UNDP/UNFPA/WHO/WORLD BANK SPECIAL PROGRAMME OF RESEARCH, DEVELOPMENT AND RESEARCH TRAINING IN HUMAN REPRODUCTION

ANNUAL TECHNICAL REPORT 2001

Executive Summary

Section 1 - Promoting family planning

Section 2 - Making pregnancy safer

Section 3 - Reproductive tract infections and sexually transmitted infections

Section 4 - Unsafe abortion

Section 5 - Promoting sexual and reproductive health of adolescents

Section 6 - Gender and reproductive rights in reproductive health

Section 7 - Technical cooperation with countries

Section 8 - Implementing best practices

Section 9 - Monitoring and evaluation

Section 10 - Communication and dissemination of information

Section 11 - Clinical trials and informatics support

Appendix 1 – Staff of the Deparment, December 2001 Annual Technical Report 2001 17 Section 1 Promoting family planning family Promoting 18 Annual Technical Report 2001 for family planning acceptors. and providers for tools other and guidelines norms, of ment develop- the into input provides information this data, trial clinical with together phases; provision service routine and introduction development, product the during gathered are perspectivesefficacy. Users’ and safety their of trials scale large- subsequent and methods of introduction the to work this link goals Programme’s The men. including users ous vari- of needs the to respond and side-effects, severe less and fewer with associated delivery,are service simplify and leads for new methods and approaches that are easier to use planning services. The Programme has pursued high-priority family quality of delivery the for required blocks building ing severalinter-connect- the of one provides regulation fertility The Programme’s research on improved and new methods of lions ofmen,women andfamilies. health benefit and could meet the needs and demands of mil- public significant a to lead could new planning family of methods totally or improved of availability have the Experts that services. determined high-quality to access of lack the side-effects,and of fear a to attributed especially traception, con- modern towards ambivalence an include methods tive contracep- of use the to children. Obstacles their of number the limit or space to desire a expressing despite planning, familyof method any use not do couples million 120 least at hand, other pregnancy.the unplanned On an of occurrence the and concerns health including reasons, of variety a to owing year a within use its discontinue reversiblemethod a to use a method of fertility regulation. Nearly half the users of glimpse at the behaviours that a determine couple’s decision a only offers statistic this acceptance, mean necessarily not does use Because planning. family of method a used larly regu- worldwide couples million 570 approximately 1995, In Section 1-Promoting familyplanning Section Research onthedevelopment of ofmethods INTRODUCTION C. d’Arcangues, P.D. Griffin, H. Hertzen,von K.M. Vogelsong, M. Mbizvo, E. Vayena fertility regulation fertility • studies. Research on levonorgestrel is continuing in three multicentre Levonorgestrel Progress 29 memberorganizations. of total a includes now and 1996 in founded was traception in this area. An international Consortium on Emergency Con- activities launch to organizations other stimulated also has research Programme’s The tested. being also are pounds ine device (IUD) and a 10 mg dose of mifepristone. New com- intrauter- the of efficacy the confirm further to continued has tested. Research being are regimens simpler practical, very not is apart hours 12 levonorgestrel of doses two taking As methods. these of delivery service of ease and acceptability safety,the improveefficacy, further to is traception. aim The con- emergency for technologies new on research of front fore-the in been has Programme the decade, past Overthe Specific objectivesSpecific of research

published in2002. Kingdom. United the and be will study the of results The Switzerland Sweden, Slovenia, Mongolia, India, gary, Hun- Georgia, Finland, China, in clinics planning family 15 from enrolled were women 4136 of total A course. inter- followingunprotected hours 120 to up given when mifepristone,of dose mg 10 single a to and apart hours 12 taken doses mg 0.75 two lev- to mg compared 1.5 onorgestrel of dose single a of side-effects and cacy effi- investigatedthe which 2001, during completed was study multinational double-blind, randomized, large, A EMERGENCY CONTRACEPTION Annual Technical Report 2001 19 A randomized, double-blind launched in study China to was compare 10 mg gestrinone with of 10 mg of mifepristone for emergency contraception when adminis- tered up to 120 hours intercourse. after The unprotected study will include and will be completed in 2002. women 1200 40 countries for the treatment of endome- triosis. In addition to its antigonadotrophic the activity, compound also has some anti- progestogenic It activity. is anticipated that due to its long duration of action—gestri- none is administered twice weekly in the management of endometriosis—one dose of the drug might be sufficientfor effective emergency contraception. Gestrinone is registered and used in more than more in used and registered is Gestrinone In order to determine whether low-dose mifepristone is more is mifepristone determineto low-dose order whether In effective than levonorgestrel, the Programme carried out a large, multinational, double-blind study comparing the effi- treat- two and mifepristone of mg 10 of side-effects and cacy described as above. ments of levonorgestrel, New projects initiated during the year during projectsNew initiated Mifepristone The Programme has given technical assistance to a large study launched by Chinese scientists to further the evaluate efficacy and safety of the 10 mg dose of mifepristone. It is planned to recruit in 30 centres. a total of 4000 women Gestrinone IUD in emergency contraception Several reports on the use of an IUD for traception emergency suggest that the method con- could be highly effective due to for this However, lack indication. of prospective, well- IUD the of side-effects and efficacy the on studies conducted as a means of emergency it contraception, is to not possible give any recommendations regarding its Thus, a use. large, and acceptabil- side-effects study of the multicentre efficacy, ity of the TCu380A IUD for this indication was launched in China. A total of 1883 women were recruited and 100% was IUD the followed study, this In up insertion.IUD after year one for effective as a method of emergency inserted up to contraception 120 hours following when unprotected intercourse. Short-term side-effects and removal rates up to 12 months after insertion did not differ from those seen interval insertion in of the copper IUD. studies of Research on the development of methods of fertility regulation on the development Research

y rates and 95% CI CI 95% and rates y alue = 0.02 P v

—pregnanc or trend:

est f (China) T Three centres in Nigeria participated in the previous mul- previous the in participatedNigeria in centres Three regimen, ticentre Yuzpe study and on the levonorgestrel and the two-pill levonorgestrel regimen of emergency contraception has now been registered in that country. A study seven-centre is ready to be launched in Nigeria one-dose a of side-effects and efficacy the investigate to regimen of 1.5 mg compared of to levonorgestrel a two- hours). 24 of interval an at taken mg (0.75 regimen dose This study will include a total of the end of 2003. completed by to be expected 3150 women and is The 12-hour interval between the two tablets of levonorg- of tablets two the between interval 12-hour The mul- double-blind, a and impractical, sometimes is estrel whether investigating therefore is China in study ticentre this interval could be increased to 24 as hours, this may be The more recruitment for convenient women. of over by completed be to expected is trial this for women 2000 the end of 2001.

The Programme has collaborated with Chinese investigators investigators Chinese with collaborated has Programme The in further evaluating the efficacy of the 10 mg dose of mife- pristone. During a three-year collaborative initiative funded by The Rockefeller Foundation, a randomized, double-blind around centres 10 in women 3052 with out carried was study The results indicated that China. the doses of 10 mg and 25 pregnancy raw a with effective equally are mifepristone of mg reportedThe treatments rate led if of to any, 1.1%. very few, Failure rates side-effects. were correlated with the time gap since unprotected intercourse (P=0.02), as shown in Figure Women 1.1. treated after 48 hours had a risk of pregnancy 2.3 times higher than women treated within 48 this hours After (rela- 1.2–4.5). [CI]: interval Confidence 95% 2.3; risk: tive the 10 mg emergency dose registered contra- was for study, ception in China. Mifepristone • • 20 Annual Technical Report 2001 • • gonadotrophin (hCG)immunocontraceptive. chorionic human the of formulations to three of year acceptability past clinical likely the and characteristics during performance the out evaluate carried been have Studies Progress andinvestment.than sufficienttojustifytheeffort methods based on steroid hormones—were considered more long-acting with associated side-effects other and metabolic the of immunocontraceptive—free effective and safe a for, perceivedbutthe our advantages demands of,potential and approach to contraception was a long-term, high-risk endeav- novel totally this of development the that recognized was It tional andnationalagenciesfor several decades. interna- of number a by supported investigation extensive of subject the been has molecules, response reproduction-specific to immune time-limited and controlled a on based contraception, of method new totally a of development The and vaginal administration ofthisdoselevonorgestrel. oral after examined be will tissue endometrial in steroid the of levels as well as pharmacokinetics the addition, lation. In dose of single 1.5 mg of levonorgestrel a on follicular of growth and effectsovu- the examining is Chile in study Another Cebus apellamonkey asamodelfor thisresearch. the of feasibility the test to Chile Santiago, in launched was study a human, the in investigated be cannot cycles fecund sible mechanisms of action of emergency contraceptives. As the Programme’s collaborating centres to investigate the pos- Severalinitiativesresearch have with together planned been studies Mechanism ofaction Specific objectivesSpecific of research Section 1-Promoting familyplanning Section

n (i lre prils fr lctn a lwr u more but slower a eliciting for particles, larger (ii) and duration, short of response immune fast a eliciting for have been prepared consisting of (i) very small particles, immunogens PLG-entrapped of batches test year, past the During microspheres: (PLG) Polylactic–polyglycolic studies areplannedwiththisformulation. of immunity to ensure efficacy. For this reason, no further acceptable and yet continue to generate clinically a sufficient levelconsidered be would they which at point a to not be possible to reduce local reactions to the emulsion may it that concluded been has it year, past the during research intensive of spite In decades. two than more over immunocontraceptive hCG prototype a of opment the is standard emulsion formulation used by the water-in-oil Programme in its devel- A emulsion: Water-in-oil INJECTABLE IMMUNOCONTRACEPTIVE SIX-MONTHLY, NONSTEROIDAL, FOR WOMEN Specific objectivesSpecific of research New projects initiatedNew projects during 2001 • the cycle. 7 of on administered day Cyclofem first of tive when efficacy contracep- likely the evaluate to out carried was study A 7. day as late as given DMPA is of injection first the whereas days 5 first cycle,the within administered is menstrual the of injectable monthly the Cyclofem of injection first the present, cycle. At the of day same the on initiated if be could use their facilitated be would injectables of provision service The native todepot-medroxyprogesterone acetate(DMPA). levonorgestrel these, butanoate, is being investigated of as a possible One improved 1980s.alter- early and 1970s late the and in Programme Health the Child and (NICHD) of Development Institute Human National US con- the programme by synthesis ducted chemical a in prepared were levonorgestrel of esters injectable long-acting of number A thefirsthalfof2002. during formulation this of trial clinical I Phase a initiate to Sweden Stockholm, in Agency Products Medical the from sought be study,this approvalwill of outcome satisfactory a to Subject 2002. outinmid-February ried the assessment preliminary of the histopathology will be car- and 2001, December early in commenced autopsies 2001, preparation.November matrix early Treatmentthe in started of injection single a from resulting reactions local the mine A dose-finding study was recently initiated in rabbits to deter-

INJECTABLE HORMONALCONTRACEPTIVES within aclinicallyacceptable range. or absent either were preparation, the of doses to-low medium- receiving those in especially studies, these in involved animals the of most in months. reactions Injection-site six least at for sustained being antibodies of level high a with response immune good a elicited has small volume of the water-in-oil emulsion. This approach the conjugate-containing matrix particles suspended in a that of injection single shown a with achieved be was can immunization it rabbits, in studies initial In sulfate. dextran and hemihydrate sulfate calcium from formed in incorporated a composite inorganic/biopolymer matrix are immunogens the which in system delivery release past slow- the particulate, new a using obtained been have during year data encouraging matrix most The sulfate system: hemihydrate–dextran sulfate Calcium ment ofbetterbatch-to-batchreproducibility. achieve- the and levels loading higher on depend will resulting in underdosing. Further studies with this system a low loading of the microspheres with immunogens thus to due possibly disappointing, were materials test these immunesustained response. with obtained results Initial Annual Technical Report 2001 21 COMBINED VAGINAL RING VAGINAL COMBINED BASIC RESEARCH ON IMPLANTATION RESEARCH BASIC An anti-implantation or menstruation-inducing agent is an approach attractive to fertility regulation since it needs to be then and menstrualcycle, any in occasion one on only taken only on an “as needed” basis or as a back-up method, for example, in the case of condom breakage. Such a method would be free of the logistical associated with the problems use of many and existing methods of family side-effects planning and, because of its infrequent use, should be rel- atively inexpensive and, therefore, affordable by women in partsmany of the world. A collaborative initiative in The between 1998 the of end the at area established was implantation of basic research in Rockefeller Foundation and the Programme. The primary objective of this research industry, initiative with collaboration is eventual in to development, for identify leads promising as novel anti-implantation or menstruation-inducing agents, in acceptable and safe effective, woman-controlled, are which and their mechanism of action. their mode of administration in window implantation the (i) on: is research the of focus The and development the (ii) level; endometrial the at primate, the demise of the primate corpus luteum; and (iii) preimplanta- tion embryo–uterus–corpusThe work luteum is interactions. Ger- China, Australia, in centres 6 of network a in done being support financial with USA, and Kingdom United India, many, Acceptability studies show that women methods of contraception that need do not require daily interven- long-acting tions and that are under the The user’s control. vaginal ring is one approach that meets these needs. Most steroid hor- mones are absorbed efficiently through thevaginalwall and can be released from a silastic The ring. ring can be easily inserted in the vagina, checked, removed and replaced by number a for worn be can continuously It herself. woman the constant a provides it coitus; to related not is use its weeks; of rate of drug release resulting in a steady of plasma the level minimum dose required for contraception; metabolic side- effects are reduced by avoiding the first-pass effect through fertility returns. rapidly and upon removal, the liver; Progress The Population Council will launch a Phase III clinical trial ring of µg 150 releasing vaginal contraceptive combined a of course the over daily estradiol ethinyl of µg 15 and nestorone of The a Programme is year. planning to provide support to research centres in this trial. clinical two Specific objectives of research of Specific objectives Specific objectives of research of Specific objectives Research on the development of methods of fertility regulation on the development Research In all centres it was observed that, after receiving the injection on first day 5, women had limited or no ovarian activity. In contrast, of those women in the Latin American centres who received the first injection on day 7, 18% showedfol- licular growth and 5% ovulated; only 3% of women Chinese in centre, who the received the initial injection on day 7, showed some evidence of follicular growth. With regard to cervical mucus, women who received the injection on day 5 exhibited fair or poor mucus quality and poor sperm pen- Three etration. per cent of those who received the injection on day 7 showed good mucus or good sperm at penetration some point during the two weeks following the injection. Thus, administering the first injection on day 7 of theof and cycle activity ovarian of inhibition same the provide not does mucus quality and sperm penetration as when given on day first the receiving after pregnancy of risk theoretical the But 5. to remain low. be expected 7 would injection on day Cyclofem: initiation of Cyclofem treatment of Cyclofem initiation Cyclofem: A study was undertaken to test whether the of first injection the once-a-month combined Cyclofem, could safely be administered injectable as late as day 7 contraceptive, of a menstrual cycle—as is the practice with other injectable jeopardizing its such high contraceptives as DMPA—without level of efficacy. The clinical trial wasHealth International initiated (FHI) in three by Family Latin American centres, and the Programme supported the activity inclusion Ovarian of differences. ethnic possible a address to Chinese centre and cervical mucus changes were monitored in 158 women allocated randomly to receiving the first 5 injection or on day menstrual 7 of their cycle. on day Discussions have taken place during various the contacts past in the year lev- pharmaceutical of with supplies trial clinical obtaining industry for strategies alternative to review test- clinical of stage next the enable to butanoate onorgestrel ing These to discussions be are carriedin progress out. and no new projects were initiated with butanoate levonorgestrel during 2001. Additional clinical trials to further evaluate the safety and effi- and safety the furtherevaluate to trials clinical Additional cacy been butanoate have of on levonorgestrel hold sev- for problems. of formulation pending the investigation years eral legal recent more but now resolved been largely have These problems are still the preventing custom preparation of clini- cal trial batches. Progress butanoate Levonorgestrel 22 Annual Technical Report 2001 mals and a variety of treatment modalities, including single including modalities, treatment of variety a and mals ani- of involvingnumbers planned larger are studies Further especiallyestrogenandprogesterone.hormones, circulating of patterns expected the in changes measuring by systemically and tests, histopathological and tochemical immunohis- using level cellular the at locally both ventions, studies are under way to investigate the impact of these inter- significant. Other statistically not therefore,were results, the and small were experiments these in used animals of bers antifertility effect resulting an from these various of interventions, but the obtained num- was evidence implan- Some site. the tation to restricted be to seems appearance whose or implantation during increased is production whose cules mole- the of some of function the of immunologicalinhibition Studies carried out during the past year include chemical and initiatedNew projects during 2001 celltypes.vessels, ofcertain andthecontrolleddestruction ofblood proliferation the molecules, specific of production decreased and increased both include changes tion. These implanta- of time and site the at uterus human and monkey mouse, the in and luteum corpus monkey the in occur that complicated and interactive structural and functional the changes on obtained been has information further 2001, During Progress Foundation andtheProgramme, respectively. providedbybeing supervision technical Rockefellerand The Section 1-Promoting familyplanning Section e breakthrough bleeding resulting from continuous exposure to x ogenous progestogens

- Specific objectivesSpecific of research progestogen-only methods of contraception endure the irreg- the endure contraception of methods progestogen-only using women million 15 than more the of proportion large A submitted by the6centresinInitiative. work future for plans and reports progress the assess to tee cluded with a one-day meeting of the Project Review Commit- wereproposed. research of lines additional con- meeting The and identified, were development further for leads individual promising reviewed, were data composite the session, During this collaborators. local the and investigators, Committee Review of Project sets both involving session storming brain- one-day a by followed was year.This past the during investigators presented and discussed the results obtained in their projects CONRAD/CICCR-supported and Foundation with a two-day symposium which during the WHO/Rockefeller started meeting The (CONRAD/CICCR). Research ceptive Contra- in Collaboration Industrial for Consortium Program’s Development and Research Contraceptive the of forWomen gators engaged in the Research Program on Monthly Methods investi-the with activity joint a convenedas was meeting this in Australia, format, established Melbourne, the with accordance In in 2001. December held was Committee Review The annual meeting of the initiative’s investigators and Project potential. gate theirantifertility investi- further to molecules, of combinations and molecules BASIC RESEARCH ONENDOMETRIALBLEEDING

o ratruh bleeding breakthrough to related mechanisms Various viders. pro- from expect can larities irregu- bleeding experience who women that assistance result, counselling is the main a available.As locally not or expensive too often are but effects positive have drugs anti-inflammatory steroidal apro- Non- of method. gestogen-only benefits the of some negates and beneficial moderately only is of estrogens administration The prob- lem. this alleviate or vent pre- to women to available are options Few lives. their some, religious for dimensions of and, economic socio- cultural, the on impacts life and sexual their impli- on cations significant has This induce. methods these that bleeding vaginal in ularities Annual Technical Report 2001 23 AND SOCIAL SCIENCE RESEARCH AND SOCIAL SCIENCE MALE HORMONAL CONTRACEPTION: CLINICAL CONTRACEPTION: MALE HORMONAL Specific objectives of research of Specific objectives gen, progesterone and levonorgestrel. Additional studies will gen, progesterone and levonorgestrel. focus on the production and activation of matrix metallopro- teinases (MMPs) in the endometrium and the regulation of their production and activation by progestogens. Finally, a mouse model of menstruation will be used to evaluate the effects of levonorgestrel on endometrial breakdown or fra- and gility, to investigate whether treatment with MMP inhibi- tors can limit these These effects. studies will provide new insights into the cellular and molecular underlie bleeding. progestogen-induced breakthrough mechanisms that Androgen/progestin combination Androgen/progestin A the Phase suppression II of trialspermatogen- to evaluate of administration the androgen/progestin com- esis following nearlyis men Indonesian complete. to DMPA, + TU bination, The study compares the efficacy of500 the mg TU administration at of six-week intervals with that of a regimen 500 of mg TU injected at six-week intervals + 250 mg DMPA Progress alone Androgen The Programme, together with the State Family Commission Planning of China, funded a Phase in (TU), undecanoate III testosterone androgen, the of safety trial cacy and effi- Phase the of results successful the on based was This 2001. androgen injectable this of efficacy contraceptive the of trial II in The Chinese 10-centre men. Phase III study will evaluate of the androgen when effects it is adminis- the contraceptive tered as a 1000 mg initial loading dose, by followed 500 mg intervals, Recruitmentat in four-week 1000 of men. subjects has been initiated. Programme managers, policy-makers and donors are becom- are donors and policy-makers managers, Programme ing progressively more aware of plan- family the in participation male increased need of, benefits health for, and public with its part- in collaboration The Programme, ning activities. ners, has established and maintained a leadership role in the development of male This contraceptives. is a step for- ward toward the goal of increased shared responsibility in this area, as articulated at the International Conference on Population and Development (ICPD). In order to maximize the impact of available funding, the research agenda must identify and exploit the leads that The male reversible contraception promising. method that is are feasible and most hormonal a is application clinical to closest the be to believed method that suppresses spermatogenesis to azoospermia or severe oligozoospermia, resulting in temporary infertility. The work of the Programme in such clinical trials plemented by a is portfolio of com- accompanying acceptability and research. behavioural Research on the development of methods of fertility regulation on the development Research affected affected particularlyThis will progestogens. The Cochrane The LibraryCochrane , Issue 5, 2002. by by contraceptive steroids, To To implement the recommendations for made further at the research 1999 meeting on “Steroids Breakthrough and Bleeding,” Endometrial cosponsored by the and Programme the US NICHD, a project proposal entitled “Studies on the role of progestins in endometrial breakthrough bleeding” three-year This 2001. in funded and approved reviewed, was project proposes to investigate, in vitro, the nature estrogen and progesterone receptors in human microvascu- of the estro- to cells these of responses the and cells endothelial lar New projects initiated during 2001 during projectsNew initiated A systematic review of the evidence for the efficacy ofvari- of progestogen- ous in therapies the treatment or prevention supportedby being is bleeding endometrial irregular induced the Programme, as one of the reviews conducted Collaboration. Cochrane through the of Group Regulation Fertility the The protocol for the review was reviewed and accepted in in 2001 and published A second double-blind, randomized, placebo-controlled, clin- placebo-controlled, randomized, double-blind, second A ical trial was conducted to test the effect of vitamin E as an antioxidant, and of low-dose aspirin as an anti-inflammatory agent, alone and in combination, on Norplant-induced pro- longed bleeding. Participating centres were located in Bei- jing (China), Jakarta (Indonesia), Analysis Santiago (Tunisia). (Chile), Tunis and Domingo (Dominican Republic) Santo of data from 480 subjects indicated that treatment with vita- Although patterns. bleeding on effect beneficial no had E min treatment with low-dose aspirin often led to cessation a of prolonged more bleeding episodes, significant rapid differ- Furtherences were rarely observed. detailed analysis of the data is ongoing. mid-2002. should be completed by The review Two Two studies were undertaken to assess the effects of ferent treatments dif- on progestogen-induced prolonged bleed- in completed was trial placebo-controlled double-blind, A ing. improv- in mifepristone of efficacy the testing Chile, Santiago, After Nor- pattern bleeding of Norplant ing the vaginal users. plant insertion, 120 subjects who complained of prolonged bleeding received 100 mg of mifepristone or placebo on two consecutive at days intervals of 30 a over days period of six months and were followed for a total of 13 ment months. Treat- with mifepristone significantly reduced the incidence and duration of prolonged bleeding episodes. A mild bene- ficial effect persisted after the end of treatment. One preg- group. nancy occurred in the mifepristone-treated Progress have have been proposed as men- of described mechanisms the understand better to in need a is there Figure 1.2. Clearly, are these how and bleeding irregular of and struation provide provide the necessary knowledge to formulate appropriate treatments and to develop new methods free of these side- effects. 24 Annual Technical Report 2001 The Programme is also supporting studies on users’ perspec- tiation. Data analysiswillbecompletedin2002. levelsenergy sexualand increased activity followingini- trial reported men Many short-lived. site, being injection as it the described at they pain report did men While planning. familyfor responsibility the of partners relievetheir to desire a expressed in men status.Other health current interested their learning were men these con- earlier; hormonal years male 10 a traceptive of trial a in participated had teers volun- the of One-third acceptable. be to regimens the find available to date indicate that the and participants their wives Data partners. their or participants study the by reported as function sexual or behaviour in changes any and products study the of acceptability assess to developed were ments Instru- conducted. being is compounds study the of use of men, a study to assess users’ perspectives and acceptability DMPAregi- + TU the of trial clinical the with association In Behavioural science andsocial research in collaboration withtheCONRADProgram. conducted and funded be will 2002. study in The begin may trial the and manufacturerongoing the are with Negotiations compounds. study the of nonavailability the to due delayed was (NET-EN) enantate norethisterone progestin the with The initiation of a multicentre Phase II/III trial of TU combined inthispopulation(Figure1.3). of infertility concentrations more sperm quickly and completely to a level suppresses androgen DMPAthe of to addition the that cate indi- results Preliminary intervals. 12-week at administered Section 1-Promoting familyplanning Section 500 mg ( of administrationeither500mg T U +DMP T U at 6-week interv A) als +250mgDMP TU at 6-week interv A at 12-week interv als ( the Indonesian centres in early 2002. the Indonesiancentresinearly tocol has been approved is expected and the trial to begin in 250 mg DMPA administered at eight-week intervals. + The pro- TU mg 500 (ii) and intervals; eight-week at administered DMPAmg 150 + TU mg 500 (i) are: tested be to regimens The Indonesia. and India China, in sites at implementation This study seeks to determine whether a sufficient titre of antibody can be delivered titre to the lumen of sufficient the male reproduc- a whether determine to seeks study This to achieve immunocontraception to themalereproductive ofantibodies ducts Delivery Progress cations for malecontraceptive development. focus on the unique aspects of their research that have impli- function. to encouragedInvestigatorsfor sperm are required sperm- of specific proteins, and specific intracellularand function pathways and or events expression acrosome the as formation, flagellar such events developmental of ulation targets include the identification, research characterization and manip- Potential spermiogenesis. and spermatogenesis to related physiology male on research basic goal-oriented innovative, supports Programme the fertility, male of lation As a complement to the clinical research related to the regu- Specific objectivesSpecific of research TU alone)or DEVELOPMENT OFNOVEL APPROACHES TO BASIC SCIENCELEADS TOWARD THE als MALE FERTILITY REGULATIONMALE FERTILITY

