Adviser for Sexuality feed-back information this magazine was and Family Planning at the WHO Re- the only source for many of them to get gional Office for Europe sometime in the up-to-date information on the related mid-1980s. That time we collaborated topics in those years. in a UNFPA sponsored International Due to the increase of the postal charges, Postgraduate Training Course Series more and more copies were sent in bulk in Family Planning, in which – as part (30-50 copies) mainly to the visiting of the handouts – we distributed copies nurses, usually to the address of a chief among the participants. After the retire- nurse, who distributed them among the ment of Miss Haddad, her successor Dr. subscribers. Daniel Pierotti requested the Department Some years ago, because of a drastic cut of Obstetrics and Gynecology, University in financial resources, the WHO Regional Medical School of Debrecen, Hungary to Office for Europe was no longer able start publishing Entre Nous in Hungarian. to provide funding for the Hungarian We were glad to accept this proposal and edition of Entre Nous. Fortunately at that the first introductory issue of the ”Hun- time local funding sources were procured garian Entre Nous” appeared in 1989. to sustain the publication of Entre Nous The public interest rose immediately Hungarian. Unfortunately, these sources and we received many requests to send have also been exhausted, which means the next copies, which were planned to be that we are no longer able to continue published twice a year. publishing this important sexual and The first copies had a very simple for- reproductive health magazine. The cor- mat (similar to that of the original Eng- responding text will disappear from the lish/French version). Later, as Entre Nous imprint of Entre Nous. became a real magazine we changed the Entre Nous Hungarian was prepared The editors and staff of Entre format, however, due to limited funds we at the Family Planning Centre of our continued to use the desktop publishing Department for nearly two decades. The Nous wish to extend their technique with black-and-white printing. whole work – including translation, edi- At the beginning, the Hungarian tion, reproduction and distribution – was heartfelt thanks to Dr. István edition was a “gleaning” version; only done by the team of the Family Planning those articles were translated which were Centre and I owe my ex-colleagues from Batár for his many years of regarded as relevant/interesting for the the Centre a very, very large thank you Hungarian readers. This excerpt pub- for all their hard work and time on this hard work and dedication as lication became, year by year, a more magazine. Yes, ex-colleagues because I 30 complete version of the original one and have in the meantime retired. editor of Entre Nous Hungar- later issues were nearly translated in their I certainly hope that this unfavorable entirety into Hungarian, with the excep- situation of ceasing to publish Entre Nous ian. Both he and the Hungar- tion of Resources (these attracted only Hungarian may change in the future those who could use the original docu- and that re-launching of this project for ian version of Entre Nous will ments/ books/periodicals). the benefit and pleasure of not only the The limited funding, despite a slight Hungarian readers, but all of us, will be a increase in the mid-1990s, did not allow possibility. In the meantime, fortunately be missed. We wish him all the us to increase the number of copies (500) more and more of my Hungarian col- we published even though we had new leagues are able to read English and thus best in his years of retirement. subscription requests following every new will be able to continue to enjoy Entre issue. This limited number of publica- Nous in its English format. tions limited our capability to strongly advertise the Hungarian Entre Nous. The István Batár, 500 copies were distributed mostly among MD, PhD, Dr. med. habil. visiting nurses and doctors (mainly Editor, Entre Nous Hungarian resources Lisa Avery