indicate that the administrationthe that indicate men in Italy. Preliminary results NET-EN+ the TU of tives regi- completed in2002. be will analysis data and ment or mood sexual behaviour. Study affectrecruit- not negatively does intervals or doses tested the of any to according combination hormonal the of on the suppression of sperma- the DMPA + TU of administration of effects and positive encouraging the on Based during 2001 initiatedNew projects fetv dss f oh TU and DMPA—was both designed for of doses effective injec- tions, and the determine the lowest between the interval lengthen regimen, tion injec- the simplify trial— to intended this of expansion an above), (described togenesis Annual Technical Report 2001 25 The prostasome as a potential new target for fertility for new as a potential target prostasome The in men regulation the prostate gland and adhere Prostasomes are secreted by antibod- antisperm with men Infertile cells. sperm to fuse and ies all antibodies have to prostasomes and these antibodies The an appear on agglutinating to spermeffect have in vitro. goal of the proposed research is to identify and sequence in the hope that one or more individual prostasome proteins, be may specific to the male tract reproductive and be a suit- able target for a contraceptive approach. In of the funding, first the objectives year will focus on the identificationof prostasome proteins which are detected by sperm-aggluti- nating autoantibodies in sera from immunologically infertile men and the definition of some of the specific prostasome gene sequences which produce the proteins against which the human autoantibodies are produced. kinase protein Human sperm mitogen-activated in sperm functions and their role (MAPK) cascades sperminves- potential to and used being are ligands Natural tigate the presence and ligand-stimulated role human sperm of function. This work a is par- series ticularly interesting given the preliminary of data obtained on a kinases in be to Milestones sperm. progestin-stimulated in kinase novel in achieved the firstyear ofwork include the identification of sperm novel MAPK sperm known which by are activated lig- ands and confirmation that the proteins are indeed sperm- specific; the cloning and microsequencing of novel MAPK; and the demonstration of a role for MAPK in human sperm flagellar motility and acrosome reaction. New projects initiated during 2001 during projectsNew initiated Thirteen outline proposals were received in response to the second announcement inviting proposals on basic science an Following fertility regulation. male towards leads research Sci- Basic Male Review to Subcommittee the by review initial ence Research Proposals, ten investigators were invited to submit full proposals for peer At review. a meeting held in July 2001, the Committee recommended funding of of three these proposals; the Scientific and Ethical Review Group recommendation. (SERG) endorsed this Antispermatogenic effects and thyroid of luteinizing hormones The co-administration of luteinizing hormone and thyroxine seems to restore testosterone synthesis Norway rats; at the same time, in this regime arrests sperma- aged Brown togenesis prior to the round and elongated spermatid stage. The of objectives the proposed research are to demonstrate the reproducibility of this antispermatogenic phenomenon in a more traditional and relevant animal model (three-month- on preliminary data provide to and rats), Dawley Sprague old the mechanism of such a response. Research on the development of methods of fertility regulation on the development Research The main objective of this study has been to characterize and characterize to been has study this of objective main The The inves- clone a sperm membrane progesterone receptor. spermato- human selected from RNA extracted have tigators zoa, and have performed reverse transcriptase polymerase on chain these reaction samples (RT-PCR) using oligoprim- ers designed from different regions of the human terone proges- receptor RNA Evidence sequence. to date seems to exclude the possibility that a DNA transcript corresponding to the specific membrane progesterone receptoris present in human sperm; the investigators have hypothesized that post-transcriptional or post-translational modifications of the novelty the establish to order In occur. may receptor genomic of the additional receptor, funding will be provided to repeat small the as sequencing, and purification protein on work the amount of protein used in the initial studies makes the inter- support consid- Additional be will difficult. results of pretation protein is identified. that a novel ered in the event Investigation of the possible presence of the of the possible presence Investigation of the C at the level isoform receptor progesterone human sperm plasma membrane The results of this study have demonstrated that the inhibi- tory effect of GnRH antagonists on sperm–zona pellucida binding is achieved via a reduction in the number of sperm that bind to the zona, and not to the pattern of sperm move- ment, frequency of sperm–zona collisions, or the number or quality of acrosome-reacted These spermatozoa. data sug- gest that the antagonists may somehow inhibit zona recep- tors on the sperm plasma membrane and in the recognition of the be endogenous involved ligand may that, therefore, the Additional zona. experiments demonstrated that several distinct transcripts for the GnRH receptor are present in rat and mouse testicular germ cells, indicating that GnRH or a GnRH-like peptide does normally act on these cells. Fertili- zation was significantly reduced infemale rats treated with with incubated were that oocytes vitro, in antagonists; GnRH fertilized be to likely less spermwere antagonists GnRH and than controls incubated with sperm alone. A follow-on pro- characteriza- further and the identification on focusing posal, has been solicited. tion of the sperm GnRH receptor, Inhibition of sperm–zona pellucidaInhibition of sperm–zona binding in humans hormone (GnRH) gonadotrophin-releasing by antagonists tive tive ducts to saturate a target antigen, in order to immunocontraception. Initial achieve results obtained using tetanus toxin as an antigen indicated that immunoglobulin G (IgG) and immunoglobulin A (IgA) do enter the prostatic rete fluids of testes the mouse and andrat; the however, concen- trations delivered are relatively low, depend on the route of investi- The species. animal between vary and immunization, gators animals immunized using a recombinant antigen pre- viously shown to be important for the fertility of the guinea either when observed were effects antifertility No PH-20. pig, male or female mice or rabbits were immunized. Whether sufficient antibody can access the male tract to reproductive remains unconfirmed. immunocontraception effect 26 Annual Technical Report 2001 WPRO SEARO EURO EMRO AMRO AFRO from: Women Trent MacKay, NationalInstituteofChildHealthandHumanDevelopment, Bethesda,MD, USA David Grimes,Family Research HealthInternational, Triangle Park, NC, USA Collaborating scientists agency Members Jayasree Sengupta,AllIndiaInstituteofMedicalSciences, New Delhi,India Ho Pak-Chung, University ofHongKong, HongKong SpecialAdministrative) RegionofChina(Chairman Gemzell-Danielsson,Kristina KarolinskaHospital,Stockholm, Sweden Luigi Devoto, University ofChile, Santiago, Chile Cheng Linan,ShanghaiInstituteofFamily Planning Technical Shanghai,China Instruction, Szent-GyörgyiGyörgy MedicalUniversity, Albert Bártfai, Szeged, Hungary Members RESEARCH GROUP ONPOST-OVULATORY REGULATION METHODSFORFERTILITY IN2001 Annex 1a Section 1-Promoting familyplanning Section Number Developing countries 2 1 1 2 4

% oftotal 33 17 17 33 67

Number Countries intransition Countries 1 1

% oftotal 17 17

Developed countries Number 1 1 1

% oftotal 17 17 17

Totals 2 1 2 1 3 6 Annual Technical Report 2001 27 2 1 4 3 4 10 Totals

20 30 30 80 30 % of total

2 3 3 8 3 Number Developed countries Developed

10 10 % of total Research on the development of methods of fertility regulation on the development Research

1 1 Countries in transition Number

10 10 10 % of total

1 1 1 Developing countries Developing Number WPRO SEARO EURO EMRO AMRO

Members from: AFRO Women Women Doug Colvard, Contraceptive Research and Development Program (CONRAD), Arlington, VA, USA VA, (CONRAD), Arlington, Program Research and Development Contraceptive Doug Colvard, Collaborating agency scientist Collaborating John Beale, Cranbrook, Kent, United Kingdom United Kent, Cranbrook, John Beale, Sweden Hospital, Stockholm, Marc Bygdeman, Karolinska AZ, USA Tuscon, Richard Elton, Chairman ( ) Australia Adelaide, Centre, Flinders Medical Jones, Warren Australia Sydney, Research Centre, Clinical Immunology Rob Loblay, Sweden Hospital, Uppsala, University Odlind, Viveca IL, USA Evanston, NorthwesternSusan Pierce, University, Northampton, and Social Change, USA MA, Women Project on College, Smith Schrater, Faye of Medical Education and Research, Chandigarh, India Institute Shobha Sehgal, Postgraduate Russian Federation Gennadi Sukhikh, International Moscow, Institute of Biological Medicine, Members Annex 1b Annex 2001 IN ON IMMUNOCONTRACEPTIVES GROUP RESEARCH 28 Annual Technical Report 2001 SEARO EURO EMRO AMRO Jeffrey Spieler, UnitedStates Agencyfor Development, International Washington, DC, USA NationalInstituteofChildHealthandHuman Development, Spirtas, Bethesda, MD,Robert USA Amy Pollack, EngenderHealth,New York, NY, USA Gabelnick, ContraceptiveHenry ResearchandDevelopment Program (CONRAD),Arlington, VA, USA Douglas Colvard, Contraceptive ResearchandDevelopment Program (CONRAD),Arlington, VA, USA Barone,Mark EngenderHealth, New York, NY, USA Collaborating scientists agency Ilpo Huntaniemi,University of Turku, Turku,) Finland(Chairman Hecht,UniversityNorman ofPennsylvania, Philadelphia,PA, USA David Hamilton,University ofMinneapolisMedicalSchool,Minneapolis, MN,USA Anton Grootegoed,Erasmus University Rotterdam, the Netherlands Patricia Medicine, Cuasnicu,InstituteofBiology andExperimental BuenosAires, Argentina Stella Campo, ResearchCentre (CEDIE),BuenosAires, Endocrinology Argentina Sub-Committee fortheReview members Science Basic ofMale Research AFRO from: Women Members Frederick Wu, University ofManchester, Manchester, UnitedKingdom Christina Wang, Harbor-University ofCalifornia atLosAngelesMedicalCenter, Torrance, CA,USA(Chairwoman ) vonSigrid Eckardstein, Institutefor Reproductive Medicine, Münster, Germany Lynette Sigola,University ofZimbabwe, Harare, Zimbabwe Somnath Roy, NationalInstituteofHealthandFamily Welfare, New Delhi,India Eberhard Nieschlag,Institutefor Reproductive Medicine, Münster, Germany Nukman Moeloek,University Indonesia ofIndonesia,Jakarta, University Meriggiola, ofBologna,Italy Cristina Maria Henry’s McLachlan,Prince InstituteofMedicalResearch,Clayton, Robert AustraliaVictoria, Peter Liu,ConcordHospital,Concord,Australia Ilpo Huhtaniemi,University of Turku, Turku, Finland Gu Yi-qun, NationalResearchInstitutefor Family Planning,Beijing,China William Bremner, University of Washington, Seattle, WA, USA LutherUniversity, Behre, Martin Hermann Halle, Germany Kiagus Arsyad, Sriwijaya University, Palembang, Indonesia Richard Anderson,MRCHumanReproductive SciencesUnit,Edinburgh, UnitedKingdom Members RESEARCH GROUP ONMETHODSFOR THE REGULATION IN2001 OFMALEFERTILITY Annex 1c WPRO Section 1-Promoting familyplanning Section Number Developing countries 3 1 1 5 1

% oftotal 19 31 6 6 6

Number Countries intransition Countries

% oftotal

Developed countries Number 11 7 2 3 2

% oftotal 44 13 69 19 13

Totals 7 16 4 2 1 3 3 Annual Technical Report 2001 29 5 2 1 2 Totals

40 40 20 % of total 100

5 2 2 1 Number Developed countries Developed

% of total Research on the development of methods of fertility regulation on the development Research

Countries in transition Number

% of total

Developing countries Developing Number Members from: AFRO Women Women AMRO EMRO EURO SEARO WPRO Mahmoud Fathalla, The Rockefeller Foundation, Assiut, Egypt Assiut, Foundation, The Rockefeller Mahmoud Fathalla, USA NY, York, New Foundation, The Rockefeller Majidi, Evelyn Collaborating agency scientists Collaborating Ruben Gonzalez, Boston Biomedical Research Institute, Watertown, MA, USA Watertown, Biomedical Research Institute, Ruben Gonzalez, Boston USA VA, Research (CICCR), Arlington, The Consortium Industrial in Contraceptive Collaboration for Michael Harper, Osaka, Japan Hideharu University, Kanzaki, Kansai Medical Kingdom Hospital, Hull, United The Princess Royal Stephen Killick, Hospital, London, United Kingdom Hammersmith White, John Members Annex 1d Annex IN 2001 RESEARCH ON IMPLANTATION INITIATIVE FOUNDATION WHO/ROCKEFELLER 30 Annual Technical Report 2001 Wu Shang-chun,NationalResearchInstitutefor Family Planning,Beijing,China Wang Jie-dong,NationalResearchInstitutefor Family Planning,Beijing,China Kamani Tennekoon, University ofColombo, Colombo, Lanka Sri Subasinghe,Chandrika The Family Lanka,Colombo, PlanningAssociationofSri Lanka Sri Song Si,ShanghaiInstituteofPlannedParenthood Research,Shanghai,China Alenka Pretnar-Darovec, University MedicalCentre, Ljubljana, Slovenia CatholicUniversity ofChile, ElenaOrtiz, Santiago,Maria Chile Cui Nian,SichuanFamily PlanningResearchInstitute, Chengdu,China Cora Ngai,University ofHongKong, HongKong, SpecialAdministrative RegionofChina Ng,UniversityErnest ofHongKong, HongKong, SpecialAdministrative RegionofChina Suneeta Mittal,AllIndiaInstituteofMedicalSciences, New Delhi,India Nicholas Mascie-Taylor, University ofCambridge,UnitedKingdom Frank Lüdicke, University ofGeneva, Geneva, Switzerland Pablo Lavin, University ofChile, Santiago, Chile Laszlo Kovacs, Szent-Györgyi MedicalUniversity, Albert Szeged, Hungary University Kirkman, HospitalofSouthManchester,Rosemary Manchester, UnitedKingdom Archil Khomassuridze, ZhordaniaInstituteofHumanReproduction, Tbilisi, Georgia Ho Pak Chung,University ofHong Kong, HongKong, SpecialAdministrative RegionofChina Gemzell-Danielsson,Kristina KarolinskaInstitute, Stockholm, Sweden Ding Ju-hong, JiangsuFamily PlanningResearchInstitute, Nanjing, China Luigi Devoto, University ofChile, Santiago, Chile Madeleine deRosas-Valera, Health&ManagementInformation System, Manila,Philippines Delgado, andPanama,Hernan ofCentral America InstituteofNutrition GuatemalaCity, Guatemala Olukayode Dada,OgunStateUniversity Teaching Hospital, Sagamu, Nigeria Horacio Croxatto, ChileanInstituteofReproductive Medicine, Santiago, Chile Magdalena Chu Villanueva, Peru University, Lima,Peru Cheng Wei-yu, Tianjin MunicipalResearchInstitute for Family Planning, Tianjin, China Cheng Linan,ShanghaiInstituteofFamily Planning Technical Shanghai,China Instruction, andGynaecologyHospital,Shanghai,China Cheng Li-cun,ShanghaiChangningObstetrics Marc Bygdeman,KarolinskaInstitute, Stockholm, Sweden Burger,Henry Henry’s Australia Prince InstituteofMedicalResearch,Melbourne, James Brown, Royal Women’s Australia Hospital,Melbourne, Len Blackwell, Massey University, Palmerston New Zealand North, Shakuntala Bhatnagar, NationalInstituteofHealthandFamily Welfare, New Delhi,India Stan Becker, JohnsHopkinsUniversity, Baltimore, MD, USA Szent-GyörgyiGyörgy MedicalUniversity, Albert Bártfai, Szeged, Hungary David Baird,University ofEdinburgh, Edinburgh, UnitedKingdom Dan Apter, The Family Federation ofFinland,Helsinki,Finland Oyunbileg Amindavaa, andChildHealth,Ulaanbaatar, StateResearchCentreonHumanReproductionandMaternal Mongolia Principal investigators Scientists in2001 RESEARCH GROUP ONPOST-OVULATORY REGULATION METHODSFORFERTILITY Annex 2a Section 1-Promoting familyplanning Section Annual Technical Report 2001 31

7 1 4 3 3 1 7 39 18 11 16 14 10 Totals Totals

5 3 8 43 29 21 21 28 18 % of total % of total

6 4 3 3 2 1 7 3 11 Number Number Developed countries Developed Developed countries Developed

3 10 10 % of total % of total Research on the development of methods of fertility regulation on the development Research

4 1 4 Countries in transition Number Countries in transition Number

7 3 57 43 50 62 38 15 10 33 % of total % of total

1 6 4 8 6 1 7 24 15 13 Developing countries Developing Developing countries Developing Number Number All

Women Women EMRO from: AFRO AMRO EURO SEARO WPRO Bao Gui-xia, Shanghai Changning Obstetrics Hospital, Shanghai, China and Gynaecology Switzerland Geneva, of Geneva, Maria Condrea, University China Wuxi, Maternal and Child Health Hospital, Wuxi Pei-ying, Fang TX, USA Galveston, Medical Branch, Texas Robert of Garfield, University USA CO, Denver, Kennedy, Kathy Switzerland Geneva, of Geneva, University Brigette Kramer, Delhi, India New All India Institute of Medical Sciences, Sunesh Kumar, Sweden Stockholm, Lena Marions, Karolinska Institute, USA Texas, Medical Branch, Texas of Shao-Qing Shi, University China Wuxi, Maternal and Child Health Hospital, Wuxi Yi-fang, Wang Shanghai Changning Obstetrics China and Gynaecology Hospital, Shanghai, Fei-ying, Wei Planning, Beijing, China Family National Research Institute for Er-ruo, Wu Planning, Beijing, China Family for Xiao Bilian, National Research Institute China Planning, Beijing, Family Institute for National Research Zhu Peng-di, Other scientists

All Women Women from: AFRO EURO AMRO SEARO EMRO WPRO 32 Annual Technical Report 2001 Alex Jordan,U.S. Food Administration, Rockville, andDrug MD, USA Rebecca Jones,Henry’s Prince InstituteofMedicalResearch, Clayton, Australia Huezo,Carlos PlannedParenthood International Federation, London,UnitedKingdom Hickey,Martha CollegeSchoolofMedicine, Imperial London,UnitedKingdom Anita Hardon,University ofAmsterdam,theNetherlands Han Li-Hui,BeijingHospitalof GynaecologyandObstetrics, Beijing,China Anna Glasier, Family Planningand Well Woman Edinburgh, Services, UnitedKingdom Gabelnick, ContraceptiveHenry Research andDevelopment Program (CONRAD), Arlington, VA, USA Ian Fraser, QueenElizabethII Research Institutefor MothersandInfants, Sydney, Australia Anibal Faundes, CEMICAMP, Campinas, SaoPaolo, Brazil Mawaheb Tawid El-Mouelhy, Cairo Family PlanningAssociation,Cairo, Egypt Lindsay Edouard,UnitedNationsPopulation Fund,New York, NY, USA Laneta Dorflinger, ResearchFamily HealthInternational, Triangle NC,Park, USA Soledad Diaz,ChileanInstituteofReproductive Medicine(ICMER),Santiago, Chile CentersforKate Curtis, DiseaseControlandPrevention, Atlanta,GA,USA Horacio Croxatto, ChileanInstituteofReproductive Medicine(ICMER),Santiago, Chile Henry’sMelissa Brasted, Prince InstituteofMedicalResearch,Clayton, Australia Frank Alvarez, PROFAMILIA, SantoDomingo, DominicanRepublic Biran Affandi, University Indonesia ofIndonesia, Jakarta, scientists Other Sugito Wonodirekso, University Indonesia ofIndonesia,Jakarta, Julianto Witjaksono, University Indonesia ofIndonesia,Jakarta, BektiSubakir,Sri University Indonesia ofIndonesia,Jakarta, Henry’sLois Salamonsen,Prince InstituteofMedicalResearch,Clayton, Australia Peter Rogers, MonashMedicalCentre, Clayton, Australia Rebecca Massai,ChileanInstituteofReproductive Medicine(ICMER),Santiago, Chile Gu Sujuan,BeijingMunicipalResearchInstitutefor Family Planning,Beijing,China Vivian Brache, PROFAMILIA, SantoDomingo, DominicanRepublic Rim BenAissa,ResearchCentrefor HumanReproduction, Tunis, Tunisia Hany Abdel-Aleem,AssiutUniversity, Assiut,Egypt Principal investigators Scientists in2001 RESEARCH GROUP ONLONG-ACTING SYSTEMIC AGENTS REGULATION FORFERTILITY Annex 2b WPRO SEARO EURO EMRO AMRO AFRO from: Women All Section 1-Promoting familyplanning Section Number Developing countries 3 2 2 5 1 8

% oftotal 30 20 20 50 10 80

Number Countries intransition Countries

% oftotal

Developed countries Number 1 2 2

% oftotal 10 20 20

Totals 10 3 2 2 6 3 Annual Technical Report 2001 33 5 3 5 2 2 31 17 14 Totals

13 55 32 29 13 % of total

4 9 4 17 10 Number Developed countries Developed

% of total Research on the development of methods of fertility regulation on the development Research

Countries in transition Number 3 6 6 3 10 45 23 16 % of total 1 3 7 2 5 2 1 14 Developing countries Developing Number WPRO SEARO All Women from: AFRO AMRO EMRO EURO

Rose Kithinji, Kenyatta National Hospital, Nairobi, Kenya National Hospital, Rose Kithinji, Kenyatta Tunisia Tunis, Reproduction, Human for Research Centre Mansour, Hayet Australia Marion Clayton, Institute of Medical Research, Marsh, Prince Henry’s Marie International, Stopes Addis Ababa, Ethiopia Mekbib, Tekle-Ab Chile Ojeda, Santiago, Thayer Luis Meirik, Ave Olav USA NY, York, Council, New The Population Suellen Miller, Turkey Istanbul, of Istanbul, Ortayli,Nuriye University Jakarta, of Indonesia, Indonesia University Ida Proemono, of Southern CA, USA Los Angeles, California, University Kathleen Rodgers, of Indonesia, Jakarta, Indonesia University Eka Rusdianto, Cambridge, MA, USA Technology, Shastri,Prasad Institute of Massachusetts USA NY, York, New Council, The Population Irving Sivin, Other scientists (continued) Annex 2b (continued) Annex FOR FERTILITY REGULATION AGENTS SYSTEMIC ON LONG-ACTING GROUP RESEARCH 34 Annual Technical Report 2001 WPRO SEARO EURO EMRO AMRO AFRO from: Women All Peter White, Nova Limited,Leicester, Laboratories UnitedKingdom Theo deRoij,AphtonCorporation, Tervuren, Belgium Peter Rees, HuntingdonLife Sciences, Huntingdon,UnitedKingdom John Powell, OhioStateUniversity, Columbus, OH,USA Dov Michaeli,AphtonCorporation, Woodland, CA,USA Pravin Kaumaya, OhioStateUniversity, Columbus, OH,USA Loughborough,UnitedKingdom Susan Hagan,AphtonCorporation, Stephen Grimes,AphtonCorporation, Woodland, CA,USA Frederick Frye, Comparative Medical,SurgicalandPathology Consultation,Davis, CA,USA Peter Fagan, Edinburgh, Services, UnitedKingdom Quintiles Pharmaceutical Faz Chowdury, Loughborough,UnitedKingdom AphtonCorporation, scientists Other Vernon Stevens, OhioStateUniversity, Columbus, OH,USA James Hampton,Peninsula Laboratories, SanCarlos,CA,USA Richard Ascione, AphtonCorporation, Woodland, CA,USA Principal investigators Scientists in2001 RESEARCH GROUP ONIMMUNOCONTRACEPTIVES Annex 2c WPRO SEARO EURO EMRO AMRO AFRO from: Women All Section 1-Promoting familyplanning Section Number Number Developing countries Developing countries

% oftotal % oftotal

Number Countries intransition Countries Number Countries intransition Countries

% oftotal % oftotal

Developed countries Developed countries Number Number 11 6 5 1 3 3

% oftotal % oftotal 100 55 45 100 100 9

Totals Totals 11 1 6 5 3 3 Annual Technical Report 2001 35 3 3 6 2 4 14 Totals

7 7 36 50 21 % of total

1 5 1 7 3 Number Developed countries Developed

% of total Research on the development of methods of fertility regulation on the development Research

Countries in transition Number

7 7 7 14 21 50 % of total

2 3 1 1 1 7 Developing countries Developing Number WPRO SEARO EURO EMRO AMRO from: AFRO Women Women Elisabetta Baldi, University of Florence, Florence, Italy Florence, of Florence, Elisabetta Baldi, University USA Bethesda, MD, National Institute of Child Health and Human Development, Richard Blye, United Kingdom Ltd., Norfolk, Bootman Chemical Safety Bootman, James Mumbai, India Chauhan, Indian Council of Medical Research, S. Pawan Planning, Beijing, China Family National Research Institute for Chen Zhen-Wen, Henan, China Institute, Planning Research Henan Family Cheng Li-Fa, Orsola Hospital, Bologna, Italy S. Antonietta Costantino, Brazil Council, Campinas, The Population Diaz, Juan USA MD, and Drug Rockville, Administration, Food Rosalie Elespuru, U.S. Riga, Latvia Health Center, and Sexual Family Erenpreiss, Yuris Huntingdon, United Kingdom The Lanes, The Larches, Ralph Heywood, Bonn, Germany Drugs Devices, and Medical Institute for Federal Kasper, Peter United Kingdom Surrey, of Surrey, University George Kass, Li Han-Min, Birth-Control Institution, Guizhou, China Planning, Beijing, China Family National Research Institute for Liang Xiaowei, Italy Florence, of Florence, Michaela Luconi, University Other scientists

All Principal investigators Principal Indonesia Palembang, University, Sriwijaya Kiagus Arsyad, Italy Florence, of Florence, Gianni Forti, University Institute of Sichuan, Chengdu, China Planning Research Family Yaqi, Gong Planning, Beijing, China Family for National Research Institute Yi-Qun, Gu Australia Wales, South New of Newcastle, The University Russell Jones, TN, USA Knoxville, Tennessee, of University Handagama, Chandindrami Maria Cristina of Bologna, Bologna, Italy Meriggiola, University of Indonesia, Jakarta, Indonesia Nukman Moeloek, University Chile Antofagasta, of Antofagasta, University Morales, Patricio Israel Ramat Aviv, University, Tel-Aviv Zvi Naor, Uppsala, Sweden Nilsson, Uppsala University, Ove Institute of Cancer Research, Sutton, United Kingdom Swerdlow, Anthony of Indonesia, Jakarta, Indonesia University Tan, Anthony United Kingdom Manchester, of Manchester, University Wu, Frederick Scientists in 2001 Scientists RESEARCH GROUP ON METHODS FOR THE REGULATION OF MALE FERTILITY OF MALE THE REGULATION FOR ON METHODS GROUP RESEARCH Annex 2d Annex 36 Annual Technical Report 2001 Zhao Heng,NationalResearchInstitutefor Family Planning,Beijing,China Yu Guobin,AnhuiFamily PlanningInstitute, Anhui,China Kathryn Yount, University, Emory Atlanta,GA,USA Yao Kang-Shou,ZhejiangInstituteofPlannedParenthood Research,Zhejiang,China Wen Ren-Qian,Family PlanningResearchInstitute, Guandong,China Tong Jian-Sun,JiangsuFamily PlanningInstitute, Jiangsu,China Song Shu-Xiu,HebeiFamily PlanningResearchInstitute, Hebei,China Powell,Chris Vernalis ResearchLimited, Wokingham, UnitedKingdom Peng Lin, Yunnan Family PlanningResearchInstitute, Yunnan, China All Women AFRO from: AMRO EMRO EURO SEARO WPRO Section 1-Promoting familyplanning Section Number Developing countries 13 11 2 1 1

% oftotal 52 44 8 4 4

Number Countries intransition Countries 1 1

% oftotal 4 4

Developed countries Number 11 5 3 8

% oftotal 44 20 12 32

Totals 25 11 7 4 9 1 Annual Technical Report 2001 37 6 2 1 2 1 2 Totals

67 17 17 33 17 % of total

4 1 1 2 1 Number Developed countries Developed

% of total Research on the development of methods of fertility regulation on the development Research

Countries in transition Number

33 17 17 17 % of total

2 1 1 1 Developing countries Developing Number Principal investigators Principal Aachen, Germany of Aachen, Kaufmann, University Peter Beijing, China Institute of Zoology, Biology, Laboratory of Reproductive State Key Yi-Xun, Liu Australia Medical Research, Clayton, Institute of Lois Salamonsen, Prince Henry’s Delhi, India New All India Institute of Medical Sciences, Sengupta, Jayasree The Rosie Maternity United Kingdom Hospital, Cambridge, Stephen Smith, USA OR, Beaverton, Regional Primate Oregon Research Center, Richard Stouffer, Scientists Scientists Annex 2e Annex IN 2001 RESEARCH ON IMPLANTATION INITIATIVE FOUNDATION WHO/ROCKEFELLER

All Women Women from: AFRO AMRO EMRO EURO SEARO WPRO 38 Annual Technical Report 2001 future directions. New Publishers, Delhi,New AgeInternational 2001:143-148. periimplantation. during endometrium In: Chander PP, Van Look PFA, eds. Sexual and reproductive health. Recent advances, Wu J, ChenJ, XuR, Wang H,ZhouP, QiaoG,ZhuP, Wang Jd. Effects ofmifepristone andlevonorgestrel onthehuman , 2001,45 :7–21. Pharmacology Sengupta J. Research inreproduction: inthelastdecade(II). the Indianscenario ofPhysiology IndianJournal and Placenta (submitted). metalloproteinase-1(TIMP-1),plasminogenactivators humanfetaltissue inhibitorofmatrix andinhibitorsinterm membranes. Ockleford CD, Feng Q,Ny T, HuZY, S, d’Lacey Byrnes C, Liu YX. metalloproteinase(MT-MMP), Expressionofmatrix administered fumagillinintherhesusmonkey. Contraception, 2000,62:155–159. Lalitkumar PGL,SenguptaJ, Dhawan DN,Lasley BL,Overstreet L,Sharma JW, etal. effectAnti-nidatory ofvaginally administered (Ala8,13,18)-magaininIIamideintherhesusmonkey. Contraception, 2000,62:39–43. Dhawan L,GhoshD, DN,Lasley BL,Overstreet LalitkumarPGL,Sharma JW, etal. effect Anti-nidatory ofvaginally for emergencycontraception: a review oftheliterature. Contraception, 2001,63:111–121. Croxatto HB, Devoto L,Durand M,Ezcurra E,LarreaF, NagleC, etal. preparations used Mechanismofactionhormonal contraception. and RecoursetoAbortion. A randomised double-blind oftwo singledosesofmifepristone comparison for emergency Clinical Research Team for Collaborative ResearchandDevelopment onMifepristone toReduceUnwanted Pregnancies Publications in2001 CONTRACEPTION RESEARCH GROUP ONPOST-OVULATORY REGULATION METHODSFORFERTILITY -EMERGENCY Annex 3a Section 1-Promoting familyplanning Section British Medical Journal (submitted). MedicalJournal British Annual Technical Report 2001 39 Reproduc- Molecular Journalof Clinical Archives of Ibadan Medicine (in press). Archives Human Reproduction, 2001 mal uterine bleeding? Bailliere’s Clinical Obstetrics and Gynecology, 2001, 14 (in Bailliere’s Research on the development of methods of fertility regulation on the development Research , 2001 (in press). of Reproduction Reviews . New York, Parthenon Publishing, Publishing, Parthenon York, New century medicine in the twenty-first . Reproductive (submitted). Contraception , 2000, 49:115–132. Journal Immunology of Reproductive ,” Endometrium“Cell and Molecular Biology of Health and Disease,” in Institute Symposium Proceedings of Kobe Contraception (in press). Contraception Massai R, Pavez M, Fuentealba B, Croxatto H, d’Arcangues C. Effect of intermittent treatment with mifepristone on bleeding of intermittent on bleeding treatment with mifepristone Effect H, d’Arcangues C. Croxatto M, Fuentealba B, Massai R, Pavez patterns in Norplant implant users. insights into the mechanisms underlying menstruationNew and abnormal uterine Vincent AJ. Salamonsen LA, Zhang J, bleeding. tissue inhibitor of metalloproteinase in the Decreased G, et al. Kovacs B, Affandi Rogers PAW, Ostor A, Zhang J, Vincent AJ, altered endometrial matrixa role for metalloproteinase/ acetate: endometrium using depot medroxyprogesterone of women tissue inhibitor of metalloproteinase balance in the pathogenesis of abnor Angiogenesis and the endometrium. Rogers PAW. GC, Weston Human Reproduction, 2000, 6:899–906. networks and human endometrial remodelling. Journal Leukocyte of Reproductive M. Brasted Salamonsen LA, Zhang J, , 2001 (in press). Immunology 2001 (in press). (in press). press). Hampton AL, Rogers PAW, Affandi B, Salamonsen LA. Expression of the chemokines, monocyte chemotactic protein (MCP)-1 protein chemotactic monocyte chemokines, the of Expression LA. Salamonsen B, Affandi PAW, Rogers AL, Hampton and MCP-2 in endometrium of normal and Norplant women ® users does not support role in macrophage infiltration a central into endometrium. of menstruation. neutrophils in the process In vitro studies of the potential role for Salamonsen LA. Lathbury LJ, Galant C, Vekemans M, Lemoine P, Kokorine I, Twagirayezu P, Henriet P, et al. Temporal and spatial association of matrix Temporal et al. Henriet P, P, Twagirayezu I, Kokorine M, Lemoine P, Vekemans Galant C, upon progestin-only contraception. endometrial and bleeding breakdown metalloproteinases with focal d’Arcangues C. New trends in contraception: the World Health Organization global view. In: Healy DL, Kovacs GT, GT, Healy DL, Kovacs In: global view. Health Organization World the trends in contraception: New d’Arcangues C. eds. McLachlan R, Rodriguez-Armas O, planning methods. in family Recent advances K. Vogelsong d’Arcangues C, of the once-a-month first injection Delayed et al. F, H, Alvarez-Sanchez Yang Massai R, V, M, Brache CA, Hays Petta on cervicaleffects acetate and 5 mg of E2-cypionate: containing 25 mg of medroxyprogesterone contraceptive injectable mucus. on endometrial bleeding Basic research Endometrial angiogenesis. Gargett CE, Rogers PAW. tive BioMedicine Online, 2001, 31:34–41. BioMedicine tive 2002:432–443. injectable once-a-month the of injection first Delayed al. et F, Alvarez-Sanchez H, Yang R, Massai V, Brache M, Hays CA, Petta function. on ovarian effects acetate and 5 mg of E2-cypionate: containing 25 mg of medroxyprogesterone contraceptive Fertility and Sterility, 2001, 75:744–748. Endocrinology and Metabolism, 2000, 85:4827–4834. Long-acting methods of fertility regulation technologies. opportunities, new and other new emergency contraception planning needs: Family d’Arcangues C. Publications in 2001 Publications Annex 3b Annex FOR FERTILITY REGULATION AGENTS SYSTEMIC ON LONG-ACTING GROUP RESEARCH 40 Annual Technical Report 2001 fertility andsemenquality.fertility Stewart TM, Brown EH, Venn A,Mbizvo MT, Farley TMM, GarrettC, etal. Feasibility ofchangesinhuman ofsurveillance combination regimenofcyproteroneacetateandtestosteronebuciclate inbonnetmonkey. RS, RajalakshmiM,PalSharma PC, Roy S, Behal DN,etal. VK, Sharma Evaluation ofefficacy, safety, andreversibility of gia, 2001,39:1385–1394. O’Connor DB, ArcherJ, Hair WM, Wu FCW. Activational effects oftestosteroneoncognitive functioninmen. Aggressive Behavior, 2001,27:79–101. O’Connor DB, ArcherJ, Wu FCW. andresponsestoprovoking reports scenarios. aggression: Measuring partner self-reports, Psychological Society,2000,8:40–41. O’Connor DB, ArcherJ, Wu FCW. Does testosteroneaffect cognitivemen?ProceedingsoftheBritish functioninnormal Society ofReproductive Medicine, 20–25October2001,Orlando, FL,USA. (GnRH)andprogesterone(P). gonadotrophin-releasing hormone Abstract (P464),57thAnnual MeetingoftheAmerican Morales P, PizarroE,Kong M. tothehumanzona pellucida(hZP)andcalciuminfluxinresponseto Sperm-binding reaction. Morales P, Cikutovic M,Pastén C, PizarroE,Kong M,LlanosMN. Effect acrosome oflysophospholipidsonthehumansperm tion, 2002(submitted). MC,Meriggiola Farley TMM, Mbizvo M. A review ofandrogen–progestin regimensfor malecontraception. 62:73–78. implants, aloneorincombinationwitha5-alpha-reductaseinhibitor, for contraception. malehormonal McLachlan RI,McDonaldJ, Rushford D, DM,GarrettC, Baker Robertson HW. Efficacy andacceptabilityoftestosterone progesterone inhumanspermatozoa. S,Luconi M,BonaccorsiL,BiniLiberatori Pallini V, G,etal. Forti ofmembraneCharacterization nongenomicreceptorsfor Publications in2001 RESEARCH GROUP ONMETHODSFOR THE REGULATION OFMALEFERTILITY Annex 3c Section 1-Promoting familyplanning Section Revista CienciaySalud,2000,4:5–13. Human Reproduction,2001,16:177–187. Steroids, 2001,67(inpress). , 2001,76 (3suppl. andSterility Fertility 1):S267. Contraception, 2000,62:195–201. Contraception, 2000, Human Reproduc- Neuropsycholo- Annual Technical Report 2001 41 Journal Journal Journal of Research on the development of methods of fertility regulation on the development Research , 2001, 64:209–215. Contraception International Journal of Epidemiology, 2001, 30:52–57. Tennekoon KH. Maternal prolactin concentrations and lactational behaviour in shortMaternal and lactational behaviour prolactin concentrations and long amenorrhoeics. KH. Tennekoon and energy balance energy expenditure Repeated measurements of energy intake, CGN. Rosetta L, Mascie-Taylor S, Vinoy European Journal of Clinical Nutrition, 2000, 54:579–585. in lactating Bangladeshi mothers. Le Strat Y, Thalabard JC. Survival analysis in reproductive epidemiology: some methodological and practical aspects. aspects. practical and methodological some epidemiology: reproductive in analysis Survival JC. Thalabard Y, Strat Le of Bank, Special Programme UNDP/UNFPA/WHO/World Regulation of Fertility. the Natural Research Group on Methods for in abstinence and calendar method use Periodic in Human Reproduction. Training and Research Research, Development the Philippines and Sri Lanka. Peru, Hungary, in Human Reproduc- Training and Research Development of Research, Bank Special Programme UNDP/UNFPA/WHO/World and lactational amenorrhea in Sagamu, feeding Infant Regulation of Fertility. the Natural on Methods for Force Task tion. African Journal Health (in press). of Reproductive Nigeria. Law CM, Egger P, Dada O, Delgado H, Kylberg E, Lavin P, et al. Body size at birth Body size pressure among children in and blood et al. P, E, Lavin Delgado H, Kylberg Dada O, CM, Egger P, Law countries. developing some methodological Analysis of postpartum lactational amenorrhoea in relation to breast-feeding: Thalabard JC. Y, Le Strat Journal33:529–549. 2001, of Biosocial Science, aspects. and practical Impact of lactation upon reproduction in the capuchin M. M, Martinez Gordon K, Serón Ferré MC, Vergara Recabarren MP, Journalof Medical Primatology , 2000, 29:350–360. apella). (Cebus monkey in Human Reproduc- Training and Research Development of Research, Bank Special Programme UNDP/UNFPA/WHO/World Correlates of lactational amenorrhea in Chengdu, China. Regulation of Fertility. the Natural on Methods for Force Task tion. Journal of Obstetrics and Gynaecology Research (submitted). Gross A, Burger H for the WHO Task Force on Methods for the Natural Regulation of Fertility. Breastfeeding patterns and Breastfeeding Regulation of Fertility. the Natural for on Methods Force Task WHO the Gross A, Burger H for Zealand Journal and New Obstetrics of and Gynaecology (in press). Australian Women. return fertility to in Australian Multicenter Study of the Lactational Look P. Van Hertzen von H, V, MH, Hight R, Labbok AE, Perez-Escamilla Peterson , Contraception contact. with reduced client provider and satisfaction duration Effectiveness, III: Amenorrhea Method (LAM). 221–230. 2000, 62: in Human Reproduc- Training and Research Development of Research, Bank Special Programme UNDP/UNFPA/WHO/World of Fertility. Regulation the Natural on Methods for Force Task Protocol and Reference Group on the Growth Working tion. American Journal of Clinical Nutrition and frequency of complementary and the timing, type, foods. infants of healthy Growth (in press). of Obstetrics:265–270. and Gynaecological Research, 1999, 25 of Biosocial Science (submitted). Obstetrics and Gynaecology Research (submitted). Cui N, Tang G, Li M, Xie L, Yang X. An analysis of breastfeeding patterns and menses returning An analysis of breastfeeding in Chengdu, China. X. Yang G, Li M, Xie L, Tang Cui N, Blackwell LF, Brown JB, Vigil P, Gross B, Sufi S, d’Arcangues C. Home definition of the potentially fertile of the potentially Home definition and infertile phases C. S, d’Arcangues Sufi Gross B, Vigil P, JB, Brown LF, Blackwell monitor and the ovarian obtained by Correlation of results Part I. monitor, ovarian the home of the human ovulatory cycle by Fertility and Sterility (submitted). radioimmunoassay, those obtained by Becker S, Ahmed S. Dynamics of contraceptive use and breastfeeding during the post-partum period in Peru and Indonesia. during the post-partum use and breastfeeding and Indonesia. period Dynamics of contraceptive in Peru Ahmed S. S, Becker Studies, 2001, 55:165–179. Population Publications in 2001 Publications Annex 3d Annex FERTILITY OF REGULATION ON NATURAL GROUP RESEARCH 42 Annual Technical Report 2001 identifying the unmet needs of clients, and the services services the and clients, needed toaddressthem. of needs unmet the while identifying users potential and users both for regulation fertility of methods of acceptability care. the indicate findings These improved for recommendations evidence-based with agers man- programme and policy-makers provide perspectives sion-making for policies and programmes. Findings on users’ deci- informed for information sound scientifically provide to services. ductivedesigned health is work programmeof The that have an care important bearing on the of access to and quality use of repro- of aspects neglected the address to is objective third perspectives.The and behaviours practices, users’ influence that contexts sociocultural and constraints the understand to is objective second The methods. lating availableregu- currently fertility or emerging of and services health reproductive of users potential or users as spectives per- and behaviours women’s and men’s understand better focus The of primary the Department’s work in this area is to and thesociocultural context oftheseservices. ods, influenced also is they care the of quality the by receive meth- various of acceptability and contraceptivepractice ing infections (STIs). Their reproductive health behaviour, includ- transmitted sexually and pregnancy unwanted of risks dual the of assessment their and supplies, and services health reproductive available the providers, with interactions their increasingly by become shaped are has users of needs services and Perspectives important. of use the to con- straints the as well as preferences and needs health ductive and services, an understanding of men’s and women’s repro- of programmes levels policies, improvedinformed through achieve health reproductive to effort global the of part As Section 1-Promoting familyplanning Section INTRODUCTION ANDOBJECTIVES Research onusers’ perspectives I.H. Shah, I.K. Warriner, S. Jejeebhoy HIV infection have been recorded among women attending women among recorded of been have infection rates HIV high and infrastructure, poor from suffer erished, impov- relatively are sites Both province. Natal KwaZulu site in rural one and urban one in conducted was study The made available here. in2001andarereported to, behavioural constraints change. New findings from South and Africa were for, opportunities explore to (iii) and risks; sider appropriate, practical and effective in coping with these develop strategies that sexually active individuals would con- to pregnancy; (ii) unintended and HIV/AIDS) (including STIs spectives of sexually per- active individuals the about the dual determine risks of to (i) objectives: main three address to designed Zimbabwe.is and study Zambia The Uganda, nia, Tanza-of Republic United Africa, South Kenya,greatest: is epidemic HIV the where countries African southern and ern east- six in ongoing been has project research a multicountry HIV/AIDS, to related behaviour risk and planning family between interactions the assess to attempt pioneering a In Family planningintheera ofHIV/AIDS Progress under asocialscienceresearchinitiative onqualityofcare. aspects of users’ perspectives, some of which are supported health reproductive technologies and services. Several on projects focus on various perspectives and needs their and decision-making, health reproductive women’s and men’s understand better to aims perspectivesusers’ on Research Specific objectivesSpecific of research RESEARCH ACTIVITIES Annual Technical Report 2001 43 . , Research on users’ perspectives on users’ Research South Africa a, a, y iews in Ken v r people do not contract AIDS between preventive and furtherrisky Nonetheless, behaviour. 42% deepen the chasm of all respondents reported used having a ever condom and there are signs that dual protection used is ever had who acceptable women and men to 476 the Of some respondents. a condom, 63% reported using the condom in planning. another method of family addition to interviewswere in-depth and FGDs the from results 2001, In 1.1). countries the six Box (see for synthesized A separate study examined the relationship between wom- en’s status, sexual behaviour, and HIV/AIDS in Cameroon. Little is known about behav- sexual risky the from herself protect to mechanisms ability her to status linking a woman’s iour, including HIV infection. The study found that of women higher status were more likely to communicate with their partners and negotiate preventive measures against These HIV/ AIDS. findings support the concept ofwomen’s eco- nomic and educational advancement as protection against HIV infection through increased ability behaviours. to sexual negotiate safer Family planning Family policy-makers and managers in low-income of methods effective highly promoted typically have countries including ones, effective less of expense the at contraception barrier The methods. advent of the HIV epidemic, together with increasing awareness of the incidence of and other their role STIs as cofactors in HIV transmission, represents a powerful new consideration in the relative priority given to provid- planning family by contraception of methods different barrier Specifically, ers. methods (mainly the male condom) assume new importance because of their dual role in pro- Choice, discontinuation and switching of contraceptive and switching discontinuation Choice, Zambia and Zimbabwe and Zambia

anzania, T y of common findings from in-depth inte United Republic of Uganda, Summar x 1.1. Bo As in many other countries, condom use is associated with Fatal- it. encourage promiscuity and is sometimes thought to istic attitudes and misconception about the condom coupled with safety the belief of that responsible the and moral “AIDS is also a problem because you some- if [AIDS] can it get can you but condom trya use and yourself and protect If a body person rapes rapes you. he you, time doesn’t have user). contraceptive (urban woman, a condom,” for Unlike Unlike in five other participating countries, sexual violence pro- to barriers major as Africa South in noted were rape and and STIs. pregnancy tection against unwanted “Condoms are known. Most of the men don’t want them. They They them. want don’t men the of Most known. are “Condoms fight with us when we talk condoms,” about woman, (rural user). contraceptive However, However, despite high levels of of awareness HIV/AIDS, strong of moral the condemnation risks of within stable relationships or condom monogamous marriages inhib- use its behavioural change. For example, opposition to condom FGDs. many commonly noted in use was antenatal The clinics. study involved three phases: (i) focus group discussions (FGDs); (ii) a active women survey 18–35 years of of age and 622 523 sexually active sexually Findings indicate in-depth interviews. and (iii) follow-up men; about knowledgeable universally nearly are respondents that leading contraceptive methods (condoms, oral contracep- tives, injectables and favourable female attitude toward family sterilization) planning. The majority and of respondents have cited condom use as a being protective against HIV/AIDS and most were aware that condom use provides HIV/AIDS. pregnancy and unwanted dual protection against 44 Annual Technical Report 2001 f alr o mto-eae raos uh s side-effects, as such reasons method-related or failure of doms are more likely than the pill to be discontinued because Paraguay (13%) and Turkey (13%). At 12 months of use, con- the main exceptions condoms, being Bangladesh (8%), on Colombia (9%), rely users all of 1–6% HIV.Typically, only of ing seven are currently classified as having a low prevalence Colombia, Nicaragua, Paraguay and Peru), while the remain- (Brazil, epidemics concentrated have five further A babwe). epidemics (Dominican HIV Republic, Guatemala, generalized Kenya as having and Zim- UNAIDS by classified are tries coun- 16 the of Fouranalysed. were (DHS) Surveys Health Data in from the 16 Demographicparticipating countries and towards thecondom. method choice from highly effective methods such as the pill contraceptive in occurred shift widespread a if future the in births unwanted of potential incidence the the and abortion of for demand implications probable the assessed also sons that implied dissatisfaction with the methods. rea- The paper for use of discontinuation following events and unwanted births) abortion, (e.g. failure of consequences (iv) and discontinuation and failure rates with the pill and the condom; of comparison (iii) users; pill to compared users condom of characteristics (ii) use; condom in trends worldwide of tion examina- an (i) covered: and 2001, August in (IUSSP) tion of Popula- Study Scientific the for Union International the of Conference Population General XXIV the at presented was of incidence the of paper abortion. The for demand future terms and births unwanted in method, this of use spread study also sought to identify the consequences of more contraceptive.This wide- a as condom Tropical the and reassess to Hygiene Medicine of School London of University the from scientists with collaboration in out carried was study A marriage. including relationships, stable within method contraceptive a as condom the public of promotion vigorous strong for rationale health a the is into there spread population, has heterosexual HIV general where countries of number ing tecting against unwanted pregnancy and STIs. In the increas- Section 1-Promoting familyplanning Section ercentage discontinuing use of contraceptive method by 12 months, and of by report type Fi % gure 1.4.

P ed reasons f o r discontinuation(16countries) otnain f otaetv ue.Rsac ta explores the that Research use). to contraceptive of regard continuation with especially behaviour, and satisfaction knowledge, client behaviour; provider (e.g. outcomes diate interme- effectson the quality assess improved to of service care.of Additionally,initiativethe designed proposals sought standards objective and/or cli- providers clients, potential of ents, perspectives the from of services quality health the reproductive assess to research supporting on focusing A research initiative on quality of care was launched in 2000, science researchSocial initiative ofcare onquality il wud teeoe se cle fr acrig o the to according for,authors. called seem therefore, would, sible acces- abortion safe and contraception emergency making and abortion on restrictions Liberalizing countries. income low- in attractive or feasible is strategy this that suggest to evidence little is injectable.However, there an or pill the as neous use of the condom together with another method such protection: simulta-favourto “double-method”a approach of in argues it discontinuation, for reason stated commonly a couples.effective more formarried is a desire method Since of two-thirds almost by months 12 within abandoned is that one also but marriage in method used rarely a condom the is only Not disappointing. are results these epidemics, HIV generalized with countries in use condom increased vastly for need health public the episodes.against pill set of When 54% with compared months 12 than more lasted episodes use condom of 32% only average,countries, On 16 these in the using condom is 70 percentage points higher than in using the pill. in failure to due month 12th the by continuance dis- of risk relative the child, another for desire the as well as use of start the at children living of number and age the Adjusting for place of residence, women’s level of education, tive method,objectionsby thehusband,andinconvenience. effec- more a to switch to wish familiar: the are use condom stopping for stated reasons major the child, a for desire and failure to addition 1.4). In (Figure availability or access cost, health concerns, husband’s disapproval, inconvenient to use, n ai n Sngl n find- and Senegal and Mali in implemented was methods tive contracep- of access to barrier this addressing study a In 2001, pregnancy. unrecognized an harm that may believing contraceptives clients, ating nonmens-tru- to contraceptives deny providers planning family countries, developing some In aged. treatment—is especially STI encour- or abortion perspectives, providers’ health, maternal ple, reproductive health—for exam-health—forreproductive of areas under-studied rel- atively the in care of quality the Annual Technical Report 2001 45 Social sci- Social Asia-Pacific PopulationAsia-Pacific Jour- Research on users’ perspectives on users’ Research TECHNICAL COOPERATION WITH COUNTRIES TECHNICAL COOPERATION tives tives on quality of care compare with clients’ views on the same in Egypt, Peru and Uganda. A parallel FRONTIERS study on users’ perspectives is also perspectives being providers’ implemented the from in findings and countries; these study will from complement perspectives the data on clients’ FRONTIERS The study. project will examine the per- quality; of following definitions providers’ areas: under-researched of view ceptions of servicesperceptions of clients’ rendered; services rendered; perceptions of clients in general; provid- workenvi- their of perceptions providers’ and motivation; ers’ ronment. Study findings will be supervisor of assistance training systems in for these countries, the designing and will of be of in relevance other Dissemination countries. developing of findings and discussion of interventions will be undertaken non- local health, of ministry national the others, among with, plan- family and agencies donor organizations, governmental institutions. ning training Extensive Extensive technical cooperation was provided to the project China. in Care” Health Reproductive of Quality the “Improving Social policy and dissemination briefs science research of findings of series the Programme, the by 1999 in Launched briefsare The 2001. in briefscontinued policy research ence intended to highlight the policy and relevance programmatic impact of social science research, and the to analytical build capacity and technical writing skills of in-country investiga- tors through collaboration extensive during the development of this publication. A brief on the role traception in of reducing emergency the con- induced abortion rate in Shang- hai, China was produced in 2001. It is that investigated based the knowledge, on attitudes and a acceptability study of emergency contraception (anordrin, IUD, levonorgestrel) among women seeking surgical termination of first-trimester contraception emergency of knowledge Although pregnancy. was low, 86% of the respondents would be for preference their expressed and willing contraception emergency to use obtaining it from drugstores. if Hypothetically, these women had emergency used contraception, levonorgestrel-only had access had had and failure contraceptive their of aware been to emergency contraception, 60% of the induced abortions been averted. could have In 2001, a special issue of the nal was devoted entirely to the studies in South Asia sup- ported under a collaborative research initiative by The Ford Pro- Special the and Foundation Rockefeller The Foundation, The issue included 14 papers topics covering such gramme. per- users’ and health, maternal behaviour, health-seeking as services.and technologies health, reproductive on spectives Copies of the journal were widely distributed among policy- other interested parties and makers in South Asia. Providers’ perspectives perspectives Providers’ are frequently overlooked in studies of quality of A care. study will document attitudes providers’ perspec- and gain a deeper providers’ understanding of how The area of quality of maternity care is an important focus of research for women in developing countries, particularly in where Turkey maternal and infant health indicators have assess will study The development. economic behind lagged the quality of antenatal, delivery and three different postpartumtypes of hospitals care providing services in to exam- will low- project The Istanbul. in women middle-income and ine indicators of quality of care from perspectives providers’ and clients’ experiences, using several methods to exam- interviews, collect exit interviews, in-depth from ranging data, and records, medical individual and records facility of ination direct observation of provider and client interactions. Find- policy-mak- and programme- provide will study the from ings ers with data to assist in the development of strategies quality of care. strengthen services and improve to Quality care of submis- 15 from selected care of quality on projects new Two initiated during were 2001. sions, New projects initiated during 2001 during projectsNew initiated A study carried out in Shanghai, China examined the accu- racy of the reporting of premarital activity compar- by sexual ing data from two periods in time. The study asked respondents investigators if they had engaged in premarital sex at the time of application for a marriage license and, again, at The results indicate home the 4–6 respondent’s weeks later. that underreporting rates were higher at the initial visit than at the follow-up. A number of factors may explain the including the possibility crepancy, that dis- respondents felt freer to acknowledge premarital sex once these Nonetheless, findings flag the importance exploring of they were married. optimal procedures to obtain reliable behaviour. reporting of sexual The pandemic of HIV/AIDS has brought forth the importancethe forth brought has HIV/AIDS of pandemic The of sexual behaviour. A number of studies supported under the social science research initiatives on “Sexual Behaviour Repro- in Men of “Role the on and Health” Reproductive and ductive Health” provide insights into the patterns of sexual in and high-riskdifferentials and behaviour the behav- levels iour. However, obtaining reliable and valid data on sexual remains a major methodological challenge. behaviour Research on sexual behaviour on sexual Research ings are expected for the year of 2002. the implementation The of a six-question study checklist for provid- consists ers, using WHO approved criteria for ruling out pregnancy. It will determine whether this simple and safe intervention improves access to family planning services and should be used more widely. 46 Annual Technical Report 2001 ning Commission. Technical cooperation with other Compre- countries National Plan- Family Chinese State the by the undertaken Programmes hensive to central is project This Section 1-Promoting familyplanning Section oil cec poet o wt te eiinpbiain of revision/publication the manuscripts. with or projects of science implementation social the with in-country, assisting, entailed Annual Technical Report 2001 47 2 1 1 3 2 5 1 10 Totals

10 10 % of total Research on users’ perspectives on users’ Research

1 1 Number Developed countries Developed

% of total

Number Countries in transition

10 20 10 10 20 20 90 50 % of total 1 2 1 1 2 2 9 5 Developing countries Developing Number WPRO SEARO EURO EMRO AMRO from: AFRO Members Women

Collaborating agency scientists Collaborating USA NY, York, Council, New Population The Casterline, John B. Brazil Rio de Janeiro, Foundation, Leal, Ford Ondina Fachel USA DC, Washington, International Development, Harbison, US Agency for Sarah USA NY, York, Division, New Kandiah, United Nations Population Vasantha USA DC, Washington, Council, The Population Townsend, John