WHO COLLABORATING CENTRES Social science methods for research on WHO Collaborating Centre Research in Human Reproduc- Research in Human Reproduc- reproductive health, HRP/UNDP/UNFPA/ for Research on Reproductive tion tion WHO/World Bank, 1999. Health Dept of Obstetrics and Gynaecol- Department of Women’s and Research Centre of Maternal and ogy Children’s Health Section for A valuable tool for those interested in conducting Child Health Protection Albert Szent-György Medical Internatinal Maternal and Child social science research in sexual and reproductive 22 Mashtots Avenue University Health (IMCH) 375002 Yerevan, Armenia Semmelweis utca l. Uppsala University Hospital health. It provides an overview of research design Director/Head: Prof. G.G. Okoev H-6725 Szeged, Hungary SE-751 85 Uppsala, Sweden options, methodology and analysis, ethical considera- Website: Prof. Attila Pal Director/Head: http: //www.armobgyn.com Email address : palattila@obgyn. Prof. Gunilla Lindmark tions and practical aspects of research planning and szote.u-szeged.hu Email address : implementation. Available in English and Spanish at WHO Collaborating Centre for [email protected] www.who.int/reproductive-health/publications/ Research on Sexual and Repro- WHO Collaborating Centre for ductive Health Evidence-Based Research Syn- WHO Collaborating Centre for rhgeneral.html International Centre for Reproduc- thesis and Guidelines Develop- Development of Quality Indica- tive Health (ICRH) ment in Reproductive Health tors to Improve Perinatal Health Faculty of Medicine CeVEAS-Centre for the Evaluation Systems Department of Obstetrics Turning research into practice: suggested Ghent University of the Effectiveness of Health Care and Gynaecology actions from case studies of sexual and De Pintelaan 185, 3P3 Azienda USL Modena-NHS Local University Hospital of Lund B-9000 Ghent, Belgium Health Authority Lund University reproductive health research, HRP, WHO, Director/Head: Via L.A. Muratori 201 SE-221 85 Lund, Sweden 2006. Prof. Marleen Temmerman I- 41100 Modena, Italy Director/Head: Prof. Karel Marsal Website: http: //www.icrh.org Director/Head: Dr Nicola Magrini Website: http: //www.gyn.lu.se This document looks at research utilization from Website: http: //www.ceveas.it WHO Collaborating Centre for WHO Collaborating Centre for the perspective of researchers and donors, as well as, Perinatal Medicine and Repro- WHO Collaborating Centre for Research in Human Reproduc- policy makers and programmers. Its aim is to help ductive Health Maternal and Child Health tion The Perinatal Centre, Departe- Unit for Health Services Research Department of Woman and Child enable increased utilization of research findings and ment of Obstetrics/Gynaecology and International Health Health monitoring of the extent to which research findings Institute for the Care of Mother Istituto per l’Infanzia IRCCS Burlo Division for Obstetrics and and Child Garofolo Gynaecology are used to improve sexual and reproductive health. Podolské nabrezi 157 Via dei Burlo 1 Karolinska Hospital C1:05 Available in English at www.who.int/reproductive- CZ-147 10 Prague 4, Czech Repub- I-34123 Trieste, Italy SE-17176 Stockholm, Sweden lic Director/Head: Director/Head: Dr Kristina health/hrp/index.htm Director/Head: Dr Petr Velebil Dr Adriano Cattaneo Gemzell-Danielsson Email address : Website: Email address : [email protected] http: //www.burlo.trieste.it [email protected] Research Issues in Sexual and Reproductive Health for Low and Middle Income Coun- WHO Collaborative Centre WHO Collaborating Centre for WHO Collaborating Centre in tries, Global Forum for Health Research and for Research on Reproductive Promotion of Appropriate Tech- Education and Research in Hu- Health nologies in Perinatal Care man Reproduction WHO, 2007. Research Centre for Molecular Perinatal Centre of MCHRI Geneva Foundation for Medical Endocrinology University of Oulu Research Institute of Maternal and Education and Research (GFMER) This document presents a framework to highlight the P.O. Box 5000 Child Health 5 Chemin Edouard Tavan needs, gaps and priorities for research in sexual and FIN-90014 Oulu, Finland 93 Burebista Street CH-1206 Geneva, Switzerland Director/Head: Prof. Pirkko Vihko MD-2062 Chisinau, Republic of Director/Head: reproductive health. Available in English and Spanish Website: http: //www.whoccr.oulu.fi Moldova Prof. Aldo Campana at www.who.int/reproductive-health/publica- Director/Head: Prof. Petru Stratulat Website: http: //www.gfmer.ch WHO Collaborating Centre for Email address : [email protected] tions/rhgeneral.html Research in Human Reproduc- WHO Collaborating Centre for tion WHO Collaborating Centre for Research & Training in Service Zhordania Institute of Human Research in Human Reproduc- Aspects of Family Planning Reproductive Health Assessment Toolkit for Reproduction (ZIRH) tion Department of Public Health Conflict Affected Women, CDC and USAID, 43, Kostava Street Research Centre of Obstetrics, Hacettepe University Medical 2007. 0109 Tbilisi, Georgia Gynecology and Perinatorlogy School Director/Head: Russian Academy of Medical Sihhiye A great toolkit that was developed to meet the need 31 Prof Archil Khomassuridze Sciences TR-06100 Ankara, Turkey Email address : [email protected] 4, Oparin Street Director/Head: Prof. Ayse Akin for accurate reproductive health data among conflict 117997 Moscow, Website: http: //www.halksagligi. affected populations. It contains sampling instruc- WHO Collaborating Centre for Russian Federation hacettepe.edu.tr Sexual and Reproductive Health Director/Head: tions, training manuals, questionnaires, data entry Federal Centre for Health Educa- Dr Ekaterina Yarotskaya WHO Collaborating Centre for and analysis guides. Available in Enlgish at www.cdc. tion (BzgA) Email address : Research Synthesis in Repro- Ostermerheimer Str.220 [email protected] ductive Health gov.reproductivehealth/productsandpubs D-51109 Cologne, Germany Department of Obstetrics and Director/Head: Dr Elisabeth Pott WHO Collaborating Centre for Gynaecology Website: http: //www.bzga.de Research and Training in Repro- Division of Reproductive and CDC Reproductive Health Epidemiology ductive Health Child Health Series, CDC. WHO Collaborating Centre for Department of Obstetrics and University of Birmingham Research in Male Reproduction Gynecology Metchley Park Road, Edgbaston Consists of four modules that introduce the re- Institute of Reproductive Medi- University Medical Centre of Birmingham B15 2TG, United searcher to useful concepts such as public health cine of the University Ljubljana Kingdom Domagkstr. 11 Slajmerjeva 3 Director/Head: Prof. Khalid S. Khan surveillance, maternal health and reproductive tract D-48149 Münster, Germany SI 1525 Ljubljana, Slovenia Website: http: //www.bham.ac.uk infection epidemiology and questionnaire design. Director/Head: Director/Head: Prof. Helena Dr Eberhard Nieschlag Meden-Vrtovec Available in Enlgish at www.cdc.gov.reproductive- Email address : eberhard. Email address : health/productsandpubs [email protected] [email protected] WHO Collaborating Centre for WHO Collaborating Centre for

No.67 - 2008 The European Magazine for Sexual and Reproductive Health

WHO Regional Office for Europe

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