Kofi Awusabo-Asare, University of Cape Coast, Cape Coast, Ghana (Co-chairman) of University Awusabo-Asare, Kofi Mexico Health, Cuernavaca, Public Mario for Bronfman, National Institute Egypt Cairo, of Cairo, American University Sahar el-Tawilla, Turkey Istanbul, Foundation, Willows Gokgol, Turkiz Aykut Beijing, China Planning Association, Family Gu Baochang, China Bolivia La Paz, Inc./Mothercare/Bolivia, John Snow Kaune, Veronica USA (Co-chairman) MD, Baltimore, Johns Hopkins University, Koenig, Mike of Natal, Durban, South Africa Mturi, University Akim Jasper Delhi, India New Visaria,Growth, Institute of Economic Leela Members Annex 1 Annex HEALTH ON REPRODUCTIVE RESEARCH AND OPERATIONS FOR SOCIAL SCIENCE PANEL SPECIALIST IN 2001 48 Annual Technical Report 2001 Zhao Peng-Fei, ShanghaiInstituteofPlannedParenthood Research,Shanghai,China Xiao Yu, SichuanFamily PlanningResearchInstitute, Chengdu,China Wei Yuan, ShanghaiInstituteofPlannedParenthood Research,Shanghai,China Alejandro Villa, CentrodeEstudiosEstadoySociedad,BuenosAires, Argentina Peter Riwa, Healthscope Tanzania Ltd.,Dar-es-Salaam,UnitedRepublic of Tanzania Mburano Rwenge, InstitutdeFormation etdeRechercheDémographique, Yaoundé, Cameroon Helen Rees, University of SouthAfrica Witwatersrand, Bertsham, Silvina Ramos, CentrodeEstudiosEstadoySociedad,BuenosAires, Argentina Hospital,Bangkok, Chulalongkorn Somchai Niruthisard, Thailand Stella Neema,Makerere InstituteofSocialResearch,Kampala,Uganda Salif Ndiaye, Recherches-Sud,Dakar, Senegal Nations,Marilyn Tropical InstituteofAppliedSocialMedicine, Brazil Fortaleza, K.A. Narayan, Jawaharlal InstituteofPostgraduate MedicalEducationandResearch,Pondicherry, India Peter Mwarogo, Development Programme, Communications Nairobi,Kenya Support Andrew Mushingeh,University ofZambia,Lusaka,Zambia William Muhwava, Unionfor Population African Studies, Dakar, Senegal Frank Mugisha,InstituteofPublic Health,Kampala,Uganda Janet Molzan Turan, University ofIstanbul, Istanbul, Turkey Farid Midhet, The AsiaFoundation, Islamabad,Pakistan Amir Mehryar, Institutefor ResearchinPlanningandDevelopment, Tehran, Iran Osegbemi Makanjuola,University ofJos, Jos, Nigeria Pranitha Maharaj, University ofNatal,Durban,SouthAfrica Sarah Loza,SocialPlanning,AnalysisandAdministration Consultants, Cairo, Egypt Liu Yun-rong, NationalResearchInstitutefor Family Planning,Beijing,China Magdalena Kleincsek,EducacionPara elMejoramiento delaCalidad Vida, Santiago, Chile Pimonpan Isarabhadki, MahidolUniversity, Salaya, Prathom, Nakorn Thailand Monica Gogna,CentrodeEstudiosEstadoySociedad,BuenosAires Garate,Maria Branoe SA,Lima, Peru Graciela Dominguez,CentrodeEstudiosPoblación, BuenosAires, Argentina Dieng,Centredeformation etderechercheensantélareproduction,Dakar,Thierno Senegal Fatimata Diallo, CellulederechercheensantélareproductionauMali,Bamako, Mali ofPublic University, Health,Marmara Sandra Cali,Department Istanbul, Turkey Aysen Bulut,University ofIstanbul, Istanbul, Turkey Evasius K. PopulationBauni, African Policy ResearchCentre, Nairobi,Kenya Paul Bakutuvwidi,Centred’Information Technique etdeRecherchepourleDevelopment, Kinshasa,Zaire andChild Samina Ali,Maternity Welfare AssociationofPakistan, Lahore, Pakistan Principal investigators SCIENTISTS IN2001 Annex 2 SEARO EURO EMRO WPRO AMRO AFRO from: Women All Section 1-Promoting familyplanning Section

Number 15 Developing countries 17 36 3 4 4 7 3 % oftotal 100 11 11 19 42 47 8 8 Countries intransition Countries Number

% oftotal

, Argentina Developed countries Number

% oftotal

Totals 15 17 36 3 4 4 7 3 Annual Technical Report 2001 49 Asia-Pacific Asia-Pacific Journalof Journal of African Journal Research on users’ perspectives on users’ Research Journalof Biosocial Science (in press). Asia-Pacific Population Journal, 2001, 16:225–238. Asia-Pacific Asia-Pacific Population Journal, 2001, 16:11–28. Asia-Pacific Asia-Pacific Population Journal, 2001, 16:177–194. Asia-Pacific Asia-Pacific Population Journal,Population 2001, 16:45–62. Asia-Pacific Prevention of unwanted pregnancy and HIV infections: perspectives of young men and women in KwaZulu-Natal, in KwaZulu-Natal, men and women of young perspectives and HIV infections: pregnancy of unwanted Prevention Asia-Pacific Population Journal, 2001, 16:29–44. Asia-Pacific Osagbemi MO, Adepetu AA, Nyong AO, Aliu YF, Olowolafe EA, Oshadumo LO. The practice of spouse-sharingThe practice among the EA, Oshadumo LO. Olowolafe YF, Aliu AO, Adepetu AA, Nyong Osagbemi MO, practices. of HIV/AIDS and perception of risk predict self-protective does knowledge Okun people of Nigeria: Sciences, 2000, 4:144–156. Environmental Neema S, Garimoi CG. “I do not know his movements”: vulnerability of women with HIV/AIDS in Uganda. Working Paper No. 4. No. Paper Working Uganda. in HIV/AIDS with women of vulnerability movements”: his know not do “I GarimoiCG. S, Neema Institute of Social Research, 2001. Kampala, Uganda, Makerere Neema S, Garimoi CG. HIV test decision among men and women in Uganda. Working Paper No. 3. Kampala, Uganda, 3. No. Paper Working in Uganda. HIV test decision among men and women Garimoi CG. Neema S, Institute of Social Research, 2001. Makerere Neema S, Garimoi CG. Affected by AIDS: orphans as a family burden in Uganda. Working Paper No. 2. Kampala, Uganda, 2. No. Paper Working in Uganda. orphans burden as a family AIDS: by Affected Garimoi CG. Neema S, Institute of Social Research, 2001. Makerere Maharaj P. Male attitudes to family planning in the era of HIV/AIDS: evidence from KwaZulu Natal, South Africa. from KwaZulu evidence of HIV/AIDS: planning in the era Male attitudes to family P. Maharaj Kampla, 1. No. Paper Working and determinants of HIV/AIDS. of condom use in the era Perceptions Garimoi CG. Neema S, Institute of Social Research, 2001. Uganda, Makerere Char A. Women’s perception of their reproductive health before and after sterilization in rural Maharashtra, India. sterilization and after in rural Maharashtra, health before of their reproductive perception Women’s Char A. in among ruralExperiences relationships women and perceptions of marital sexual PJ. Pelto E, Joshi A, Dhapola M, Kurian India. Gujarat, dynamics and fertility decision making in urban Family matter? Do mothers-in-law Khan A, Sajan F. Kadir MM, Fikree FF, Pakistan. squatter settlements of Karachi, Annex 3 Annex IN 2001 PUBLICATIONS squatter urban in women young among use contraceptive influences What MH. Rahbar F, Sajan MM, Kadir A, Khan FF, Fikree , 2001, 27:130–136. Planning Perspectives International Family Pakistan? settlements of Karachi, preliminary findings of the survey. of HIV/AIDS: in the era behaviour and sexual planning Family P. Maharaj Puberty and health of adolescent knowledge rituals, reproductive S. Veerammal PJ, DK, Pelto KA, Srinivasa Narayan schoolgirls in South India. De Silva WI, Jin Ban D. Biomedical facts and social constructs: the relative attention paid to prenatal and postpartum attention paid to prenatal relative the periods and social constructs: Biomedical facts WI, Jin Ban D. De Silva in Sri Lanka. Argentina, 2001, Buenos Aires, Diario 12, 14 de mayo, página médicos dieron la alarmaLos en un tema tabú. Dillon M. Area de Salud. CEDES, P. Maharaj Report Health World on an inter-country Men. meeting. Joint Young of African The Health and Development South Africa. 2001:21–22. of HIV-AIDS, Organization and UNAIDS Programme results care-seeking and morbidity in rural Karnataka,Antenatal care, India: S. Kilaru A, Ganapathy S, Z, Mahendra Matthews study. of a prospective Population Journal, 2001, 16:63–74. Population Southern African, 2001, 27:245–257. Studies Health, 2001 (in press). of Reproductive in an urban slum of New and correlates of morbidity in pregnant women Prevalence Bahl R, Rattan A, Bhandari N. S, Mayank Delhi. 50 Annual Technical Report 2001 safer sexual activityandcondom use. Zhao P, LiuS, QianH. atpublicImproving STIclinicsiskey quality ofservice topromoting correctcare-seekingbehaviour, inShanghai. planning services Zhao P, Zhou Y, Wang S. Evaluation ontheeffectiveness andfeasibility ofintegrating STI/HIVcounsellingwith existing family Province. Xiao Y, SandersS, Wu S, LuoL. The influenceof women’s employment conditiononbreast-feeding and working inSichuan Pacific , 2001, 16:161–176. Population Journal Unisa S. Andhra Pradesh, treatmentsamongchildlesscouplesinRangaReddyDistrict, India. Sequence offertility squatter settlementsofKarachi, Pakistan. Sajan F, FikreeFF. influencegynecologicalmorbidities: ageatmarriage Does early acasestudyamong young women in for theXXIVIUSSPGeneral Conference, Salvador, Brazil, 2001(published inCD-ROM andtheIUSSPweb site). Rwenge M. sexuelsStatut delafemme auCameroun. etcomportements Provinces deL’Ouest etduCentre. Paper prepared ideológica? BuenosAires, Argentina,CEDES, 2001. 12,14demayo.Diario Ramos S, GognaM,Petracci M,RomeroSzulikD. Los médicos frentealaanticoncepciónyelaborto: una transición Washington, DC, USA,2001:14. . ofGynecologyandObstetrics Journal International Vol. 70, SupplementNo. 1. XVI FIGO World Congress, BookofAbstracts, Ramos S, Durand T, GognaM,Petracci M,RomeroSzulikD. Ob-Gyn’s inArgentina. opinionstowards abortion andGynecology(ISPOG),BookofAbstracts.Obstetrics Buenos Aires, Argentina. 2001:62. Argentina. Ramos S, GognaM,Petracci DM,DominguesM,Durand T, RomeroM,etal. Ob-Gyn’s opinionstowards contraception in Gynecology (ISPOG),BookofAbstracts. Buenos Aires, Argentina,2001:42. andGynecology. and of PsychosomaticObstetrics PsychosomaticObstetrics Congress ofInternational XIII International Ramos S, GognaM,Petracci DM,Durand T, RomeroM,SzulikD. Ob-Gyn’s inArgentina. opinionstowards abortion Journal dans lespays duSud.Paris, L. 2001:71–97. Harmattan, sénégalais. In: Sandron F, GastineauB, eds. Petit V. Changements socio-économiques, communautés villageoisesetdiffusiondelaplanification rural famiale enmilieu Asia-Pacific , 2001,16:93–108. Population Journal Pasha O, FikreeFF, Vermund S. ofunmetneedforDeterminants family planninginsquattersettlementsKarachi, Pakistan. and Medicine(inpress). Osagbemi MO, AdepetuAA,Nyong AO, JegedeAO. The copingstrategies oftheOkuninNigeria. Osagbemi MO, AdepetuAA,Nyong AO. amongtheOkun,Nigeria. Spouse-sharing ofReproductive Journal Health,2001,5:36–55. African Osagbemi MO, AdepetuAA. Gender differences amongtheOkun,Nigeria. inspouse-sharing inthereasonsfor participation Section 1-Promoting familyplanning Section Family PlanningNews ofChinaMedicalAssociation,2001,4:5–6. Journal of Psychosomatic Obstetrics andGynecology. ofPsychosomatic Obstetrics Journal Psychosomatic Congress ofInternational XIIIInternational Reproduction andContraception, 2001,21:40–45. Sexually Transmitted Diseases(inpress). Journal ofBiosocialScience (inpress). Journal Dynamiques familiales etinnovations socio-démographiques. Etudes descas Journal ofSexJournal Research(inpress). Journal ofSocialScience Journal Asia- Annual Technical Report 2001 51 RESEARCH ACTIVITIES RESEARCH Research on the safety and effectiveness of contraceptives and effectiveness on the safety Research Progress and vasectomy cancer Prostate Studies from the USA in the late 1980s and early 1990s on the potentially increased risk of prostate cancer in vasect- omized men, raised questions about the long-term safety of the procedure. The Programme sponsored a multinational research project to assess whether there was any evidence vasectomized among cancer prostate of risk increased an for men in three developing countries—China, Nepal and the of Korea. Republic In collaboration with Family Health International (FHI), the Programme undertook a multicentre, hospital-based, case– control study in these three countries where vasectomy is The common. study involved 353 cases of prostate cancer, of which 294 had histopathologically confirmed cancer, as determined by the study reference pathologist. 879 A controls were matched total to these The cases. of overall risk of prostate cancer was 1.21 (95% Confidence intervalnonvasectomized with [CI] compared vasectomized in 0.79–1.87) Risk increased with the men. time since the procedure (0.75 more or 30 for 1.39 and years 20–29 for 1.21 years, 10–19 for years), though the trend was not statistically significant. If there were an increased risk of prostate cancer attributable to the vasectomy, excess mortality would be about 1 addi- tional prostate cancer death per men 100 000 vasectomized (upper 95% confidence limit: 4 additionalcases). The final in 2002. manuscript from this study will be published T.M.M. Farley, P.J. Rowe P.J. Farley, T.M.M. contraceptives contraceptives INTRODUCTION Research on the safety and effectiveness of of and effectiveness on the safety Research The overall The objectives of overall the work on the and safety efficacy evi- collect to (i) are: regulation fertility of methods existing of dence on the safety and effectiveness of different methods coun- developing in men and women among contraception of tries;and (ii) to address unanswered questions on a priority methods of fertility regulation when used in basis on existing countries. developing Objectives Most of the information on the safety and clinical perform- ance of methods of fertility regulation is generated in devel- oped countries and it may not be appropriate to extrapolate it to developing countries. The health and social endemic with interactions situations be may there and different very are conditions not seen in the developed address To countries. these issues, the Department carries out research on safety and the performance of methods of fertility regulation in Clinical countries. developing trials leading to product regis- tration are conducted under ideal conditions with carefully screened and monitored These volunteers. may not reflect actual conditions when the products are made available to a wider population Therefore, observational of epide- users. miological methods must be used to study the safety effectiveness under and actual conditions of This use. evidence norms, of promotion and development the for basis the forms meth- different of use the for materials training and guidelines ods of fertility regulation and for the development of quality high- family planning services. Progress in those areas is summarized in the section on “Promoting family norms and tools”. planning 52 Annual Technical Report 2001 h wr HVpstv, o kon o e eesr for necessary be to known now HPV-positive, were who women control and cases to restricted The were (HPV). analyses key papillomavirus human controls the or with cases infected the were whether assess to cells exfoliated cervical or specimens biopsy used studies These France. Lyon,(IARC), Cancer on Research for Agency International the of umbrella the under 1985–1997 period the in countries eight in conducted cancer cervical of studies case–control of analysis pooled a for funds contributed Programme The cancerCervical andsteroid hormonecontraception years following vasectomy many were shown tobeunfounded. disease cardiovascular of risk increased about potential a 1980s the ofthe in concerns safety earlier Similarly, the procedure. confirm populations different in ducted con- studies two the from vasectomy and cancer prostate between association of lack the on results reassuring The safetythe long-term oftheprocedure. study to which in population ideal an yearsago,is 20 it than has try a large number of men who were vasectomized more were aged between 35 and 44 years of age. Since the coun- they when 1970s the in vasectomizedwere men of majority vasectomyratesof highest 1.5). the (Figure world the in The of one has country Zealand. NewThe in women of surveys men confirm the high of rates of vasectomy from reported group the earlier control the with interviews from results The been submittedfor publication. vasectomy.with cancer prostate of risk has report study The aged 40–74 years). There was no evidence of any increased men Zealand New of tribution dis- age 44% the on (standardized of prevalence ardized corresponding to an age-stand- vasectomized, were age-matched controls the of 26% all, age range of 40–74 the years. within Over- (T1) disease stage T2 or above) and 217 with early (stages cancer prostate firmed 784 cases of histologically con- involved study The completed. been now has collection data study was this launched in of 1997 and phase main The land. Zea- New Dunedin, Otago, of and Social Medicine, University Preventive of Department the cancer vasectomy,and by coordinated prostate of study trol a national, multicentre, case–con- funded jointly Programme Human the and (NICHD) and Development Health Child of International Institute National US the (FHI), Health Family Section 1-Promoting familyplanning Section rev Figure 1.5.

P alence ofv oped countries, it is possible to carefully monitor women who devel- In risk. the of magnitude the has as uncertain, been has both, or behavioural, or biological is risk increased this whether but cancer, cervical of risk higher at are users OC combined long-term that years many for known been has It more is which result a consistent withprevious studies. status, HPV for adjustment after users, contraceptive hormonal long-term for risk increased 1.9-fold a showed controls and cases all on based underestimated results the However, women. have HPV-positive among may effect true given the estimates the cervical of cancer, risk increased an with associated be to shown been not has (DMPA) acetate depot-medroxyprogesterone and progestogen-only oral or injectable contraceptives. Since OCs betweenablecombined weredistinguish not authors to the in contraceptive exacthormonal of used. type Forexample, the included studies the of pooled analysis was that they collected no information on the limitation One effect. such an minimize should controls and cases HPV-positive to adjustment for behavioural factors, but restricting studies the analysis many in inadequate confoundingand residual observed to due mayhavebeen risk elevated the that thought long-term use of combined oral contraceptives with (OCs). It was previously risk excess an shown persistently has that literature scientific of body the with consistent are they but cautiously, interpreted higher be must and somewhatestimates previous than are risks These risk. increased 4-fold a had years more or 10 for contraception hormonal used had a who women had while cancer, cervical yearsof risk increased 2.8-fold 5–9 of period a for contraceptives hormonal used had who cancer.Women cervical of development the asec t omy (New Zealand men 40 –74 yearsofage ) Annual Technical Report 2001 53 at enrolment, and partlyand enrolment, at 3 Research on the safety and effectiveness of contraceptives and effectiveness on the safety Research HIV and steroid contraception HIV and steroid The Programme is sponsoring a multicentre study in Brazil, Thailand and Kenya, Zimbabwe to assess the impact of dif- ferent contraceptive methods on the clinical course of HIV with Women HIV are infection invited to participate infection. in an observational cohort study with six-monthly follow-up Study visits end-points for four years. include progression of HIV disease, the incidence of opportunistic infections, and changes in These CD4 will cell be counts. analysed accord- methods used. ing to the contraceptive Recruitment to the study has been slower than partly expected, as a result of the cells/mm 500 least at of count CD4 requirement that women have a because the study is unable to offer volunteers much care and support for their HIV infection, in particular, antiretrovi- Over ral 5000 therapy. women have been screened for HIV The majority of volunteers and almost 300 enrolled. infection use hormonal contraception (primarilyin Nairobi DMPA and combined OCs in Harare); nonhormonal methods are used by less than 20% of the study cohort. Recruitment and fol- in 2002. will continue low-up ing intrauterine device (IUD) and oral preparations. Concerns preparations. oral and (IUD) device intrauterine ing have been raised that progestogen-only preparations can decrease bone mineral density and thus increase the sub- sequent risk of osteoporotic fracture. It is progestogen-only unclear of use current the whether with noted decrease any or persists. is transient contraception Investigators at the Reproductive Health Durban, South Africa are conducting Research a prospective study of Unit, women among contraception progestogen-only of impact the in the age ranges of 15–19 the years period of maximal age covers bone group mass younger and 45–49 years. The acquisition, and any decrease due to progestogen-only con- traception may affect the peak bone mass In achieved. the pro- with mass bone in decrease transient a group, age older gestogen-only contraception may result in a woman starting her menopause-related decline in bone mass on an already density. bone mineral low in 425 The the women study 15–19 has years recruited over dis- range age years 42–49 the in women 190 and range age tributed over four user norethisterone groups: DMPA, enan- tate (NET-EN), combined OC, and nonhormonal methods. Since most young women in South two-monthly injectable preparation, it was Africadifficult to identify are six-monthly given at followed be will women the All users. DMPA young intervals for fiveyears. The baseline data on bone mineral density (Figure 1.6) show that the younger women are still acquiring bone mass, and their levels are levels lower seen in than the the women aged 42–49 years. None of women the in the younger age group had previously used any method. hormonal contraceptive Worldwide, Worldwide, over 30 million women currently using are progestogen-only estimated contraceptives, including levonorgestrel-releas- to the rings, vaginal be implants, injectables, Bone density contraception and progestogen-only A total of 1513 women received condoms alone and 1575 the 1575 and alone condoms received women 1513 of total A combined condom plus EC regimen. Overall 2942 (95.3%) completed the the study, majority of discontinuations stem- ming from personal group EC plus condom reasons combined the in women Two or method. a desire to change stopped because the of side-effects. A total of 45 pregnancies 1.50 of rate pregnancy cumulative 12-month a with occurred, (SE 0.32) per 100 women in the combined group and 1.49 inter- and analysis The group. alone condom the in 0.33) (SE that observation the by complicated are data the of pretation the than better significantly appeared regimen combined the worse condom alone regimen in one centre and significantly In addition, the cluster design randomized com- in the other. plicates the analysis and computation being are design the of by raised questions methodological standard The errors. addressed together with a group of statisticians in London, and a definitive analysis and interpretation of the results is in 2002. expected The effectiveness of male condoms to prevent pregnancy is high when they are used unwanted consistently and cor- with rectly, annual failure rates in the range of 1–2%. How- ever, typical use pregnancy rates are considerably higher (10–20%, depending on the setting), and could potentially be improved by providing ready access to emergency con- traception (EC) in the that event a condom was not used or was perceived to have broken or study To leaked. whether required, as home at take to EC with users condom providing investigators in Shanghai and Tianjin, China, conducted a cluster randomized trial between 1997 and 1998 of condom use with and without EC. The purpose of this study trial whether condom users should be provided with was EC to to dif- from recruited were Volunteers required. as home at take factories ferent and work units and were randomly assigned the and alone condoms with provided was one groups: two to tab- levonorgestrel mg 0.75 (two EC plus condoms with other from the same factory or work unit Volunteers received lets). the same intervention and all were followed up at monthly one year. intervals for Efficacy of a combined condom and emergency combined Efficacy of a regimen contraception have have used OCs for long periods; however, where cervical cancer screening and control programmes are inadequate or nonexistent, these results are more In worrisome. March 2002, the Department is convening a consultation to review the available evidence regarding the relationship between cervicaland cancer, infection HPV hormonalcontraceptives, and will consider the range of risks and cervical cancer inci- dence rates at which any excess health concern. risk becomes a public 54 Annual Technical Report 2001 Section 1-Promoting familyplanning Section ment for the year of recruitment, occupation, education, age, adjust- following cohort reference the in than higher g 38.5 wasaverage on cohort abortion the weightin abortion. Birth induced followingan birth preterm forCI: 0.6–1.5) (95% 1.0 and weight birth low term for 0.9–4.7) CI: (95% 2.0 weight, birth low for 0.8–3.3) CI: (95% 1.7 were (RR) risks relative the analysis, regression logistic in confounders potential for (Table referencecohort the 1.1). controlling with After pared com- abortion and of history a 1.7%, with women those was in higher was weight birth low of incidence overall The more previous inducedabortions. first-trimester ofpreg- nancy.9 weeks Of these, 1235 had a of history one and 267 of first two or the in care antenatal for came who women pregnant nulliparous 2953 of total a recruited They China. Shanghai, in investigators by conducted was study cohort pregnancy-based sub- prospective a a pregnancy,in sequent birth preterm and weight birth low of risk the on abortion induced first-trimester a of impact the Toevaluate ofinducedSequelae abortion th weight [<2.5 kg] (% P Lo r e-term deliv w bi T r able 1.1. er Outcome of pregnanc y [<259da y s] (% ) ) y f o llowing medicallyorsurgicallyinduced in thethreestudygroups (Table 1.2). incidence similar weighta belowwith g 2500 birth a had 135 only deliveries, term the Among [0.73–1.19]). 0.94 (RR tion abor- induced surgically or medically of history a with those between difference no was women. There the of acteristics remained unchanged after adjustment for demographic char- RR The abortion. of history no with women with compared 0.61–0.96) CI: (95% 0.76 of medically RR an of with history abortion, induced a with women those in lower slightly was rate The (3.6%). deliveries preterm 505 of total a was there weeks, 28 beyond up followed women those Among 94 mole. hydatidiform and one was spontaneous there and a abortion, induced an had 359 weeks), 28 after 48 and before, (70 follow-up to lost were (0.8%) women 118 gether delivery.Alto- after weeks 6 and 4 between and delivery at had three follow-up at 28–30 weeks interviews of pregnancy, and ofpregnancy, weeks 16 first the within recruited were All (33.6%). Shanghai and (32.4%) Chengdu (34.8%), jing Bei- from recruited were women pregnant 656 14 of total A 3.2 1.4 women. induced as abortion, well as a surgically group of primigravid single a of history a with compared women of group similar a with and them cases) (index abortion mifepristone-induced single a of history a China with in pregnancy early in women study enrolled three-centre a come, out- pregnancy subsequent on abortion To assess the impact of medically induced settings. other to applicable be not may outcome, pregnancy adverse of risk low at ulation study,this waswhich performed pop- a in from results The birth. preterm or weight birth low of risk the increase significantly not did abortion induced surgically vious gestational age. The study shows that pre- and use contraceptive prior recruitment, at size body maternal infant, the of sex 2. 3.5 0 3.4 1.7 Annual Technical Report 2001 55 Annual tech- Annual 0.83 3.04 0.94 0.61 3.69 1.19 Research on the safety and effectiveness of contraceptives and effectiveness on the safety Research insertion (Figure There 1.7). were few ectopic pregnancies, year of use. the fifth none of which occurred beyond Interim six-year data on the 20 µg/day levonorgestrel-releasing clinical IUD (Mirena) compared performance of the in presented were the device TCu380A the with nical report 2000. The levonorgestrel-releasing device had high rates of device removal for menstrual-related reasons, in particular amenorrhoea. The overall continuation rate 68.5% at and device levonorgestrel the for 42.7% was years six for the TCu380A. These rates were based on only a small number of women completing six years of use, and will be updated in early 2002. New projects initiated during 2001 during projectsNew initiated of two trial implantable contraceptives Randomized women for The most extensive data on the safety and effectiveness of implantable contraceptives refer to the six-capsule levonor- gestrel-releasing Norplant There device. have been reports of difficult and time-consuming removals of the device, and likely are and developed been have units fewer with implants to replace Norplant. While the two-rod five-yearlevonorg- estrel-releasing Jadelle has been compared with Norplant and the single-rod in a multinational moderately-sized study, etonorgestrel-releasing Implanon with Norplant gle-country in study, there have been a no formal sin- comparisons This identifiedwas as a high and Implanon. Jadelle between research priority by the technical consultation convened to review the available data on the safety and effectiveness of (see below). contraceptives implantable The Programme has designed a multinational randomized implemented be to Implanon and Jadelle trialof comparative in 8–10 centres, of which 7 or 8 will be in developing coun- The primary are tries. objectives to compare the clinical per- formance of the devices in terms con- of method the in contraceptive reflected as efficacy acceptability their assess and tinuation rates and reasons for The discontinuation. impact on vaginal bleeding patterns, common adverse effects and 0.97 2.85 0.98 ) (%) ery v llow-up (% e-term deli r Loss to to fo Loss P The randomized comparative The study randomized comparative of TCu380A the and the Multiload (ML) 375 copper-releasing device started in early the 1990s, and the interim 10-year results are shown Table 1.3. in Both devices are highly effective pregnancy in and similar have How- continuation overall rates. preventing ever, the intrauterine pregnancy rate with the TCu380A is about half the rate of the ML 375 device at all times since The long-term follow-up of cohorts copper-releasing TCu380A of device continued. In women the period using the 1989–1998, a total of 5953 women had this device inserted as part of trialsrandomized Programme-sponsored compar- ing the safety and 1990–1991. effectiveness period the in of place took insertions the of majority different devices. The The first large cohort of users completed 10years of use at the end of 2001, and over 500 are expected to complete 12 years of use by the end of The 2002. Programme will con- tinue to users follow up to 15 years from insertion, thus pro- viding unique information on long-term contraceptive safety and efficacy of this device. Previous research gramme’s been have used to progressively extend data from the Pro- the approved lifespan of the device from the initial three to ten years. Up to 160 million women worldwide use IUDs of as advantage the their have pre- IUDs planning. family of method ferred being long-acting with and easy a relatively to rapid remove, return of fertility upon removal. The demonstration of their long-term safety and efficacy is an important aspect of the work of the Programme. Long-term safety and effectiveness of intrauterine safety of intrauterine and effectiveness Long-term devices This study confirms the excellentamong outcome women in China of pregnancy observed in previous studies and demonstrates of no medical effects previous adverse or sur- gical abortion on the course or outcome The final results from the study of arepregnancy. being written a subsequent up for publication in an international journal. The wealth of data collected in the study on the course and pregnancy in primiparous will be further women analysed. outcome of 56 Annual Technical Report 2001 end ofthreeyears. the at Jadelle) or Implanon (either implant new a of option efficacy, all women randomized to Implanon will be given the of deviceshave differentperiods two Implanon. the of Since each to allocated randomly device and be followed up for three years, will the approved lifespan women 1000 of total A beassessed. will or removal insertion of difficulties any Section 1-Promoting familyplanning Section Expulsions

— T L o oss follow-uto u Figure 1.7. tal medicalremo — Intrauterinepregnancy — P Ec T e able 1.3. topic pregnanc lvic inflammatory

C mulati p C umulativ v e v intrauterineandectopicpregnanc a ls y disease e netprobabilitiesofdiscontinuation(standarderror) h dvcs i wl b iprat o lc tee differences these place to important be will it devices, the between differences clinical any are there whether onstrate zation). While a randomized trial of the two implants will dem- compared with controls (users of nonhormonal IUDs or users sterili- Norplant the among problems health minor of dence showed2001 in werethere differencesthat some inci- the in The Post-Marketing Surveillance of study Norplant published 11.3 (1.0) 29.9 (1.5) 11.6 (1.2) 0.4 (0.3 2.7 (0.5) 0.8 (0.3 y rates by device (interim data, ) ) 10.6 (1.0) 30.3 (1.7) 14.9 (1.2) 0.5 (0.2) 5.3 (0.7) 0.1 (0.1 ) cut-off June2001) 0.047 0.003 0.011 0.63 0.88 0.85 Annual Technical Report 2001 57 NORMS AND TOOLS NORMS AND Research on the safety and effectiveness of contraceptives and effectiveness on the safety Research Specific objectives/targets The work on the development and dissemination of norms family “Promoting on chapter another reportedin is tools and under- activities specific some but tools”, and norms planning taken under the umbrella of the work on safety and tiveness of effec- contraceptive methods are reportedThese here. include on reviews the safety and of effectiveness implanta- sper- the of safety the of review a methods, contraceptive ble micide nonoxynol-9, and a methodological issue regarding the analysis and presentation of results from contraceptive trials. developed norms/tools New for contraceptives on implantable Consultation women The first scientific publication The on1969. in published was women for implant contraceptive a progestogen-releasing first implant, Norplant,was approved in 1983by the Finnish drug regulatory authority, and several other implants have been since approved Altogether that 60 over date. countries have registered implants for female contraception and they have been used by an estimated 11 million women world- wide. In view of the increasing importance of implants for women, safety their on evidence available the review to consultation a and effectiveness was convened by the Programme in May 2001. levonorgestrel- five-year the on information extensive is There releasing implants Norplant and Jadelle from studies con- ducted in developed and developing countries, addressing metabolic and clinical outcomes, including adverse effects, of bleach disinfection on the female condom, and the mini- mum amount of bleach required to disinfect used condoms. the on one studies, of series two sponsored Programme The structural integrity of condoms female subjected to repeated cycles of disinfecting, washing, drying and lubrication, and soak of duration and concentration necessary the on another to kill gonococci, chlamydia and HIV that might be found on the condoms after intercourse. The first series ofexperiments was completed in 2000 and demonstrated that female condoms could withstand seven cycles of chemical and physical challenge with minimal loss likely more were condoms the However, integrity. structural of to have holes than fresh ones, most The second seriesrepeat handling. of experiments on disin- probably caused by Reference National the in conducted was condoms of fection Centre for Sexually Transmitted Diseases, Johannesburg, con- a at considered be will results new the and Africa South sultation in January 2002. The consultation strongly recommended that used condoms used that recommended strongly consultation The should be disinfected before washing in order to protect the the con- user from furtherHowever, to exposure pathogens. sultation was unable to make any recommendation regard- effect the on available furtherwas until information reuse ing In June 2000, the Department, in partnership with UNAIDS, a convened consultation on the possibility of the safe reuse of The female polyurethane condoms. device is very strong but expensive and there have been amount of reuse some by Investiga- women in South Africa. reports of a limited tors from Health the Research Reproductive Unit developed a protocol of washing, drying and relubricating the female condom and reported successful reuse in up to 50 female workers. sex Safety reuse condom of female This study is complementary to the research to assess the of effectiveness the female condom in STIs preventing (see the chapter on “Reproductive tract infections and sexually infections”). transmitted In order to generate more information on the efficacy of the initi- has Programme the contraceptive, a as condom female ated a multicentre comparative study in China, Nigeria and South Africa. Women attending family planning clinics who intend to use male condoms as their method are informed main about the female condom contraceptive and invited to participate in An the age-matched follow-up study. group of male condom users are enrolled as a control group, and In months. six for intervals monthly at followed are women all prepared, were procedures instrumentsand study the 2001, test. pilot the after finalized and sites, three the in pilot-tested fol- and, 2002, earlystart in will study the of phase main The lowing a small pilot study to assess how best to recruit and retain volunteers, a fourth site in Panama may be included. The female condom has not previously been introduced in Panama, necessitating the adaptation of training materials in other countries. developed The female condom provides protection against pregnancy as well as sexually transmitted infections (STIs). It can be preven- STI and pregnancy of method main a as either used use to partnerrefuses woman’s a when back-up a as or tion, a The male information on condom. the of effectiveness the female condom in preventing pregnancy is based on three studies, one conducted in the USA and Latin America, one in the United Kingdom and one in None Japan. of the stud- ies included a comparison group of women using a different method. contraceptive Effectiveness of female condoms condoms of female Effectiveness in context. An in equal context. number of IUD users will, be therefore, enrolled and followed up in each site as a concurrent non- startto enrol- expected is study The group. hormonal control end 2005. completed by follow-up ment in mid-2002 with 58 Annual Technical Report 2001 Section 1-Promoting familyplanning Section who were enrolledinthestudy. poses among women at lower risk of HIV infectionpur- than planning those family for used when N-9 of safety the about questions raised also butinfection, HIV of risk the reduce to pointing result signalled the end of N-9 as a disap- potential method This gel. comparison the using those than infection HIV of unexpectedrisk 1.5-foldan higher had gel containing N-9- the of users the that showed 2000) July Africa, South Conference,AIDS Durban, International (vanXIIIth Damme, study the from results infection. Preliminary HIV of risk high with a similar vaginal gel not containing N-9 among women at compared N-9 of mg 52.5 containing gel vaginal a of study (UNAIDS) sponsored a multicountry randomized double-blind in women. The Joint United Nations Programme on HIV/AIDS HIV against protection provide to able demonstrably if tries, coun- developing in potential women to available the rapidly made be had to and vitro in properties virucidal have to shown was It years. 30 than more for purposes traceptive con- for used been has (N-9) nonoxynol-9 spermicide The sexually transmitted infections”). and infections tract “Reproductive on chapter the (see work global this to contributing is Programme vaginalthe and intercourse through infection HIV acquiring of risk the against women and protect to safe used a be could develop that to microbicide effective way under work intense is There ofnonoxynol-9 Safety pub- be will lished in2002. report, summary the with together 3), Annex in (listed meeting the for prepared papers background The cations andassociatedprogramme costs. easier and to remove,insert thus reducing the risk of compli- are rods or capsules two or one using devices recent more The removal. and insertion implant for with skills demonstrated counselling in trained providers of number adequate an requires This implants. the of removal and insertion tic asep- strictly good-quality ensure to particularly services, familyplanning requires implants contraceptive of Provision existing medicalconditions. pre- with women among profile safety their assess to need healthy,werebe knownwomenwho to on urgent an is there generated was implants all about information effectiveness and safety the Since profile. safety satisfactory a and ness effective-contraceptive high a has implant this that suggest extensiveless are Implanon Jadelle,or forthan but Norplant assess- safety ment. Data a full on the three-year etonorgestrel-releasing implant for insufficient were consultation the to available data the but devices, the registered to internationally similar is devices these of performance clinical the levonorgestrel-releasing that suggest China in approved on and manufactured implants available data The implants. these of effectiveness contraceptive high the demonstrate data These perspectives. users’ and requirements service ception. contra- to access for criteria eligibility medical the regarding the recommendations the of into incorporated conclusions be will consultation The promoted. be not condoms such that recommended consultation the and STIs, or pregnancy against condoms silicone-lubricated over protection addi- tional any provided condoms lubricated N-9 that evidence no was there addition, In methods. contraceptive available other with compared high not was spermicides of tiveness effec- contraceptive the that noted was It option. preferred safely use spermicides containing N-9, if this were a woman’s could infection HIV of risk no or low at be to known woman HIV.of risk high However,at are a women where settings in tion, it is not advisable to use N-9 for prevention of pregnancy infec- HIV acquiring of risk the increases N-9 that possibility the Given chlamydia. and gonorrhoea against as such nor STIs, other infection, HIV against protection no provided spermicides containing N-9 that concluded consultation The tive health. with coordinated other agencies concerned with dissemination family planning and reproduc- its and 2002 in published willbe the meeting from report final study.The sponsored UNAIDS- the from analysis final the awaiting 2001, October prevalenceHIV settings). delayedwas until consultation The low- and high- both in users regular as well as (occasional user of types differentfor information this of implications the fits of N-9 and the extent of use of the product, and to assess to review all available evidence regarding the risks and bene- consultation technical convenea to offeredProgramme The ing risk factors”ing risk as causesofdiscontinuation ofmethods. as “compet- regarded method. are a reasons of other These than efficacy in terms of acceptability and continuation of use importance greater of are which this, for etc.) use, of ience safety,conven-of (perception reasons other their are use. There forstopping thereason not generally is efficacy tive, effec- highly are methods contraceptive modern most Since method. contraceptive a of performance the of assessment the factorsin for,important sons are discontinuation method rea- and of, rates method. The another to change to prefer because they no longer need contraception, or because they either reasons, many for method contraceptive their change of involuntary pregnancy, but couples or women stop using or occurrence the is end-point main the contraceptive trial, a In completed. be can analysis the before“failed”)(or end-point at different times and not all individuals have experienced an cohort the enter individuals where studies prospective most of typical are observations “right-censored” Such analysis. the in incorporated be to are still method contraceptive their and using long sufficiently followed been not have who methods. participants from informationallows technique The and summarize present information from prospective to studies of contraceptive used widely is technique life-table The ofcompetingAnalysis risks data Annual Technical Report 2001 59 Sta- 20:3601-3610). The conventional Research on the safety and effectiveness of contraceptives and effectiveness on the safety Research tistics in Medicine, 2001, estimate (complement of the Kaplan-Meier) corresponds to a hypothetical rate where discontinuations for other reasons did not occur, while the the rate of cumulative discontinuations in incidence the presence estimates of The Kaplan-Meier other estimates are more appro- peting causes. com- priate when estimating the effectiveness of a contraceptive appropri- more be may incidence cumulative the but method, ate when making programmatic decisions regarding contra- ceptive methods. It remains to be seen whether clinicians, scientists and policy-makers prefer to remain with the con- ventional method facilitating comparison with existing data, or whether incidence the estimate cumulative gains in popu- studies. contraceptive the presentation of larity for cumulative cumulative incidence rate is always less than the conven- tional estimate, and all methods contraceptive would appear than before. efficacy contraceptive greater to have The Programme sponsored a simulation study of the differ- risks competing of analysis of methods two the between ence data which formed the basis of a discussion of the strengths and weaknesses of the two approaches (Farley et al., 20:3589-3600) used data from a pub- There are several well established ways of analysing time-to- analysing of ways established well several are There data event where an individual is subject compet- to several ing causes for failure. Standard methods of analysis using multiple decrement life-table methods have been adopted since the 1960s. Following theoretical developments in sta- tistical methods, there has been renewed interest in a sel- dom-used technique of summarizing data—the cumulative incidence rate. In particular, Tai and colleagues (Statistics in Medicine, 2001, method estimated how show to IUDs trialtwo WHO of lished discontinuation rates based on cumulative incidence were smaller than those based on the more commonly used Kap- lan-Meier The estimates. extent of the difference depended in a nonstraightforward way on the rates of discontinuation for other reasons. The authors argued for a the wider cumulative use incidence of in the analysis and presentation of contraceptive trials. The implications for such a recom- mendation are far reaching—the corpus of data on contra- which ceptive effectiveness, forms the basis for many policy decisions and recommendations on contraceptive methods, to would have be The recalculated using the new technique. amount of work involved would be enormous makers and users would be veryIn particular, confused. the and policy- 60 Annual Technical Report 2001 Robert Spirtas, NationalInstituteofChildHealthandHumanDevelopment, Spirtas, Bethesda,MD,Robert USA Jennifer Agencyfor Smith,International ResearchonCancer, Lyon, France Sivin, Irv The Population Council,New York, NY, USA Silvia Franceschi, Agencyfor International ResearchonCancer, Lyon, France Ann Duerr, Centersfor DiseaseControlandPrevention, Atlanta,GA,USA Collaborating scientists agency David Skegg, University ofOtago,) Dunedin,New Zealand(Chairman Phil Hannaford, University ofAberdeen,UnitedKingdom Gao Ersheng,ShanghaiInstituteofPlannedParenthood Research,Shanghai,China Tsungai Chipato, University ofZimbabwe, Harare, Zimbabwe Valerie Beral, Radcliffe Infirmary, Oxford, UnitedKingdom Craviotto, delCarmen Maria Mexico NationalInstituteofNutrition, City, Mexico Members SPECIALIST PANEL FOREPIDEMIOLOGICAL RESEARCH INREPRODUCTIVE HEALTH Annex 1

WPRO SEARO EURO EMRO AMRO AFRO from: Women Members Section 1-Promoting familyplanning Section Number Developing countries 1 1 1 1 3

% oftotal 17 17 17 17 50

Countries intransition Countries Number

% oftotal

Developed countries Number 2 1 1 3

% oftotal 33 17 17 50

Totals 2 1 1 2 2 6 Annual Technical Report 2001 61 Research on the safety and effectiveness of contraceptives and effectiveness on the safety Research Ahmed Abdennadher, Office National de la Famille et de la Population, Tunis, Tunisia Tunis, Population, Famille et de la Office National de la Ahmed Abdennadher, Brazil Campinas, UNICAMP, Eliana Amaral, Armenia Yerevan, Armenian Centre of MaternalSimon Alexaniants, and Child Health Protection, Brazil de Fora, Juiz de Fora, of Juiz University Amaury Federal Andrade, Hungary Szeged, Bártfai, Albert University, Medical György Szent-Györgyi School of Debrecen, Debrecen, Hungary Medical University Batár, Istvan Durban, South Africa Health Research Unit, Mags Beksinska, Reproductive Tianjin, China Planning, Family Institute for Tianjin Municipal Research Cao Xiaoming, China Chen Zhu ping, Ren Ji Hospital, Shanghai, Planning, Beijing, China National Research Institute of Family Yimin, Cheng Nairobi, Kenya Science Campus, of Nairobi Health Cohen, University Craig Zealand Dunedin, New of Otago, University Brian Cox, Nigeria Health, Sagamu, Research in Reproductive Dada, Centre for Oluwakayode Thailand Damrong, Chulalongkorn Bangkok, Hospital, Reinprayoon Hui-min, Beijing Obstetrics Hospital, Beijing, China and Gynaecology Fan Brazil Campinas, Disease, Research and Control of Maternal and Infant Centre for Anibal Faundes, South Africa Johannesburg, Diseases, Transmitted Sexually Centre for National Reference Glenda Fehler, Research, Shanghai, China Shanghai Institute of Planned Parenthood Zhuan-chong, Feng Sweden Umeå, Marie-Louise Hammarström, Umeå University, Institute of Guangdong, Guangzhou, China Planning Ho Jialiang, Family China Hospital, Beijing, Wu Hong Kang, Xuan Thailand Kiriwat, Siriraj Hospital, Bangkok, Orawan Chile Santiago, Hospital Ramon Barros Luco-Trudeau, Lavin, Pablo Research Institute of Sichuan, Chengdu, China Planning Liu Xiaozhang, Family Research Institute of Sichuan, Chengdu, China Planning Luo Lin, Family Research Institute of Sichuan, Chengdu, China Planning Luo Shi-yuan, Family of Copenhagen, Denmark Health, University Institute of Public Elsebeth Lynge, Zimbabwe Harare, School of Medicine, of Zimbabwe University Mashu, Alexio Kenya Nairobi, Medical Research Institute, Christina Mwachari, Kenya Tianjin, China Tianjin Municipal Research Institute, Dunren, Peng Chile Santiago, Hospital José Joaquin Aguirre, Ernesto Pizarro, Slovenia Ljubljana, Gynaecological Clinic, Alenka Pretnar-Darovec, Nanjing, China Health Institute, Qian Shao-zhen, Jiangsu Family Thailand Bangkok, Centre, Health Research Atisook Ronachai, Siriraj Family Panama en Reproducción Humana, Panama, Ruiz, Centro de Investigación Eyra Chile Santiago, Medicine, Chilean Institute of Reproductive Schiappacasse, Veronica Umeå, Sweden Inga Sjöberg, Umeå University, Thailand Bangkok, Chulalongkorn University, Unnop, Jaisamrarn Chile Temuco, Frontera, of University Valdes, Patricia Maternity Shanghai, China and Child Health Hospital, Xiulan, International Peace Yang China Wuhan, Medical University, Tong-ji Planning Research Institute, Family Yuying, Wei Beijing, China Union Medical College, Peking Yu-ming, Wu Planning, Beijing, China Family Shangchun, National Research Institute for Wu Research, Shanghai, China Shanghai Institute of Planned Parenthood Yuan, Wei Tianjin, China Planning, Family Municipal Research Institute for Tianjin Min Zhao, Yue Zhang Shaozhen, Xin Hua Hospital, Shanghai, China Principal investigators Principal Annex 2 Annex IN 2001 SCIENTISTS 62 Annual Technical Report 2001 WPRO SEARO EURO EMRO AMRO AFRO from:

Neil Poulter, CollegeSchoolofMedicine, Imperial London,UnitedKingdom Bill Potter, Stapleford Cambridge,UnitedKingdom ScientificServices, Mike Pope, The Female Health Company, London,UnitedKingdom Mojca Pirc, GynaecologicalClinic, Ljubljana, Slovenia Pan Xin-Ian,Peking UnionMedicalCollege, Beijing,China Olsen, Jorn The DanishEpidemiologyScienceCentre, Aarhus, Denmark Ni Ming-hong,RenJiHospital,Shanghai,China Olav ChileanInstituteofReproductive Meirik, Medicine, Santiago, Chile CentreforAbdel MalekM’Hamdi,Ariana HumanReproductive Research, Tunis, Tunisia Szent-GyörgyiGyörgyi Meszaros, MedicalUniversity, Albert Szeged, Hungary Liu Zhonghua,Family PlanningResearchInstituteofSichuan,Chengdu,China Li Zhifang, Family PlanningResearchInstituteofSichuan, Chengdu,China La Carlo Vecchia, InstitutodiRicercheFarmacologiche, Milan,Italy Orawan Family Kiriwat,Siriraj HealthResearchCentre, Bangkok, Thailand Jiang Lin-lin,RenJiHospital,Shanghai,China andGynaecologyHospital,Beijing,China Han Lihui,BeijingObstetrics John Gerofi,EnersolPtyLtd.,Annandale, NSW, Australia Gao Ya jie, Tianjin MunicipalResearchInstitutefor Family Planning, Tianjin, China PeaceGan Xianqin,International andChildHealthHospital,Shanghai,China Maternity Fang HuiIan, Tong-ji MedicalUniversity, Wuhan, China Fan Xinlin,Family Planning ResearchInstituteofSichuan,Chengdu,China Fan Guang-sheng,Peking UnionMedicalCollege, Beijing,China Soledad Diaz,ChileanInstituteofReproductive Medicine, Santiago, Chile Walter Vitor daFonseca, Instituteof Woman Brazil andChildHealth,Fortaleza, Ding Wan-hua, JiangsuFamily HealthInstitute, Nanjing,China Ding Ju-hong, JiangsuFamily HealthInstitute, Nanjing,China Karen Davis, University of Texas MedicalBranch, Galveston, TX, USA. Cui Nian,Family PlanningResearchInstituteofSichuan,Chengdu,China Patricia Claeys, Centrefor International Reproductive Health,Ghent,Belgium Chen Yuan qing,Family PlanningResearchInstituteofSichuan,Chengdu,China Chen Xiaoqin,Family PlanningResearchInstituteofSichuan,Chengdu, China Chen Gui-ying,NationalResearchInstitutefor Family Planning,Beijing,China CollegeofScience,Limmie Chang,Imperial Technology andMedicine, London,UnitedKingdom Queen Cebekhulu,Reproductive HealthResearchUnit,Durban,SouthAfrica Emily Banks,CancerResearchFund,Oxford, Imperial UnitedKingdom Ron Ballard,Centersfor DiseaseControlandPrevention, Atlanta,GA,USA Luis Bahamondes, Centrefor andInfant ResearchandControlofMaternal Disease, Campinas, Brazil Tsedmaa Baatar, andChildHealthHumanReproduction,Ulaanbaatar, StateResearchCentreonMaternal Mongolia Mohamed Ali,LondonSchoolofHygieneand Tropical Medicine, London,UnitedKingdom scientists Other Women All Section 1-Promoting familyplanning Section Number Developing countries 19 20 38 4 1 8 6

% oftotal 41 17 13 43 83 9 2

Countries intransition Countries Number 4 1 4

% oftotal 9 2 9

Developed countries Number 1 3 3 4

% oftotal 2 7 7 9

Totals 20 24 46 4 7 1 8 6 Annual Technical Report 2001 63 2 2 9 1 68 15 37 39 Totals

7 1 6 22 15 % of total

5 1 4 15 10 Number Developed countries Developed

9 4 7 Research on the safety and effectiveness of contraceptives and effectiveness on the safety Research % of total

6 3 5 Countries in transition Number

3 3 7 1 69 43 56 % of total

2 2 5 1 47 29 38 Developing countries Developing Number (continued) Mongolia Mirjana Puksic, Gynaecological Clinic, Ljubljana, Slovenia Ljubljana, Gynaecological Clinic, Mirjana Puksic, Slovenia Ljubljana, Clinic, Stane Pusenjak, Gynaecological Centre on Maternal State Research Reproduction, Ulaanbaatar, and Child Health and Human Erdenetungalag Radnaabazar, South Africa Hospital, Soweto, Chris Baragwanath Helen Rees, Hani Slovenia Ljubljana, Clinic, Primoz Gynaecological Res, Miami, FL, USA Center, Cancer Comprehensive Schlesselman, Sylvester J. James Chile Temuco, of Frontera, University Silva, Alejandra London, United Kingdom Medicine, Tropical London School of Hygiene and Emma Slaymaker, Tianjin, China Research Institute, Tianjin Municipal Song Li juan, Planning, Beijing, China Family for Sun Hong-zhu, National Research Institute Nanjing, China Health Institute, Family Jin-Zhang, Jiangsu Tao Thailand Chulalongkorn Bangkok, Hospital, Unnop, Jaisamrarn Miami, FL, USA Cancer Center, Comprehensive Sylvester Walker, Gail Research, Shanghai, China Shanghai Institute of Planned Parenthood Yue-bao, Wang Beijing, China Union Medical College, Peking Li-Ju, Weng Hua Hospital, Shanghai, China Hong , Xin Wong Obstetrics Ming-hu, Beijing and Gynaecology Hospital, Beijing, China Wu Beijing, China Union Medical College, Peking Mu-zhen, Wu Chengdu, China Planning Research Institute, Family Sichuan Provincial Shi Zhong, Wu Research, Shanghai, China Institute of Planned Parenthood Shanghai Yue-zhe, Wu Research Institute of Sichuan, Chengdu, China Planning Xiao Ling, Family Research Institute of Sichuan, Chengdu, China Planning Xie Li, Family Maternity and Child Health Hospital, Shanghai, China Bang yuan, International Peace Yang Nanjing, China Institute, Health Ming-ming, Jiangsu Family Yun Institute of Sichuan, Chengdu, China Planning Research Ming rong, Family Yun Tianjin, China Institute, Tianjin Municipal Research hao, Wen Zhang Tianjin, China Municipal Research Institute, Tianjin Zhao Dan ping, Zhu Xiao-ling Zhu, Beijing Obstetrics Hospital, Beijing, China and Gynaecology Maternity China and Child Health Hospital, Shanghai, Zhuang Liu-qi, International Peace Other scientists (continued) Annex 2 Annex IN 2001 SCIENTISTS Members

Women Women SEARO from: AFRO WPRO AMRO EMRO EURO 64 Annual Technical Report 2001 Sneyd MJ, Cox B, Paul C, Skegg DCG. High prevalence ofvasectomy inNew Zealand. andre-lubrication. washing, drying Potter B, Gerofi J, Pope M, Farley T. women. urban SouthAfrican ofUrbanHealth: Journal Bulletin ofthe New York Academy ofMedicine,2001,78(inpress). Pettifor AE,BeksinskaME,ReesHV, MqoqiN,Dickson-Tetteh KE. The acceptabilityofreusethefemale condom among Lancet, 2002(accepted). Study Group. Oral contraceptives cancer: case–controlstudy.pooled analysisoftheIARCmulticentric andcervical Moreno V, BoschFX,MuñozN,MeijerCJLM,ShahKV, Walboomers JMM,etal. Cancer for Cervical theIARCMulticentric devices, intrauterine of Norplant, andsterilization. O,Meirik Farley TMM, SivinI,for Collaborative theInternational Post-Marketing ofNorplant. Surveillance Safety andefficacy implants: II. Non-reproductive health. CollaborativeInternational Post-Marketing ofNorplant. Surveillance Post-marketing contraceptive ofNorplant surveillance implants: I. Contraceptive efficacyandreproductive health. CollaborativeInternational Post-Marketing ofNorplant. Surveillance Post-marketing contraceptive ofNorplant surveillance Medicine, 2001,20:3601–3610. Farley TMM, Slaymaker E,AliM. Competing approachestoanalysisoffailure timeswithcompetingrisks. age.women ofchildbearing Donaghy M,ChangCL,Poulter N. Duration, frequency, recencyandtypeofmigraine ofischaemicstroke andtherisk in Collaborative Factors GrouponHormonal inBreastCancer. Breastfeeding andbreastcancer. Lancet, 2001,358:1389–1399. data from52epidemiologicalstudiesincluding58209women withbreastcancerand101986women withoutthedisease. Collaborative Factors GrouponHormonal inBreastCancer. Familial breastcancer: collaborative reanalysisofindividual andGynaecology,2001,21:270–273. of Obstetrics Che Y, Zhou W, Gao E, Olsen J. and in prematurity a subsequent Induced pregnancy: abortion a study from Shanghai. and cardiovascular ofEpidemiology , 2002(submitted). diseaseinyoung Journal women? International Chang CL,Shipley MJ, MG,Poulter Marmot NR. Can cardiovascular factors risk explain theassociationbetween education ofacutemyocardialeducation andtherisk infarction andstroke. MG,FarleyChang CL,Marmot TMM, Poulter NR. The influenceofeconomicdevelopment ontheassociationbetween papillomavirus infection,cancer. andcervical Castellsagué X,BoschFX,MuñozN,MeijerCJLM,ShahKV, DeSanjoséS, etal. Male circumcision,penilehuman mineral density. A, Casabonne D.Banks E, Berrington Overview of the relationship between use of progestogen-only contraceptives and bone PUBLICATIONS IN2001 Annex 3 Section 1-Promoting familyplanning Section British Journal of Obstetrics andGynaecology,2001,108:1214–1221. ofObstetrics Journal British Journal ofNeurology,Journal , 2002(submitted). andPsychiatry Neurosurgery Contraception, 2002(submitted). Structural Structural integrity of the polyurethane female condom after multiple cycles of disinfection, Contraception, 2001,63:187–209. The Lancet,2002(submitted). Obstetrics andGynecology,2001,97:539–547. Obstetrics Contraception, 2001,63:167–186. International Journal ofEpidemiology,2002(submitted). Journal International Contraception, 2001,64:155–159. The Lancet,2002(submitted). Statistics in The Journal Journal Annual Technical Report 2001 65 (in press). Contraception (in press). Contraception (in press). Contraception (in press). Contraception (in press). Contraception (in press). Contraception (in press). Contraception (in press). Contraception (in press). Contraception (in press). Contraception Research on the safety and effectiveness of contraceptives and effectiveness on the safety Research (in press). Contraception (in press). Contraception (in press). Contraception Hickey M, d’Arcangues C. Vaginal bleeding disturbances and implantable contraceptives. contraceptives. and implantable disturbances bleeding Vaginal M, d’Arcangues C. Hickey Curtis K. Safety of implantable contraceptives for women: data from observational studies. data from observational studies. women: for contraceptives of implantable Safety Curtis K. implants. use of contraceptive and concurrent Breast-feeding Diaz S. women. for contraceptives used in implantable of steroids Metabolic effects Dorflinger L. return rates, of fertility and outcome of discontinuation effectiveness, women: for contraceptives Implantable Glasier A. pregnancies. women. for contraceptives of progestogens of implantable Toxicology Jordan A. women. for contraceptives on implantable perspectives Users’ Ortayli N. women. for contraceptives polymers of implantable of Toxicology Shastri P. Council. Implants at the Population in Contraceptive Recent Developments A. Sivin I, Moo-Young Croxatto H. Mechanism of action of implantable contraceptives for women. women. for contraceptives of action of implantable Mechanism H. Croxatto Background papers prepared for consultation on implants consultation prepared for papers Background for contraceptives during use of implantable events Non-menstrual adverse Cochon L. F, Alvarez A, Faundes V, Brache data from clinical trials. women: women. for contraceptives and implantable Health services at the clinic level Miller S. Chikamata D, Croxatto H. Progestin implants for female contraception. contraception. female for Progestin implants H. Croxatto 66 Annual Technical Report 2001 • • • through thefollowing: achieved be will delivery.objective This service of part gral inte- an planning family in practices best make to systems established by WHO, and to encourage providers and health for family planning, using the formal guidelines process being guidelines evidence-based create to is overallobjective The and affordable family planningservices. focus that explicitly on ensuring a high quality of clients accessible, acceptable and providers for materials support and utes to their efforts by developing evidence-based guidelines contrib- Department The care. of quality their substantially However, many family planning programmes have to improve of family planning and reproductive health services generally. use the influences greatly provided care of ices. quality The serv- health relevant the of support full the without anteed guar- be cannot rights progress. scientific These of benefits the and choice access, to right have the individuals right. All human a as also but health improving for intervention key a as only not recognized is information, and services ning plan- family including care, health sexual and Reproductive Section 1-Promoting familyplanning Section

family planning. promoting for materials core of package a developing up-to-date; and kept are they that ensuring and availableevidence best creating a system for developing guidelines based on the gramme ofresearchfor promotingfamily planning; establishing the context for norms and tools within a pro- Promoting familyplanningnorms andtools OVERALL OBJECTIVE INTRODUCTION H.B. Peterson, S. Johnson, K. Church of these guidelines is also critical. Thus, the ultimate impact of in services family ofquality planning. The dissemination, adaptation and the utilization delivery ensure to insufficient is important, while guidelines,evidence-based of creation The research priorities. ered for guidelines and some of these gaps, become in turn, availableconsid- as and synthesizedappraised, evidence is identified are evidence in gaps Key priorities. research the and guidelines the between exists loop feedback a Further, base. evidence the of part become likewise method the of acceptability on research as well as research efficacy and evaluated,safetydevelopedand are methods newtools. As and norms for base evidence the into directly feed research efficacy and safety from and research, sciences social from relevantother research. and programmes findings the Thus, these from derived findings the on based is fourth the and The first three goals areby supported research programmes Establishing thecontextEstablishing • • • • infamily planning,namely: of theDepartment goals fourmajor the links frameworkthat a on based is ning plan- family in tools and norms developing for context The

successfully used at country level.successfully usedatcountry are that guidelines into evidence available translate to determi- nants ofsuccessfulfamily behavioural planning; and and sociocultural the assess to to evaluate thesafety andefficacyof existing methods; (including methodsfor dualprotection); contraception of improveddevelopmethods and newto Annual Technical Report 2001 67 who can safely how to safely and effec- Medical eligibility criteria for con- Promoting family planning norms and tools and norms planning family Promoting Selected practice recommendations for contraceptive traceptive traceptive use provides guidance regarding The appropriate medical eligibil- methods. use contraceptive conditions. 50 over with women for determined are criteria ity The use provides guidance regarding include Recommendations methods. contraceptive use tively instructions on when and how to start contraceptives situations. what to do in problem and community, and aim to assist in the preparation of guidelines of preparation the in assist to aim and community, for service The delivery. Medical eli- Selected practice Medical eligibility criteria provide provide electronic updates on the Department’s web site as appropriate, determine the need to con- and vene an expert group to formally reassess working the guidelines. decide whether the new evi- new the whether decide in change a warrants dence rec- their and guidelines the and ommendations; identify new, relevant evidence through ongoing, com- searches; literature prehensive evidence; of the determine the quality (and validity) determine the originality of the evidence;

for for contraceptive use and the recommenda- practice Selected tions for contraceptive use are the evidence- and consensus- based foundation of family planning They guidance. WHO’s are intended for policy-makers, family planning managers programme and the scientific The Developing a package Developing • • • • • Creating a system Creating The Department’s gibility criteria for contraceptive contraceptive for criteria gibility use and the recommendations for contra- ceptive use are based on evi- dence and expert consensus. The Department is developing a system for the guidelines ensuringand the recom- that mendations remain up to date as new evidence comes forth (Figure The 1.9). proposed system would include five steps as follows: guidelines will be contingent on contingent be will guidelines the development of strategies for successfully implementing best practices in family the at plan- users of needs The ning. country level will, in turn, help creating for priorities determine and implementing the guide- lines (Figure 1.8). 68 Annual Technical Report 2001 process. ment has worked in South and Africa Zambia to facilitate this Depart- The planning. family for guidelines delivery service some in 55 the countries preparation and revision of national other collaborating partners, this document has been used by and (USAID) Development International for Agency States in1998–1999. sions were printed With thehelpofUnited French, Indonesian, Russian, Spanish and Viet Namese ver- contraceptiveeach method. of use the uing Arabic,Chinese, lines based on the recommendations for initiating and contin- and revision provision guide- of national medical and service preparation the in programmes health planning/reproductive family national to guidance provided has contraception. It of reviewingfor methods selecting criteria eligibility medical the for improving access to high-quality care in family planning by The 1996 document was an important first step in the process 1995. and 1994 Genevain in held meetings Group Working Scientific followingtwo 1996 first in publishedwas which edition, the updates document This 2001. May in printed 2001 and February in site web Department’s the on published for planning: contraceptive wascriteria use eligibility medical document The and providers clients planning family for The Medical criteria forcontraceptive eligibility use to meettheneedsoffamily planningclient (Figure1.10). how on research science social from evidence best compile interaction The ices. provide quality family planning serv- to system health the and community capacity the of the enhance to resources will be developed delivery service and gerial practices community and Family The the guidance (Figure1.10). of use the support to aids education and training include materials provider The encounter. the quality of are improve the family planning to intended They mendations. recom- practice the Selected and criteria eligibility the from derived primarily be will planning providers family for book Section 1-Promoting familyplanning Section eiinmkn tool Decision-making n the and Client–provider eore will resource and the NEW NORMSAND NEW TOOLS mrvn acs t qaiy ae n family in care quality to access Improving let and Client Medical Mana- Hand- clients and for famil Decision-maki y planning Contrace C Medi p ri rovider te n ri ca g a to l Eligibilit

f or o s p l e Us ti

v y e Contrace R Se norethis- (DMPA), acetate terone pills, depot-medroxyproges- injectable pro- gestogen-only contraceptives, com- bined contraceptives, oral combined low-dose following family planning methods: the covers document revised The Group. the Workingby considered also were conditions various the of classification the of implications Programmatic obtained. not was considerations theoretical or evidence indirect on conditions. selected Information with womenby use method contraceptive of appropriateness the for evidence direct tify database.MEDLINE reviewthe of iden- wasto purpose The the in contained literature recent reviewmost detailed the of reviewed new evidence from a systematic obtained primarily representativesseveraling of organizations.and agencies It includ- countries, 17 from participants 32 together brought Group Working The 2000. March 8–10 on Geneva meeting in held Group Working Scientific a of recommendations main the summarizes document this of revision 2000 The trn dvcs (IUDs), devices uterine intra- II, copper pills, tive and contracep- emergency I implants ae (NET-EN) tate ec l ecte o mm d r P e p n e Us ti ac da v t t i ce i o n eoe enan- terone e s

f or , Norplant Norplant , Pr Communit Fami ac c Other resources for enhancingOther qualit t l a i y ces re infamilyplanning an d Client and y

P H lanning Providers andbook for for Familyandbook In Pr C li P te o e rovider Material vi n r ac t- de t r i on

Delive a Mana n s d

Se y g r

o rv y eria f i

ce l Annual Technical Report 2001 69 who Medi- addresses how Promoting family planning norms and tools and norms planning family Promoting Selected practice recommendations for con- for for safe and effective use of family planning methods is provided; the discussion and process are tailored to of the the individual client needs with the provider’s statements or actions depending, as much as possible, on the client’s and or statement; answer previous the client is enabled appropri- respond to to provider the and possible express as quickly her/his purposes as as possible. as quickly ately,

can safely and effectively use contraceptive methods, in i.e. identifying the medical appropriateness of contraceptive choices for women with Selected certain practice medical recom- conditions, the contracep- for mendations tive use addresses to safely and effectively use contraceptive meth- ods. Practical guidance is provided on common clin- ical issues, for example, what should a woman do if she misses a dose of cal eligibility criteria for contraceptive use the oral contraceptive pill. Both of these guidelines revised and developed are based on a system review ongoing an that ensures of relevant new evidence. When evidence warrants, Selected practice recommendations for Selectedrecommendations practice use contraceptive The document site web Department’s the on published be will use traceptive printingand submitted Itfor in isthe onefirst of half of 2002. produced guidelines consensus evidence-based, key two the by the Department improving for the quality of care in family counterpart,its Whereas the servicedelivery. planning • • The ECPG for family planning has, to date, been developed in partnership with INTRAH/PRIME, the Johns Hopkins Uni- Information (JHU) Health School Population of Public versity Program and the JHU Center Communication for Programs. The general approach of the ECPG INTRAH/PRIME regional was staff, discussed including with trainers and pro- viders, for a preliminary assessment of the usability of the group this from response The audience. target this by ECPG interest and was very expressed in they positive, incorporat- ing the ECPG into their countryThe firstprogrammes. draft was completed, and reviewed by experts in client–provider tech- The 2001. July in component process the for interaction nical content was then reviewed during an expert working group meeting in October 2001. Pretesting and field-testing of the ECPG will be carried out in 2002. are met to based meth- Decision-making tool Decision-making Medical eligibility criteria con- for expressed expressed by the client Selected practice recommendations methods, methods, fertility awareness- Handbook for family planning clients and , providers Essential care practice guides (ECPGs) are a synthesis the client’s needs as evidence-based best practices in client–provider com- are used; munication technical information needed appropriatefor choice and the process for the decision-making process planning of for is family cli- and interactive; ent-driven provides provides the technical information necessary optimal for and methods; delivery of nonsurgical contraceptive possible; the extent promotes the client’s informed choice and role in family planning service delivery; enables providers to apply evidence-based best prac- tices in the client–provider interaction during delivery of planning services; family encourages encourages providers and health systems integral an to as interaction client–provider promote in practices best part of service delivery.

ods, ods, coitus interruptus, lactational amenorrhea method, and and male sterilization. female • • • • • • • • The primary objective of the ECPG for family planning is to tool that: the use of a normative create and facilitate traceptive traceptive use and the supported be will ECPG the addition, In use. contraceptive for by the training and educational materials for clients and providers, and an adaptation guide. for for family planning clients and . providers It will be from and derived supported by the The target audience for the ECPG health workers for at the primary family level working planning in facilities with is This limited ECPG resources. will describe and facilitate the key elements of the client–provider interaction in the provi- sion planning of servicesfamily women and adolescents, for entitled is ECPG this Accordingly, men. of the latest information to that will definehave the greatest impact on improving reproductive essential interventions The health. ECPGs are designed to support three technical areas: childbirthpregnancy, and neonatal care; family plan- (STIs) infections transmitted of sexually and prevention ning; and HIV infection. The Essential care practice guide for family planning practice Essential care levonorgestrel-releasing levonorgestrel-releasing IUDs, IUDs for traception, emergency barrier con- The guiding principles to support are: these objectives 70 Annual Technical Report 2001 • • • • • • • • • by the Working Groupwere asfollows: the byGroup.Working considered addressed questions The also were recommendations the of implications grammatic evidence or theoretical considerations was not obtained. Pro- below.listed indirect questions on the Information by sented repre- challenges clinical common key address to evidence MEDLINE direct identify to the was review in the of contained purpose The database. literature recent most the of review detailed systematic a from primarily obtained dence evi- new reviewed It organizations. and agencies several of representatives including countries, 16 from participants 33 together brought Kingdom Group 2001. Working The October 3–6 on United London, in held meeting Group Working Scientific a of recommendations main the summarizes use The sions. pending revi- group working meetingsandsubsequentprinted expert are but electronically updated are guidelines the Section 1-Promoting familyplanning Section

DMPA orNET-EN? When can a woman start progestogen-only injectables— gency contraceptive pills? emer- taking after vomits she if do woman a can What pro- of dose a misses gestogen-only pills? she if do woman a can What progestogen-onlypills? When canawoman start contraceptive injections? injectable combined repeat have woman a can When ceptives? contra- injectable combined start woman a can When progestogen-only pills? or contraceptives oral combined using while diarrhoea severe has and/or vomits she if do woman a can What oral contraceptives? What can a woman do if she misses a dose of combined contrace- oral combined start ptives? woman a can When eetd rcie eomnain fr contraceptive for recommendations practice Selected • • • • • • • • • • • • • •

IUD isfound tobepregnant? What should be done if a woman using a copper-bearing (PID)? disease inflammatory pelvic with diagnosed is IUD ing copper-bear- a using woman a if done be should What IUD? whenusingacopper-bearing abnormalities menstrual experiences woman a if done be can What IUDbeinserted? When canacopper-bearing whenusingimplants? abnormalities menstrual experiences woman a if done be can What usinganimplant? When canawoman start or NET-EN? injectable—DMPA progestogen-only a using when ties What can be done if a woman has abnormali- menstrual ables—DMPA orNET-EN? When can a woman have repeat progestogen-only inject- pregnant? not is woman a that sure reasonably be one can How users? IUD and oral implant pill, combined progestogen-only for contraceptive, follow-up appropriate the is What progestogen-only pills) shouldbegiven visits? atinitialandreturn or (combined packs pill many How routinely before providing amethodofcontraception? done be should tests or examinations What cyclesoutsidethe26–32-daymenstrual range? has she if do user Method Days Standard a can What ing IUDinsertion? forprophylacticused Should be copper-bear- antibiotics Annual Technical Report 2001 71 Section 2 Making Safer Pregnancy 72 Annual Technical Report 2001 o rvdn eiec ta wl cnrbt t coe these close to contribute gaps. will that evidence providing to oriented is health newborn and maternal in work of gramme genetics. human as such pro- 1998–2003 Department’s The disciplines related including decade, past the in medicine of areas other in made progress major the to contradiction in is This care). curative and preventive between gap (a tality mor- severeand of morbidity causes leading the particularly of remains, lack conditions pregnancy-specific forpreventive action A practice). and evidence between gap (a utilized under- remain interventions effective many mortality, natal peri- and strategiessurgical maternal and reduce medical to emergency and treatments effective incorporate could ices serv- health although that, considerableagreement is There Section 2 - Making Pregnancy Safer 2-Making Section Generating new evidence for maternal and T haemorrhag um Po Caesarean section* r eatment ofpre-eclampsia** stpar INTRODUCTION t J. Villar, M. Gülmezoglu, M. Merialdi, C. Lissner perinatal health e evaluation to be implemented between 1998 and 2003. This is now well approved aprogramme for ofwork healthresearch maternal by individually STAG1999 conducted In countries. developing in be institutions research to unlikely is that research high-priority conduct to resources and skills the possesses developing of Programme the network, this with countries. collaboration In number large of a network in a institutions strengthened collaborating has decades past the during Programme evidence-basedthe of effort programmes.capacity-building The of implementation the through make to impact position an strong a in is and level country at trality neu- and credibility has Department the advan-tage.feltthat was It comparative Department’s the account into taking health maternal in areas research priority (STAG)identified Group Advisory and Technical Scientific Department’s The 31 2 5 9 142 000 18 530 80 000 10 000 P P submitted P ublished ublications ublished

Annual Technical Report 2001 73 ) 20 14 3–8 28 (CI 17–39) 5–12

PROGRESS , blood transfusion

,

, n tion ery v tion y, intensive care intensive y, r abor Generating new evidence for maternal and perinatal health and perinatal maternal for evidence new Generating The Programme completed this large, omized multicentre, controlled rand- trial in 1999 institutions in in developing countries (Argentina, Cuba, collaboration Saudi with four Arabia and Thailand). This new antenatal care programme limits the tests, clinical procedures and to follow-up actions those scientifically improving demonstrated maternal and newborn outcomes. The selected to antenatal care effective be activities in for women complications showing no are signs distributed of over course four of visits pregnancy. There were during new 53 the either provide to antenatal allocated the randomly women) 678 care (24 units programme of antenatal care or the traditional programme presently in The use. new antenatal care model was found to be as effective as the standard model, providers, and could women from resistance major without mented be imple- reduce costs. to be able also and may In 2001, the final data analysescom- evaluation economical and satisfaction of women/provider the clinical evaluation, were papers several and completed were trial this of ponents published, including the corresponding systematic review of compari- The trials. randomized from information available all son of the economics of providing the both two for time) models and (money showed costs in difference a was there that women and providers. In the new model, for example, the than with the overall 6–15% costs lower per pregnancy were Evaluating effectiveness of practices effectiveness Evaluating the for trial controlled randomized WHO The programme care of a new antenatal evaluation ssisted deli outine uterotonics Surge blood transfusio caesarean sec sulfate Magnesium R A Safe

13 1.2 15.4* 0.7–0.19 placenta, of removal by by implementing this work plan several large multicentre trials

2.5–3

tion ed

um tum t abor r bstruct nsafe ntepar ostpa clampsia clampsia P haemorrhage labour O U E A haemorrhage (% prevented SPECIFIC OBJECTIVES OF RESEARCH SPECIFIC OBJECTIVES evaluating medical and nonmedical maternal health interven- health maternal nonmedical and medical evaluating 2.1); some tions of (Table these trials are definitive trials on the subject. By the time the last trials of this series will completed, be over 280 000 woman/newborn pairs will been studied a over period have Aof years. detailedfive descrip- tion of the progress made in each specific area is presented sections. in the following and successfully completing The goal of this programme of work is to reduce maternal morbidity and mortality through the development of accept- able and affordable evidence-based health Implementation of the maternal health research programmes. programme is achieved by: (i) evaluating the effectiveness of practices; influ- factors sociocultural of understanding the improving (ii) encing maternal health care; (iii) reviewing methodological issues related to maternal health research; (iv) conducting follow-up studies of the populations included in pregnancy- strategies implementation the evaluating (v) research; related research fundamental stimulating (vi) and results; research of on outstanding obstetric problems of global importance. In addition, during 2001, following a rigorous epidemiological methodology, activities were initiated for the preparation of maternalof summarymor- epidemiology a the descriptionof bidity in developing countries. These data will be compiled in a formal and publication should contribute to the efforts in mapping maternal ill-health and improving service coverage 2.2). Table (see under way, under and way, all major objectives should be achieved by the end of the The six-year period.Programme has demon- strated its research capacity 74 Annual Technical Report 2001 Section 2 - Making Pregnancy Safer 2-Making Section of third stage of labour; of thirdstagelabour; and intravenously, is the uterotonic of choice for the management misoprostol trial were: misoprostol trial • • of loss blood postpartum reducing in intravenously) or intramuscularly given oxytocin of dose IU 10 a vs misoprostol of mg 600 of dose single (a 2000. in completed two of efficacy the compared It regimens stage of labour was launched by the Programme in 1997 and third of management the in misoprostol of efficacy the study to trial controlled double-blind,randomizedmulticentre, This in themanagementofthird stageoflabour The WHO multicentre randomized trial ofmisoprostol likely tofollow. are countries other and 2002, in model care antenatal new tries where the trial was conducted are expected to adopt the coun- four services. The into project the research this of results incorporating for used be to materials supporting the new WHO antenatal care model has been published, as have the of implementation the meetings.for manual country The and regional special as well as symposia and meetings at presentations through initiated was results the of effort tion journals. dissemina- An extensive scientific in forpublication submitted been have pregnancy, early in bleeding for tors fac- risk and syphilis of epidemiology on papers Additional model. new the with lower be to recorded also was services patient standard model. Moreover, the waiting time for women at out- olbrtn cnrs n retn, hn, gp, Ireland, Egypt, China, Argentina, in centres collaborating with Programme the by done was coordination trial Overall greater blood lossandmoreside-effects. compared with oxytocin, misoprostol was associated with oxytocin,wasassociated with misoprostol compared xtcn 0 U amnsee ete itauclry or intramuscularly either administered IU, 10 oxytocin > 1000 ml. The key findings of the of findings key ml. The 1000 observed. of 25% in caesarean reduction section rates, only a marginal decline was hypothesized the to contrary that, show data been haveanalysed and several America reports submitted for Latin publication. in These section caesarean of context outcomes, opinions about the mode of delivery and the primary social (4), the regarding Cuba Data (4). Mexico (6), and (2) Brazil Guatemala (18), Argentina trial: the in ticipated par- countries American Latin five from hospitals Thirty-four evidence abouteffective andsafe managementofchildbirth. available best the on based section, caesarean emergency mandatory second opinion to be requested before every non- a of consisted that intervention evaluatedan trial the zation, randomi- cluster of framework the trial. Within the of ponent and financial support for the satisfaction and perception com- technical provided Programme the while centres, laborating funded with a grant from the European Community to the col- Development (CLAP). The biomedical component was mostly Human and Perinatology of Centre American Latin the with collaboration in America Latin in implemented was trial This rate ofcaesarean section second opinionfor ofthe thereduction mandatory The Latin American randomized controlled trial of trial ofanticonvulsantstrial for thetreatmentofpre-eclampsia. sulfate was magnesium beneficial. that This is now conclude the biggest-ever to conducted available was evidence cient suffi- that considered who Committee Management Safety and Data the of recommendation the on 2001 November in mately 10 000 women were recruited, the study was stopped approxi- After countries. 31 in hospitals 150 from and clinicians women involved and 1998 July in began Recruitment study resources. the service to health of use the was as serious maternal and neonatal morbidity were also assessed, death of the mother or baby. The effects on other measures of and pre- eclampsia were measures outcome eclampsia. with Primary women of treatment the for placebo with sulfate This trial, known as the “Magpie Trial”, compared magnesium burden of pre-eclampsia eclampsia: reducing thehumanandhealthservice The trial ofmagnesiumsulfate for theprevention of South Africa. treat and haemorrhage will postpartum preventbe implemented in Mexico and to strategies effective of dissemination 2002, During area. this in trials controlled randomized from evidence all of review systematic the included and 2001 in stage of labour is the norm. third The main were reports published the of management active where settings, hospital in labour of stage third the of management active the in ostol misopr- oral mg 600 to preferable is intramuscular) or nous (intrave-oxytocin IU 10 that demonstrate trial this of results countries. these in enrolled wereThe women 530 18 of total South Nigeria, Switzerland, Africa, Thailand and Viet Nam. A Annual Technical Report 2001 75 The The Cochrane Library require- The WHO The Reproductive Health prevention prevention of postpartum haemorrhage by prostagland- ins treatment of retained placenta routine antenatal care screening and alternative treatments for asymptomatic and symptomatic bacteriuria during antenatal care administration of vaginal misoprostol for labour. induction of treatment of anaemia during pregnancy during pregnancy growth management of impaired fetal

Generating new evidence for maternal and perinatal health and perinatal maternal for evidence new Generating • • • • • the understanding of sociocultural Improving factors influencing maternal and economic health care of the quality of ’ perceptions ’s and providers Women care antenatal antena- of quality the of perceptions providers’ and Women’s tal care were assessed alongside the WHO Antenatal Care trial in collaboration with the Latin American office Council Population and ofthe National Perinatal Epidemiology The Oxford, United DuringUnit, Kingdom. Oxford this University, information study, was obtained by applying both qualitative and quantitative research A methodologies. sample of 1600 pregnant women and all antenatal care providers participat- component care qualitative The included. were trial the in ing Systematic reviews the literature of Systematic Systematic reviews are conducted within the framework of the “WHO Programme to “Implement- on chapter the Map see details, (for activity Best Practices” Reproductive Health topics are Review selected ing on best the practices”). basis of their importance for developing countries, and scientists and preparing for responsibility the take countries these from maintaining these reviews. As part of this effort to synthe- size evidence for the effectiveness of maternal health care been updated. have systematic reviews interventions, seven Also, four full new reviews and two review protocols in published were accordance with devel- from scientists by or Programme the of staff by ments, oping countries with support from the Programme. systematic were reviews These published in the 2001 issue of • • Cochrane Cochrane Library as well as Library, No. 5, 2002. The main areas in been prepared through this effort are: which have reviews systematic Furthermore, a comprehensive review of the effectiveness of effectiveness the of review Furthermore,comprehensive a antenatal care in preventing maternal mortality and serious morbidity was conducted and published as a supplement to . Epidemiology the journal and Perinatal Paediatric The protective effect of calcium supplementation has provided intake calcium deficient with women to pregnancy during preventive promising very a as literature the in identified been strategy for pre-eclampsia. It is being evaluated by the Pro- intake—the calcium low with populations trialin a in gramme nutritional to benefit from such a intervention (1.5 most likely g of calcium a The day). trial is being conducted in Argen- tina, Egypt, India, South Peru, Africa A Viet and base- Nam. the of women 500 over included intake calcium of survey line selected clinics and hospitals pregnant population served by in these countries and demonstrated that the mean calcium intake is less or than approximately 50% 600 of mg/day, the 1200 mg/day recommended for pregnant The women. total sample size of the trial is expected to be 8500 women and pre- of incidence the in reduction the primaryis the objective 2002, more had than been 3000 women By June eclampsia. randomized to two arms of the trial, which is expected to be completed in 2003. A randomized, double-blind, controlled trial of calcium of calcium trial controlled double-blind, A randomized, pregnancy during to provided supplementation for the calcium intake with deficient women of pre-eclampsia prevention The Magpie study settles the issue for magnesium sulfate. The 4968 women in the study who received an an injection and eclampsia of of risk lower 58% a had sulfate magnesium pla- given women 4958 the than dying of risk lower 45% to up Side-effects cebo. were only minor: neither the mothers nor their babies have so far shown any serious adverse effects 2002. June in published were results The treatment. the from These data in conjunction with the previous eclampsia trial clearly demonstrate that magnesium sulfate is the drug of choice for the prevention as well as treatment of eclampsia complications. and its fetal 76 Annual Technical Report 2001 ment’s web site. information about the spreadsheet is available on the Depart- Additional 2002. in Spanish in published be will application, of Mexico. district illustrative this Mexicanas well as low-incomespreadsheet, The one in it applying be also will which ried out by the Instituto Nacional de Salud Pública de México, research buildingcapacity countries. these in economic translationThe was car- support also but application, facilitate only not will cost. This of estimation for tools with countries order to provide planners and managers in Spanish-speaking in Spanish into wastranslated tool spreadsheet the 2001, In identified in WHO’s Mother–baby package. interventions the on based is spreadsheet The managers. and planners national-level and district- at targeted is tool to reduce maternal and newborn and mortality morbidity. The implementing, at of the level,district a package of interventions cost the estimates that tool a spreadsheet, costing age the developed Department the 1999, In costing spreadsheet) (Spanish-language version oftheMother–baby package advocacy efforts at to both global and national levels. critical They are also care health newborn and maternal essential providing of cost global or national district, the of Estimates Cost ofmaternal health Paquete deestimacióncostos madre–bebé—modelo mize bias. mini- to and possible as comprehensive as is it that ensure to order in approach review” “systematic scientific strictly a developingin care health maternal countries. took study The of provision the for resources of availability the increase to interventions documented of range full the illustrating appraising and by policy-makers assist to poised is study The examined. were purchasing and pooling surrounding collection, revenue issues key the identified, form organizational For each sustainability. scheme’s the finally, services and, the provided of equity and quality the services, health nal mater- of utilization the on one each of impact the document and care health maternal finance to approaches, or forms, care. health maternal financing for options reviewof systematic A In 2001, the made Department progress in the preparation of health care Systematic review ofoptionsfor financingmaternal ance tothenew four-visit WHO model. resist- significant any voice not did providers the received; show that women were in general satisfied with the care they Results journals. specialized in publication for submitted as full set of publications of the WHO Antenatal the Care trial as into well incorporated results the and completed, been also has quantitativepart forthe publication.ted of analysis Data of the study has been completed and the final reports submit- Section 2 - Making Pregnancy Safer 2-Making Section The review aims to identify the range of organizational of range the identify to reviewaims The Mother–baby pack- Mother–baby

recommendations. the of implementation possible and consideration their for institutions participating the to distributed were results The journals. economics health leading to publication for mitted sub- and meetings professional at presented were findings main the reporting papers Several women. for time which saved 2001, during completed showed that the new WHO model costs reduced wasand service analysis data Final and combinedwithdatafromthe centres.WHO trial Africa KwaZuluSouth in Natal, centre additional an in lected col- also were results. data the Toend, of transferabilitythis countries that in took the part economic study, and to assess differencesto between the cost–effectiveness estimates lead for the may that factors the examine to was aim further A andforthe service healthcareproviders. using women for both service, of levelexisting the than tive care antenatal tested in the of WHO Antenatal Care trial model WHO four-visit new the whether London, United Kingdom. The overall Medicine, Tropicalobjective and was to Hygiene assess of School London the and Kingdom United Norwich, Anglia, East of University collaboration the with in completed was evaluation economic This randomized controlled trial antenatal care conducted alongsideamulticentre, Economic evaluation ofarational package for This activity was conducted in collaboration with the Depart- the with collaboration in wasconducted activity This of clusterand meta-analysis randomization trials Methodological consideration for the design, analysis in published meta-analyses independent natology.Eighty-four peri- in trials large of results the of meta-analyses of ability predict- the evaluating work previous of follow-up a is This controlled trials ofrandomized ofmeta-analysis Heterogeneity maternal health Reviewing research related methodology to in asystematicfashion. willbepublished in2002. The report collated was care maternal of cost the on information lished maternal health and services interventions. All available pub- prepared a Department review of the evidence on the cost of the 2001, In services. health maternal providing of cost the on available information scarce is However,there disease”. of “burden the on based those as such health, prehensive com- cost–effectivenesson in studies role important playan heterogeneity of trial resultsisunderpreparation. heterogeneity oftrial with meta-analyses in used tests statistical evaluationthe of an and different2001, explored. werein published was paper trials A from results of heterogeneity is there when used be to factorsaffectingmethodology the evaluated, wereand The CochraneThe s Pregnancy and Childbirth module Childbirth and Pregnancy s Library’ was more cost–effec- Annual Technical Report 2001 77 Generating new evidence for maternal and perinatal health and perinatal maternal for evidence new Generating sure, clinical anthropometric measures, and morbidity history morbidity and measures, anthropometric clinical sure, were obtained at follow-up for the children and their moth- The ers. study was completed in 2001 with a follow-up loss children the after years 12 children, eligible 10% than less of were born. Data were analysed and first the contraryto that, found results study The 2001. in submitted publication for follow-up results at age 7 when a beneficial effect in terms of blood pressure lowered was recorded, there was no such at age 12. effect Follow-up of the Magpie trial study population study trial of the Magpie Follow-up Preparatory activities are under way, in collaboration with conducting the Magpie the trialpreven- the investigators (for up children of study follow-up a conduct to eclampsia), of tion to 2 years of age Growth, born development to and mothers morbidity enrolled will in this follow-up study the to be be initiated in 2002. External trial. evaluated funding in has been obtained from the UK Medical Research Council and other donors, which will be complemented developing by in the centres Pro- collaborating three to support gramme’s countries. The Guatemalan perinatal follow-up study perinatal follow-up Guatemalan The This study was conducted within the context of a Long-term Institutional Development (LID) Grant provided by the Pro- The study gramme. is a long-term follow-up of a subsample of 14 847 newborns originally included in the Guatemalan Perinatal Study conducted between April 1984 and January The present 1986. includes follow-up a sample of newborns that showed evidence of intrauterine growth retardation at birth and a years 14 corresponding and 12 between were children control These infants. group weight of normal birth- The objective of age when contacted the for study. follow-up is to compare attained growth by anthropometric measures, sam- Blood experiences. morbidity and levels pressure blood ples were taken in a subsample of the There children. is a reproduc- the explores that study the of component maternal tive patterns of the mothers after the index pregnancy and the socioeconomic characteristics of these women at time of the follow-up. the Data collection was completed in 2000 and plans for analy- partiallyand prepared implemented were publication and sis in 2001. This data set was also used labour obstructed to for explore factors risk questions fetal and maternal to related and caesarean section, including the growth of the woman duringIt was confirmedher childhood. that shorter maternal labour. obstructed of risk the of predictor strong a was height to that attrib- comparable growth, the increases in fetal Also, utable to improved nutrition during pregnancy, are associ- ated with a larger decrease in the risk of perinataldeliv- caesarean intrapartum distress of risk in increase the to relative ery for A the reportmother. was published in 2001, and the results of a comprehensive analysis of the data will be pub- lished in 2002. This is a prospective, follow-up study years of of age, born to women enrolled in a ran- double-blind, 600 children 12 supplementation calcium of trial placebo-controlled domized, It the explores long-term during of effect pregnancy. calcium supplementation during pregnancy on the offspring’s blood pressure during pre-adolescence, particularly among chil- dren with high body mass index. Standardized blood pres- on blood in utero exposure effectThe high calcium of of follow-up long-term childhood: late during pressure trial controlled subjects in a randomized enrolled The possibility of an intrauterine programming attracted has of conditions, chronic diseases various including life, in later considerable This interest hypothesis recently. is supported which of most studies, observational of number growing a by have been conducted in populations from developed coun- tries. Concerns have been raised about the methodological data used which studies, epidemiological these of limitations from hospital records from decades and ago, included small The Pro- numbers of intrauterine newborns. growth-retarded two with collaboration in hypotheses these testing is gramme institutions in Latin America using perinatal and childhood/ adolescent data, prospectively collected in large cohorts of children. Conducting follow-up studies of populations studies of populations follow-up Conducting research included in pregnancy-related Clinical trials methodology trials Clinical The WHO multicentre, randomized controlled trial to evalu- ate the use of misoprostol in the management of the third stage of labour, mentioned above, presented special meth- generation, sequence of methods The challenges. odological described in trial this were in used blinding and concealment a paperto be published in a clinical trials The journal.paper also described how the possible existence of ascertainment bias in the main outcomes was assessed. The and practical a offers trial method the in used concealment allocation of convenient mechanism of drug administration in a hospital delivery ward that can be used even in multicen- the in gained remote experience The settings countries. developing in tre trial will be used at the local level to methods. improve research ment of Epidemiology and Biostatistics, University of West- ern Ontario, Canada. Utilizing the experience gained from the WHO Antenatal Care trial, taking statistical calculations, power and issues size sample trial, the related of design to into account stratification and clustering in the design,were in statis- methodological and papers two published reviewed tical journals in 2001. The new software ACLUSTER, now commercially available, was published by the Programme’s and Informatics SupportTrials Clinical group and distributed to collaborating centres. It is useful for sample size calcu- lations and analysis formulae for statistical packages. in standard design, not available the cluster randomized 78 Annual Technical Report 2001 r-capi–capi”ws anhd hs ciiy has activity This launched. was Pre-eclampsia–Eclampsia” Conquer to Programme “Global entitled programme service ever. time and first research the for new a undertaken Thus, been has magnitude this of effort coordinated A worldwide. research sciences basic to level country at treatments tive effec- of implementation the from ranging activities include would that project programme comprehensive a of opment scientific devel- the the lead Programmeto the to looking wascommunity that clear became also it However, funding. for donors to submitted were countries. protocols oping The devel- in institutions severalleading and USA Pittsburgh, of protocols were developed in collaboration with the University and organized was areas promising identify and review to concrete meeting a identify 2001, In research. and collaborative for opportunities estimate to order in areas these in active already agencies funding and researchers with tact the or resources the con- established it alone, research havethis conduct to capability not does Programme the As order tounderstandthepathophysiological processes. in research basic implementing in needed be will efforts ble considera- strategies, preventive new neglected. Toidentify rare in developed countries, research in these area has been severe pre-eclampsia and impaired fetal growth are relatively identifying effective preventive measures. Moreover,without because reduced be can costs and morbidity that unlikely is infant. growth-impairedIt or preterm a of care intensive and tions consist largely of symptomatic treatment for the mother nancy and impaired fetal growth. Currently preg- available interven- of disorders interventions—hypertensive therapeutic and preventive base to which on knowledge physiological patho- concrete little very is there which for countries oping There are two highly prevalent morbidities in maternal devel- importance outstanding obstetric problems ofglobal Stimulating fundamental research on 2003. early by completed be to expected of is trial evaluationthe of impact and the 2002, in completed The be 2001. will April intervention in started collection data Baseline 2001. RHL in recommended as practices effective obstetric of use the increase or change to is trial the of objective land. The and Thai- Mexico in departments maternity 40 in conducted being is the practices”). trial best The “Implementing on see chapter details, (for indicators as practices care using maternal undertaken, being is strategy outreach educational an of trial controlled randomized a practices, care health in Reproductive Health evaluatethe to from informationorder uptakeof In the Library based ontheWHOReproductiveHealth programme promoting evidence-based medicine A randomized controlled trial to evaluate a research results Evaluating implementation strategies of Section 2 - Making Pregnancy Safer 2-Making Section Library (RHL) with subsequent changes WHO now underreview for specialfundingindifferent agencies. cept of systematic reviews and priority research areas, and is con- the on based is activities of programme proposed The Research. Health the on with Committee tion Advisory WHO consulta- developingin developedboth and and in countries been developed in collaboration with a network of institutions Treatment haemorrhage ofpostpartum developing countries. in populations on focused pregnancy to related conditions fatality, risk attributable risk, relative project the of prevalence,incidence, outcomes the of case indicators updated be will The level. service the at use for information the all summarize to order in data, these pooling for approaches and aspects statistical evaluate to 2002 in organizedwas consultation a 2002. in Furthermore, initiated was stage 2002. second in publishedThe be will and uation first stage, was made available and for internal external eval- the from results discussing document, the of draft a 2001, In criteria. assessment quality and study of type country, age, by studies epidemiological located any from data extract to order in developed been has form collection data generic A and otheragencies. data- electronic papers,bases and additional documents from publishedWHO Regional Offices all of addition the with data these augment collated to strategy search a (ii) sets 1995; and after data comprehensive related other and trials WHO from data all of summary the (i) stages: two review includes systematic completed, now This, evaluation”). and nowis wayunder (for details, on chapter the see “Monitoring countries, developing in mortality and morbidity maternal of ological data from 1995 to 2001, documenting the magnitude complement these activities, a systematic review of epidemi- treat and prevent the leading causes of maternal mortality. To maternal in activities health research are concentrated on Department’s findings interventions to the priority, first a As themagnitudeofmaternalMapping ill-health mented according tothereview results. imple- be will haemorrhage postpartum of treatment the for misoprostol effectivenessevaluateof the to trial randomized multicentre, a and prepared, being are trials nonrandomized and randomized of reviews Systematic haemorrhage. tum postpar- of treatment the in misoprostol of dosage optimal effectiveness,and of risks issues the address to research of programme comprehensive a for protocol a developing are institutions, research of network collaborative WHO the of part are that centres strategy. African promising a be might misoprostol of use the that suggested have studies liminary pre- complication, this treat to used rhage. drugs the Among haemor- postpartum to due are areas rural in births 000 100 per deaths maternal 40 as many developingas In countries, NEW PROJECTSNEW INITIATED IN2001 and sequelae of morbid of sequelae and Annual Technical Report 2001 79 Generating new evidence for maternal and perinatal health and perinatal maternal for evidence new Generating Activities similar to the misoprostol research are programme being by developed a collaborating centre Thailand in to ini- tiate a comprehensive programme for evaluating the most effective strategies for the screening and treatment of uri- nary tract infection during pregnancy. The gramme will research include pro- all the screen- evaluating publications methodological of review systematic the from steps ranging ing techniques to the implementation of treatment of analysis) clinical cost (including research service health trials and modalities. Screening and treatment for urinary for tract and treatment Screening infection pregnancy during 80 Annual Technical Report 2001 Fiona Stanley, Telethon Institutefor ChildHealth,Perth, Australia Silvina Ramos, CentrodeEstadoySociedad,BuenosAires, Argentina Pious Okong, Nsambya Hospital,Kampala,Uganda Pious Ngassa, WHO Centrefor ResearchinHumanReproduction, Yaoundé, Cameroon Marc Keirse, The FlindersUniversity ofSouthAustralia, Adelaide, Australia Angela Kamara, Program, RegionalPrevention Dzorwulu, Ghana Mortality ofMaternal Ellen Hodnett,University of Toronto, Toronto, Canada Wendy Hospital,Aberdeen,UnitedKingdom Graham, AberdeenMaternity Jo Garcia,InstituteofHealthSciences, Oxford, UnitedKingdom(Chairwoman) Andres deFrancisco, GlobalForum for HealthResearch, World HealthOrganization,Geneva, Switzerland Members RESEARCH GROUP ONMATERNAL ANDPERINATAL HEALTH IN2001 Annex 1

Members EURO EMRO AMRO AFRO from: Women WPRO SEARO Section 2 - Making Pregnancy Safer 2-Making Section Number Developing countries 4 1 3 2

% oftotal 40 10 30 20

Countries intransition Countries Number

% oftotal

Developed countries Number 6 1 4 3 2

% oftotal 60 10 40 30 20

Totals 10 2 6 3 3 2 Annual Technical Report 2001 81 6 2 9 4 4 2 27 15 Totals

4 22 26 15 % of total

1 6 7 4 Number Developed countries Developed abia

Generating new evidence for maternal and perinatal health and perinatal maternal for evidence new Generating % of total

Number Countries in transition

7 7 15 30 15 41 74 % of total

4 8 4 2 2 11 20 Developing countries Developing Number Hany Abdel-Aleem, Assiut University Hospital, Assiut, Egypt Hospital, Assiut University Abdel-Aleem, Hany Nigeria Sagamu, Ogun State University, Adetoro, Olayiwola Al-Mazrou, Ministry Saudi Arabia Riyadh, of Health, Yaccob Al-Osimi, MinistryMuneera Arabia of Health, Jeddah, Saudi Saudi Ar Khalid National Guard Hospital, Jeddah, Hassan Ba’aqeel, King Principal investigators Principal Annex 2 Annex IN 2001 SCIENTISTS Leiv Bakketeig, Odense University, Odense, Denmark Odense, Odense University, Leiv Bakketeig, of Bergen, Bergen, Norway University Bergsjø, Per Argentina Rosario, Centro RosarinoPerinatales, de Estudios Liana Campodonico, Argentina Rosario, GuillermoCarroli, Centro Rosarino de Estudios Perinatales, Maternity and Child Health Hospital, Shanghai, China Linan Cheng, International Peace Canada Ontario, London, Ontario, Western of University Allan Donner, United Kingdom Oxford, of Health Sciences, Institute Lelia Duley, London, United Kingdom Medicine, Tropical Diana Elbourne, London School of Hygiene and Cuba “America Arias”, Hospital Gineco-Obstetrico Havana, Ubaldo Farnot, Kingdom London, United Medicine, Tropical London School of Hygiene and Fox-Rushby, Julia South Africa Johannesburg, Witwatersrand, of University Hofmeyr, Justus Thailand Khon Kaen, University, Khon Kaen Chusri Kuchaisit, Mexico DF, Council, Mexico The Population Ana Langer, Thailand Kaen, Khon Lumbiganon, Khon Kaen University, Pisake India Vellore, Mathai, Christian Medical College and Hospital, Matthews of East Anglia, Norwich, United Kingdom University Mugford, Miranda Viet Nam Hospital, Ho Chi Minh City, Vuong Hung Thi Nhu Ngoc, Nguyen India Medical College and Hospital, Nagpur, The Government Purwar, Manorama Cuba “America Arias”, Hospital Gineco-Obstetrico Havana, Georgina Rojas, Bogotá, Colombia Javeriana, Universidad Maria Ximena Rojas, Argentina Rosario, Centro Rosarino de Estudios Perinatales, Mariana Romero, Nutricional, Peru Lima, Instituto de Investigacion Nelly Zavaleta, SEARO AMRO EMRO EURO Women Women from: AFRO All

WPRO 82 Annual Technical Report 2001 Epidemiology, 2001, 15 (suppl. 1):1. morbidity: andserious Islam M. how mortality effectiveAntenatal caretoreducematernal isit?Paediatric andPerinatal (www.biomedcentral.com) (submitted). an exploratory studyofdatafromthe WHO Randomised Trial ofMisoprostolinthe Third StageofLabour. Hofmeyr GJ, Gülmezoglu AM, Villar J, LumbiganonPandPiaggio G. Effect ofmisoprostol onprofuseblood lossafterbirth: management ofthethirdstagelabour. Misoprostol intheManagementof Third StageofLabour. WHO multicentre randomized ofmisoprostolinthe trial Gülmezoglu AM, Villar J, NgocNT, PiaggioG,CarroliAdetoroL,etal. for the WHO Collaborative Group To Evaluate University ofEastAngliaDiscussion DocumentonHealthEconomicIssues, 2001. Galvez A,Galvez G. M,Sanabria School ofHygieneand Tropical MedicineHealthEconomicsExchange, 2001:1–4. Fox-Rushby J. Clinical trials: into thenew millennium. publications, MedicalJournal 2001. London, British Duley L, Villar J. Big isstillbeautiful: why we for continue toneedlargesampletrials identifyingbestpractices. In: Duley L,ed. andGynecology,2001(inpress). of Obstetrics Duley L,Gülmezoglu AM. Magnesium sulfate comparedwithlyticcocktail for women witheclampsia. in MedicalResearch,2001,5:325–338. Donner A,PiaggioG, Villar J. Statistical methodsfor themeta-analysisofclusterrandomization trials. Lancet, 2001,357:1565–1570. WHO AntenatalCare Trial ResearchGroup. WHO systematicreview ofrandomized ofroutineantenatalcare. controlledtrials Carroli G, Villar J, PiaggioG,Khan-NeelofurD, Gülmezoglu AM,Mugford M,LumbiganonP, Farnot U, BergsjøPfor the and Perinatal Epidemiology,2001,15:1–42. Carroli G,Rooney C, Villar J. morbidity: andserious how mortality effectiveAntenatal care andmaternal is it? Paediatric episiotomy inArgentina. Borghi J, Fox-Rushby J, BergelE,AbalosHuttonG,CarroliG. The cost-effectiveness ofroutineversus restrictive Rosario, Argentina. London, LondonSchoolofHygieneand Tropical Medicine, 2001(finalreport). Borghi J, BastusS, BelizánM,GiordanoD, AbalosE,Hutton G,etal. in Costsofpublicly services provided maternity Medicine, 2001(finalreport). A cost-minimizationanalysisofthenew WHO antenatalcarepackage . London, LondonSchoolofHygieneand Tropical Borghi J, BastusS, BelizánM,GiordanoD, AbalosE,CarroliG,etal. CostofantenatalcareandrelatedinArgentina. , 2001,323:303–306. MedicalJournal British Betrán AP, deOnisM,LauerJ, Villar J. Ecological studyofeffect ofbreastfeeding inLatinAmerica. oninfant mortality OrganizationandPolicyStudies inHealthServices , 2001,17:35–54. Bergsjø P. What istheevidence andmorbidity? for mortality theroleofantenatalcarestrategies inthereductionofmaternal . nutrition London, AcademicPress, 2001(inpress). Abalos E, Villar J, CarroliG. Pregnancy, pre-eclampsiaanddiet. In: Caballero B, ed. medicine, 3rded.,2002(inpress). Abalos E,LindheimerM. Management ofhighblood pressureinpregnancy. In: Epstein D, ed. Publications in2001 Annex 3 Section 2 - Making Pregnancy Safer 2-Making Section Evaluation ofthe WHO antenatalcarepackage. Health economicandfinancing exchange. London, London American Journal of Obstetrics andGynecology,2002(inpress). ofObstetrics Journal American Economic evaluation indeveloping alongsideanantenataltrial onCuba. countries: report Lancet, 2001,358:689–695. Encyclopedia offood sciencesand Calcium antagonistsinclinical International Journal Journal International Statistical Methods Biomed Central Annual Technical Report 2001 83 . Norwich, . Lancet, 2001, Economic evaluation of the cost of the new WHO of the cost of the new Economic evaluation Alternative Therapies in Women’s Health, 2001, 3:76–79. Women’s in Therapies Alternative Generating new evidence for maternal and perinatal health and perinatal maternal for evidence new Generating Statistics in Medicine, 2001, 20:3635–3647. (submitted). 2002 (www.biomedcentral.com), Biomed Central A study of the costs of antenatal care alongside the WHO trial in Thailand trialWHO in the alongside care antenatal of costs the of study A Costs of antenatal and delivery care for providers and women in Umlazy township, in Umlazy township, and women providers Costs of antenatal and delivery care for British Journal of Obstetrics and Gynaecology (submitted). , Issue 4, 2001, Oxford, Update Software. LibraryThe Cochrane , Issue 4, 2001, Oxford, Statistics in Medicine, 2001, 20:401–416. British Journal of Obstetrics108:689–696. and Gynaecology, 2001, pregnancy. Reviews updated updated Reviews management of retained placenta. injection for vein Umbilical Carroli G, Bergel E. of postpartum haemorrhage. prevention Prostaglandins for GJ. Hofmeyr Villar J, F, AM, Forna Gülmezoglu growth. impaired fetal suspected Betamimetics for GJ. AM, Hofmeyr Gülmezoglu growth. suspected impaired fetal Hormones for GJ. AM, Hofmeyr Gülmezoglu growth. impaired fetal Maternal suspected nutrient supplementation for GJ. AM, Hofmeyr Gülmezoglu New reviews New hypertension during mild to moderate for drug therapy Antihypertensive Henderson-Smart DJ. DW, L, Steyn Abalos E, Duley iron deficiency anaemia in pregnancy. for Treatments Cuervo LG, Mahomed K. eclampsia. for lytic cocktail versus Magnesium sulfate AM. L, Gülmezoglu Duley asymptomatic bacteriuria. choice of antibiotic and treatments for of screening tests, Review Minini L. IN 2001 LIBRARY REVIEWS PUBLISHED IN THE COCHRANE SYSTEMATIC Langer A, Nigenda G, Romero M, Kuchaisit C, Rojas G, Al-Osimi M, et al. for the WHO Antenatal Care Trial Research Group. Group. Research Trial Antenatal Care WHO the for M, et al. Rojas G, Al-Osimi C, M, Kuchaisit Nigenda G, Romero Langer A, antenatal care. satisfied with providers and Are women C. Bagwandeen Jinabhai C, J, Wamukuo Lumbiganon P, Villar J, Piaggio G, Gülmezoglu AM, Adetoro L, Carroli G, for the WHO Collaborative Group to Evaluate Group to Evaluate WHO Collaborative the L, Carroli G, for AM, Adetoro G, Gülmezoglu Piaggio Villar J, Lumbiganon P, of labour misoprostol used in the third stage of oral Side-effects of Labour. Third Stage of the Misoprostol in the Management during the 24 hours after administration. and pregnancy-induced hypertension.Calcium J. Villar Merialdi M, C. Kuchaisit B, Thinkamrop J, Thinkamrop Research Trial Care WHO Antenatal the for et al. U, Belizán M, Farnot H, Piaggio G, Lumbiganon P, Ba’aqeel Villar J, model of routine antenatal care. of a new the evaluation trial for WHO antenatal care randomized Group. trials controlled of randomised in perinatal Meta-analyses in systematic reviews ME, Carroli G, Donner A. Mackey Villar J, models. random effects and comparison of fixed medicine: low-risk pregnancy of routine antenatal care for Patterns AM. Piaggio G, Gülmezoglu D, Khan-Neelfour Carroli G, Villar J, Review). (Cochrane Lumbiganon P, Piaggio G, Villar J, Pinol A, Bakketeig L, Bergsjø P, et al. The epidemiology of syphilis in pregnancy. pregnancy. of syphilis in The epidemiology et al. L, Bergsjø P, Pinol A, Bakketeig Villar J, Piaggio G, Lumbiganon P, International Journal, 2002 (in press). of STD and AIDS to riskMaternal of perinatal relative intrapartum distress and and newborn size cesarean E. Kestler Villar J, Merchant K, delivery. cluster stratified analysis of an equivalence on the design and considerations Methodological J. Villar Piaggio G, Carroli G, trial.randomization Y. M, Ba’aqeel H, Al-Mazrou Hutton G, Mugford J, Fox-Rushby Smith S, 2001:1–56. Medicine, Tropical London, London School of Hygiene and . of antenatal care in Saudi Arabia Programme 10, 2001:1–117. Research Report and Practice, No. of East Anglia School of Health Policy University 357:1551–1564. in maternal International and practice health care. Journal evidence The gap between of AM. Gülmezoglu Carroli G, Villar J, 1:S47–S54. Obstetrics and Gynecology, 2001, suppl. 11, 2001:1–59. Research Report and Practice, No. of East Anglia School of Health Policy University Durban, South Africa. 84 Annual Technical Report 2001 Kulier R,Gülmezoglu AM,deOnisM, Villar J. Vitamin Asupplementationinpregnancy. Adetoro O, Hofmeyr GJ. Prophylactic antibioticadministration inpregnancytoprevent infectious morbidityandmortality. Protocols Villar J, CarroliG,Khan-NeelofurD, PiaggioG,Gülmezoglu AM. Patterns ofroutineantenatalcarefor low-riskpregnancy. Hofmeyr GJ, Gülmezoglu AM. Vaginal andinductionoflabour. misoprostolfor ripening cervical Annex 3(continued) Section 2 - Making Pregnancy Safer 2-Making Section Annual Technical Report 2001 85 NORMS AND TOOLS NORMS AND Implementation of evidence-based programmes of evidence-based Implementation and tools for quality services, drafting an advocacy and com- and advocacy an drafting services, quality for tools and munication paper, drafting a working guide in the family area and of community practices, and providing support build to technical and institutional capacity gender-responsive and quality manage to countryand levels at both regional programmes. Making Pregnancy Safer On the basis of available evidence, developed the a Department number has better of a achieve to countries by normative use and adaptation for meant tools and instruments quality of services. These tools standards, training tools, managerial tools and and other materi- instruments include als as described below. Standards newborn for care Standards In 2001, the Department developed standards for newborn care at first-level facilities in developing provide countries. guidance These on the essential components needed to assure quality of care during pregnancy and the period, perinatal and on how to organize services for the newborn in resource-limited settings. This document complements the Essential care practice guide for pregnancy, childbirth and externally internallyand be will standards The care. newborn be will issues available, not is evidence where and, reviewed; finalized in consensus meetings onkey interventions during spe- of need in newborns for standards of set second A 2002. cial care is in preparation and will on focus the practices rel- facilities. to referral evant research 1 Implementing evidence- B. Diallo, L.M. de Bernis, D.R. Sherratt, H. Fogstad, O. Lincetto, J. Zupan, R. Kabra R. Zupan, J. Lincetto, O. Fogstad, H. Sherratt, D.R. de Bernis, L.M. Diallo, B. INTRODUCTION INTRODUCTION to generate evidence, which is translated into

Implementation of evidence-based programmes of evidence-based Implementation

Making Pregnancy Safer “spotlight“ countries: Bolivia, Ethiopia, 1 The implementation of evidence-based programmes is being is programmes evidence-based of implementation The Offices Country and Regional WHO through mainly achieved with the indispensable collaboration of partners. In as achievements well as effect, ongoing activities hinge on several project draft Safer Pregnancy Making the factors—developing proposal for discussion among partners, developing a hier- archy of Making Pregnancy Safer aims framework, using conducting normative the work logical to generate norms Against this background, “Making Pregnancy identified by Safer” WHO as was one of 11 priorities of the Organiza- tion. It aims to contribute to the achievement of of the the goals Safe Motherhood Initiative. Basically, Making strong a Preg- intervention: two-pronged a is Safer nancy The International Conference on Better Health for Women and Children through Family Planning 1987) triggered (Nairobi, worldwide momentum October to reduce maternal and perinatal mortality and launched the Safe Motherhood years Ten Initiative. later, in 1997, a review of this Initiative in terms of reduction concluded that little had been achieved of maternal and infant mortality worldwide. More stringent and action-oriented needed. interventions were component action by the component entitled based Work . duringprogrammes the year in the latter com- the in progress on focuses and here reported being is ponent of norms and tools and on country development cooperation countries. “spotlight“ in Making Pregnancy Safer Indonesia, Lao People’s Democratic Republic, Mauritania, Democratic Republic, Moldova, Indonesia, Lao People’s Nigeria,Mozambique, the Sudan and Uganda. 14 86 Annual Technical Report 2001 highlight key messages for women and their families includ- families their to and women for messages key highlight designed been has ECPG the complete to booklet ling counsel- generic A connection. this in families and women included to guide health workers in their communication with are counselling and advice on pregnancy.Sections lescent ado- and violence to related issues addresses and malaria, and HIV of management initial incorporates also ECPG The complications). labour andpostabortion obstructed sepsis, puerperal haemorrhage, (eclampsia, ers expert opinion. It focuses on major maternal and neonatal kill- care. The ECPG is based on evidence, where available, or on postabortion for as well as newborn, the for and period tum postpar- the childbirth, pregnancy, during care emergency as well as routine essential for recommendations WHO out a with level. care,sets primary It the at practising those on focus health special of levels all at attendants birth skilled for intended is It decision-making. clinical for guide practice care newborn and pregnancy,childbirth for ECPG The care andnewborn childbirth careEssential practice guide(ECPG)for pregnancy, ofnew view in for revised manual been the evidence, has modules, five of set a midwifery, of teachers and students for modules Midwifery modules Midwifery Training tools tled Standardsforcare. andnewborn maternal enti- document the of part be will and 2002 during finalized tool care. improvingbutmaternal at aimed be will document previousThis the of those as in objectives similar commenced with care 2001, maternal for standards on work The Standards for maternal care post-abortion care)willbereadyfor distribution in2002. post-abortion labour and on on those and modules revised the that anticipated is It relevantpartners. with collaboration November 2001. This work will commence in January 2002 in on module obstructed labour, as recommended at the external review the in into incorporated be will The has completed. process been review external the after 2002 early take in to place expected is editing Final accordingly. revised and field-tested been has first The . delivery extraction Vacuum are modules new These “killers”. maternal major the manage to midwives of competency the further increasing at aims and developed been has modules new two of consisting subset early 2002. second in A beready will modules five These included. been also have 2001 in conducted review peer external an from Suggestions documents. guidance WHO recent other and midwives and doctors for guide a childbirth: and nancy Section 2 - Making Pregnancy Safer 2-Making Section Management of incomplete abortion (including and abortion incomplete of Management module delivery extraction Vacuum aaig opiain in complications Managing Management of obstructed obstructed of Management aaeet of Management preg- is a is Nations Population Fund (UNFPA), the United Nations Chil- Nations (UNFPA),United Fund Populationthe Nations United the by endorsed is and (JHPIEGO), Obstetrics and ProgramHopkins Johns Gynecology on Education for International the with collaboration in prepared was manual The agement ofeachcomplication. describes the procedures that may be in necessary the man- women with which complications present themselves; byand (iii) section three symptoms the describes two section (ii) situations; emergency in complications serious managing of principles clinical the outlines one sections: section major (i) three into divided period. is manual The postpartum the and pregnancy,childbirth during emergencies life-threatening of The manual decisions. is designed to be used for and the bedside treatment assessments clinical rapid making in them assist to and childbirth, and pregnancy in complications ing provide to manag- for written knowledge evidence-based with was workers health manual The 2000. in printed and doctors and midwives for guide a childbirth: document The andmidwivesa guidefor doctors Managing complications andchildbirth: inpregnancy ment of childhood illness childhood of ment the harmonize to ongoing are Efforts HIV-related adultillnesses. newborns,in infants, womenpregnant adolescents,and and illnesses addressing guidelines harmonized with countries provide to be Approaches” aiming “Syndromic the WHO of part will ECPG The arise. may that questions research the development. answer to needed under as organized be will research Operations is this for methodology a and idated val- be will components Selected countries. selected in ers provid- intended with field-tested be will ECPG revised The inusingtheECPGeffectively.tries evidence include developed papers, a user guide and an adaptation guide to assist being coun- material Supporting the on based comments received. 2002 early in prepared be will version next appropriateness. The and clarity usefulness, completeness, accuracy, for reviewed further was ECPG the The Philippines. and Indonesia in settings clinical in tested being tions sec- selected with 2001, in began ECPG the of Field-testing training programmes. andin-service curricula integratingnational the into care of elements essential these for educators and trainers to useful be also will ECPG The behaviour. born, and the detection of emergency signs and new- care-seeking and mother the of care home preparedness, birth ing the ECPGfor thefirst week oflife. careduring newborn ment of Child and Adolescent Health and Development, with aaig opiain i penny and pregnancy in complications Managing (IMCI), developed by the Depart- the by developed nertd manage- Integrated was completed was Annual Technical Report 2001 87 Making Strategic Strategic This tool aims to support countries in revising Implementation of evidence-based programmes of evidence-based Implementation framework framework for malaria control during pregnancy in the Afri- can region. their national strategies and guidelines that address latest issues the integrate to order in pregnancy, in malaria to related framework to the strategic As a follow-up evidence. available field- and developed be will guidelines operational document, tested in the African region in the course of 2002. tools Management During 2001, the Department, in collaboration with relevant WHO Departments, focused on identifying the management tools necessary that will assist countries in ensuring that their health systems respond to the needs of newborns, women and with a view to reducing maternal and morbidity This neonatal and work mortality. of enhancing the existing management tools and efforts related will continue in 2002, and development culminate in the pro- to health systems duction of the series of tools described below. Making pregnancy planning guide safer The Department has initiated plans health the specify will to which guide, planning safer pregnancy develop a systems requirements (including health mater- recommended the for etc.) supplies, system logistics, as such functions nal and newborn The health guide interventions. will enable imple- and plan better to programmers and managers health neo- and maternal of reduction the for interventions key ment natal mortality. It will also describe the planning processes necessary for budgeting, monitoring and evaluation. Users will be able to select the most relevant processes, methods resources capacities, own their to them adapt and tools, and and This local work context. is expected to be completed in 2002. Clinical guidelines for management of pregnant of pregnant management guidelines for Clinical HIV with women The document Clinical guidelines for management of preg- nant women with HIV The was in developed objective 2001. prevention of integration the facilitate to is guidelines these of of mother-to-child HIV transmission into existing health sys- Ethiopia in field-tested been has guide The countries. in tems and Thailand, and was presented at the East, Central and South African Association of Obstetricians and Gynaecolo- gists’ (ECSAOGS) Congress in Addis Ababa in November is planned during 2002. Publication 2001. during control malaria for framework Strategic Region pregnancy in the African During 2001, the Department worked in close collaboration WHO Roll Malaria/Malariawith Back Team the in Pregnancy and AFRO, and developed a document entitled Standards for new- The recommendations of these guidelines are included in the in included are guidelines these of recommendations The ECPG the care, newborn and childbirth pregnancy, for EPCG for reproductive tract infections, and the born care. These guidelines were developed to summarize the mag- nitude of the problem of maternal and worldwide, congenital and syphilis to provide guidance on analy- situation includes its document The prevention pregnancy. in control and sis, in improvements and operationalization of control activi- monitoring, surveillance, supervisionties, and evaluation. Guidelines on prevention and control of maternal and of maternal and control Guidelines on prevention syphilis congenital This manual was written for midwives and doctors working at the district hospital, where they are confronted with life- threatening conditions of sick and preterm newborn infants as well as preterm infants without major problems. It prepared in was collaboration with JHPIEGO, Basic Support for Institutionalizing Child Survival (BASICS) and Saving New- born Lives (SNL), and reviewed by experts throughout the These development process. measures were undertaken to ensure the production of a generic document based on the latest evidence and one that would reflect global consider- ations. Printing and distribution are expected at the end of 2002. Managing newborn problems: a guide for doctorsa guide for and Managing newborn problems: midwives During 2001, the WHO Regional Pacific Office(WPRO) for held the Western a workshop in train to the use health of workers the manual. AMRO held a introduce major the meeting to manual to officials of the MinistryThe of Health. WHO Regional Office for Africa (AFRO)meeting of convened experts to a discuss the use and dissemination of the manual in their Region. An addendum was prepared by ver- English the of re-printing A Region. African the for AFRO in 2002. sion is likely dren’s dren’s Fund (UNICEF), the World Bank, the Federation of International Gynecology and Obstetrics (FIGO) and During 2001, Internationalof (ICM). Midwives Confederation the Regional WHO the by Spanish into translated was manual the Officefor the Americas (AMRO), and intoFrench through a special grant from the Averting Maternal Death and Disabil- Univer- Columbia Health, Public of School the of Program ity The USA. Russian York, translation is New sity, in progress. The manual was formally Conference launched of the at Global Health Council, the held on 28th 31 2001 May in Annual Washington, DC, USA. The initial print run in Eng- lish was 20 000 copies, and worldwide distribution through com- has JHPIEGO and CountryOffices and Regional WHO menced. 88 Annual Technical Report 2001 natal health”. peri- and evidencenewforon maternal “Generating chapter Spanish in 2001. details are availableFurther in the previous and mortality morbidity at the district level was translated into newborn and maternal reduce to interventions of package a This spreadsheet tool that estimates the cost of implementing Mother–baby package costing spreadsheet is completion envisaged in2002. and Mozambique) and spotlight Safer (Moldova Pregnancy countries Making two in use country for and operational planning. strategic between The software bridge is currently a being adapted provide does it but resource levels, prescribe nor priorities health set it does neither practice, clinical prescribe not does EHTP planning. The tal cross-departmen- as well as management technology ment, analysis,procure- assessment needs of simulations through planning resource assist to designed is package tions. The interven- of set defined a for package software CD-ROM a as comes and tool, a and methodology a both is EHTP The opment of the Essential Health Technology Package (EHTP). Cape in Equipment Town,devel-ongoing the in Africa South Technologyand Medical for and Centre Collaborating Provision WHO the Service collaboration Health of close Department in WHO’s with worked also has Department The safer pregnancy healthtechnologyEssential package for making for field-testingin2002. the to reviewedand pleted supplementary be will and 2001, during pants. com- been manual has the workshop draft of first The for facilitator’spartici- materials a workshop as well as guide comprises manual The plan. health newborn and maternal operational an of development the for workshop planning a conduct and plan to planners and managers district assist The safer planningworkshop pregnancy manual Making Section 2 - Making Pregnancy Safer 2-Making Section will manual workshop saferplanning pregnancy Making It is intended is It guide.safer planning pregnancy Making WHO MakingPregnancySafer project. the support to actions future on partners with agreement an ening midwifery services. One such activity includes reaching byities being undertaken on strength- WHO and its partners In addition, efforts have begun to create an inventory of activ- field-tested in2002. and developed be will tool The performance. provider tive effec- to barriers the address will strategiesservices. These and midwifery strengthen needs to action of plans their appropriate develop assess to countries enable to strategies developing on focus will work Future consideration. for further issues relevant identify to as well as activities, and als relevantmateri- synchronize to 2001 December in held was Services” Midwifery “Strengthening on meeting technical A 2002. field-testing inearly for ready be reviews.to expectedexternal are and They nal These documents have been refined in 2001, following inter- • • • • • • developed. It comprises: lines relating to “Strengthening Midwifery Services” has been period. postpartum the Toguide- of set a issue, this address and the childbirth pregnancy, during emphasizes care skilled of mortality importance maternal of reduction on state- ment Bank WHO/UNFPA/UNICEF/World Joint 1999 The midwifery services strengthening at aiming modules of set A morbidity. The specific objectives of this guide are: (i)to are: guide of this objectives specific The morbidity. fessionals on how to investigate deaths and severematernal guidance to health planners, managers and other health pro- pregnancy. of complications severe and deaths the maternal investigating finalized Department the 2001, During complications ofpregnancy oninvestigatingGuideline maternal deathsandsevere approaches Pregnancytools Safer and Making Other

education ofmidwife teacher. the for programmes of development the for Guidelines programmes education midwifery of development the for Guidelines ity midwifery care Developing standards to assist practitioners provide qual- Competencies for midwifery practices sible Legislation and regulation: making safe motherhood pos- Strengthening midwifery services backgroundStrengthening midwifery services paper hs ouet a be peae t provide to prepared been has document This udln on Guideline Annual Technical Report 2001 89 Implementation of evidence-based programmes of evidence-based Implementation TECHNICAL COOPERATION WITH COUNTRIES TECHNICAL COOPERATION and the development of a background and strategy paper which defines concepts, guiding principles, objectives and strategies. The development of the concept and strategy paper will be a In priorityaddition, ongoing efforts will to in continue 2002. les- and methodologies experiences, disseminate and collect sons learned in working with individuals, families and com- munities to improve maternal and newborn health. In close collaboration with its partners, WHO will commence work to identify key family and community practices in the area of maternal and newborn health, based on evidence and con- accompany the dissemination of these To practices, sensus. This guide a will provide guide orientation will be developed. as to the processes which can be used within countries to work with these practices such that local priorities, realities and needs are reflected. Finally, efforts related to strengthening community involve- ment in improving the quality of services will The continue. individ- involving of experiences and methodologies different uals and groups in the definition, implementation and ongo- a in discussed be will services of quality the of monitoring ing guide methodological A 2002. early in beginning consultation will be developed. The main purpose of the Making Pregnancy Safer initiative is to provide technical and policy support to The countries. project has enabled the Department to collaborate proac- Advocacy and communication strategy for making for strategy and communication Advocacy pregnancy safer Work on defining an advocacy and communication strategy for making pregnancy safer at regional and international) all started in A 2001. draft has been levels (local, national, prepared and will be finalized during 2002.of Thethis strategy objective paper is to define the meansby whichMaking the Pregnancy Safer initiative can advocate support to maternal and newborn health issues among governments and all interested This parties.document will clearly identify advocacy and techniques targets, objectives/outputs, issues, tools, and will assist countries in their developing own advo- Production cacy issues. on strategy making pregnancy safer 2002. tool is planned for of this generic advocacy a human rights motherhoodAssessing safe from making for a tool pregnancy safer perspective: An assessment tool has been developed in order to bring a human rights perspective into the goals of the and Making objectives Pregnancy Safer initiative. This will assist a national multi-stakeholder team to review laws, policies and health system considerations against the major health out- “Gender and see the chapter on details, come indicators (for health”). rights in reproductive reproductive Safe motherhood: Safe a newsletter of worldwide During 2001, an informal consultation was held with WHO partners to better identify the means by which the Making Pregnancy Safer project can collaborate with and support ongoing work with individuals, families and communities to in maternal and newborn health. to improvements contribute Key recommendations provided to the Department include: better integration of the “Family and Community Practices” component into the Making Pregnancy Safer strategy; Individual, family and community issues in maternal family and community issues in maternal Individual, and newborn health The publication The SafeThe motherhood newsletter in out carried be will Revisions 2001. in reviewed was activity It that is the of expected publication the will newsletter 2002. resume to three issues per year. The Making Pregnancy Safer web site was established in during 2002. 2001 and will be further developed The Making SaferThe site Pregnancy web describe a range of investigative tools or methods investigation for of maternal the deaths; (ii) to provide guidance on the selection of tools investigative appropriate for use in dif- ferent settings and circumstances; and (iii) to promote ulti- The the generated. information the of use and dissemination mate aim of this guide is to increase awareness and knowl- edge of the magnitude as well as the causes mortality of and maternal complications of The pregnancy. approaches for investigating maternal deaths and severe complications described in this guide have countriesdeveloping where been of levels maternal morbidity are developed mainly for countriesof range wide a from reviews Case highest. their at are The provided guide as has examples. undergone exten- in 2002. and will be published review sive 90 Annual Technical Report 2001 • • • • tothesecountries,theinitiative has: support technical its of countries. part spotlight As the in health born new- and maternal improve to levels community and family individual, the at actions and processes necessary the tify cal and health systems interventions. It will also help to iden- to capacity plan, design governmentand implement effective evidence-based techni- strengthen to support policy and technical providing is initiativeSafer Pregnancy Making The initiated inallofthetenspotlightcountries. levels.havebeen country Activities and regional at systems health in and health newborn and maternal in experts prises Teamestablished.com- The Teamwas Global Safer nancy of refinement safe motherhood interventions. or 2001, During a Making Preg- introduction the support to needed ment commit- and will political interest, the revitalize to agencies partner and Offices Country Offices, Regional the tivelywith Section 2 - Making Pregnancy Safer 2-Making Section

interventions infourinterventions regions; cost–effective Safer Pregnancy Making piloting is opia Ethi- countries. ten all in motherhood safe for ventions inter- cost–effective applying and identifying in assisted childbirth; and pregnancy during attendance skilled to newborns their and women pregnant all of access the increase to levelsall at standards and revisedcare,of aimed norms 2002. This process is the first stage of implementation of during countries Philippines, three another to the extended be and will and Indonesia in started the of has Field-testing ECPG manual. this of distribution the in mobilized havebeen Regions health. All WHO newborn and maternal in norms technical for document official an as midwives and doctors for guide a childbirth: and in provided ards The Government of Bolivia has decided to use the stand- to and newborn maternal care in all ten spotlight countries. related tools and standards norms, national based evidence- of adoption and development the supported ductive in reproductive rights health”); repro- and on “Gender chapter the (see Mozambique in Human Rights into Making Pregnancy Safer” has started “Integrating on project pilot A Mozambique. and ritania regulations and laws related to safe motherhood in Mau- the reviewsupported and revision of policies,supportive this of strategy inselected districts; implementation the support to is step next the and authorities, provincial the all with Health of Minister the by 2001 November in launched was strategy Safer Pregnancy Making national the Indonesia, In Nigeria. and Mozambique Indonesia, in plan and strategy Safer reproductive health/Safe Motherhood/Making Pregnancy the supported development of a comprehensive national Managing complications in pregnancy in complications Managing countries. of number larger a to work the expand to efforts future port sup- to documented carefully being are learnt lessons The buys”. of “best- implementation the through impact an make to tion is it countries, spotlight ten perceived as credible, the highly acceptable and in to a strong posi- limited and phase tial ini- its in is initiative Safer Pregnancy Making the Although • • • • • • •

Ethiopia; agement of pregnant women with HIV was field-tested in for policies pregnancy. national in malaria their of revision the in countries supporting of objective the with initiative Malaria Back Roll WHO’s with meeting regional a countries. organized ten AFRO all in others and safety, blood malaria, HIV/AIDS, as such motherhood saferelevant to work of involvedareas are in that programmes other with linked healthactivities; andnewborn collaboration inmaternal consensus on future activities for better coordination and a reached meeting this attending Uganda. Keypartners Kampala, in 2001 October in AFRO by organized was Safer Pregnancy Making for Partnerships on meeting regional countries. A ten all in motherhood safeforable supported activities aimed at maximizing resources avail- a coherentandefficient way; egy, maximizing efforts and collecting lessons learned in with the objective of implementing the best strat-parties interested coordinating in assist to staff Safer management Pregnancy Making requested has instance, for and plans countries. ten all in activities government,Ethiopian The motherhood safe coordinating in assisted key MakingPregnancySafer of interventions. implementation the to related research operational for planned and capacity, research building in assisted tries; and coun- these in reduction poverty for strategies national respective the of umbrella the under Uganda and bique Nations United Development the Assistance of Framework (UNDAF) implementation in Mozam- the supported andMoldova;ritania Systems Health Development plans of Bolivia, Ethiopia, Indonesia, Mau- National the formulating in assisted sectorwide implementing Indonesia, MozambiqueandUganda; for Bolivia, including countries of number a in approaches support provided Clinical guidelines for man- for guidelines Clinical The Annual Technical Report 2001 91 Section 3 transmitted infections transmitted Reproductive tract infectionsReproductive and sexually 92 Annual Technical Report 2001 of HIV. plan and implement programmes for the prevention to of MTCT countries assist to (v) and HIV; of (MTCT) transmission safety acceptability, preventmother-to-child to interventions effectiveness the of and on evidence key generate to HIV;(iv) including STIs of prevention for microbicides vaginal develop to (iii) protection; dual of use the including settings, vention and management of RTIs in reproductive health care pre- the for services improvedfor advocate to STIs; (ii) vent pre- to condoms female and male of use and effectiveness the on research epidemiological key initiate to (i) are: and STIs RTIs of area the in Department the of objectives The new technologies, toolsandguidelines. and setting standards,norms policy and support, developing and cooperationevidence, technical and research agement, man- information advocacy, Organization: the of functions core the all across extends STIs and RTIs with associated burden disease the of reduction the to contribution WHO’s annually, including an estimated 5 million new occur HIV infections. STIs viral incurable of millions many and year, each worldwide occur to estimated are STIs curable million 340 Approximately (HIV). virus immunodeficiency human the of of transmissiontheir ability to increase or the acquisition risk through and directly both ill-health, reproductive of burden considerable a for responsible are (STIs), infections mitted Reproductive tract infections (RTIs), including sexually trans- Section3 - Reproductive tract infections andsexually -Reproductive infections transmitted tract infections Section3 Reproductive tract infections andsexuallyReproductive infections tract INTRODUCTION T.M.M. Farley, N. Broutet, J. Mandala, I.M. Malonza, B. Deperthes transmitted infections Objectives andrationaleObjectives Microbicides oot o wmn h frt oot il e eurd notto berequired will cohort first The women. of cohorts two in conducted be will daysand 7 of period overa gel the CONRAD. of with application coverstwice-daily protocol the This collaboration in up drawn been has gel sulfate lulose cel- the of trial clinical I Phase expanded an for protocol A Progress (CONRAD), Arlington, VA, USA. Program Development and Research out Contraceptive carried the by volunteers women in trial clinical I Phase and a studies in animal in tolerance local for tested been has and vitro, in activity anti-HIV and spermicidal good have to One such preparation, cellulose sulfate gel, has been shown this stageofdevelopment. reach they as preparations promising of testing clinical the in forcollaborate research to leads,butnewinstead product exploratory in involved directly become to Programme not decided the has reason, this For sectors. public and vate pri- the both in development and investigation under rently number of microbicidal compounds and formulations are cur- HIV.including STIs, large prevalenceof A high a with areas in especially health, reproductive on impact positive a major have to likely are activity microbicidal topical with preparations self-administered, acceptable, and effective Safe, RESEARCH ACTIVITIES Annual Technical Report 2001 93 , JAMA 2000, :1651–1655). It 357:1651–1655). Lancet, 2001, Mortality in HIV-infected mothers who breastfeed Objectives and rationale A secondary analysis of data from a trialrandomized in Nai- on robi, the of Kenya safety breast and replacement feeding by mothers with HIV infection (Nduati et al., 283:1167–1174) revealed a threefold higher mortality assigned mothers among delivery of rate years two first the within to breastfeeding compared with those assigned to replace- (Nduati et al. ment feeding be might breastfeed who women HIV-infected why unclear is at an increased risk if the results are confirmed of death, but by other studies, then advice and care for mothers with HIV infection may need to be revised. As ment’s part regular of review of the emerging Depart- scientific evidence and its possible policy implications, a statement was prepared in collaboration with the Child and Adolescent Health and The Programme convened a three-day meeting in Research November 2001 to Group discuss the extent of knowl- edge regarding condom efficacymethodological difficulties in and obtaining more information on effectiveness, the either male or female condoms, and opportunities to collect more The data. Group outlined various options for different designs, and recommended that a study be among implemented female sex workers—vaginal swabs would be col- lected before and after each act of intercourse as the well condoms as used. In this way, the infection status of partner could the be assessed, and the swabs before and after partners acts of intercourse with infected could be examined to look for the presence of any new infectious organisms in the vagina. Implemented in a setting where both male and female condoms were used and design where a such high, was clients the women’s the among infection prevalence of information on the efficacy ofcomparative the provide would to the sexually exposure of condoms in preventing types two transmitted pathogens in a reasonably short unclear whether this time. design could also be used It to study the was efficacy of male femaleand condoms in reducingof other the risk STIs, such as herpes HIV, simplex virus or human papillomavirus. The Programme is currently developing the details study of protocol and exploring sites where the the research could earlyin research commencing of aim the with conducted, be 2002. The information obtained in the to answer some study outstanding questions is on the expected efficacy and from report the in highlighted condoms, male of effectiveness the United States National Institute of Allergy and Infectious Diseases workshop in June 2000 (“Scientific EvidenceThe workshop on and STD Prevention”). Condom Effectiveness that male condoms concluded good that evidence there was reduced the risk of sexual transmission of HIV in men and evi- weaker was there but men, in gonorrhoea of and women dence regarding their effectiveness in preventing transmis- sion of other STIs. Reproductive tract infections and sexually transmitted infections tract transmitted infectionsReproductive sexually and Tri- Neisseria gonorrhoeae, Chlamydia trachomatis or In 2001, the Programme developed a protocol to through a trial,of randomized the effectiveness comparative assess, male and female condoms in reducing the risk of infection with Progress Objectives and rationale There are limited data on the effectiveness of female con- doms to prevent the sexual transmission of infectious HIV diseases. Since or the other device has been be shown to impervious to such organisms in laboratory is studies, assumed it that the data condoms clinical no are there will However, also intercourse. sexual during provide protection to support this, and the ways Programme to has address been this exploring gap in condom is knowledge. the best-known Since method for the reducing the male risk of STIs, any research on condom effectiveness must include a comparison with the male This condom. research on the effectiveness of the female condom in preventing STIs complementary is to the research on the prevention the of on “Research on preg- chapter the (see device the using nancy of contraceptives”). and effectiveness safety Efficacy of female condoms for the condoms Efficacyfemale of of STIs prevention The Phase I trial was initiated in Uganda in December, and start to in earlyis expected centres in the other two 2002. During the past year, the Programme convened an investiga- an convened Programme the year, past the During tors’ meeting to review the protocol, case record forms and procedures to be used in the expanded Phase I clinical trial which will be carried out in three centres in and Following this India, Uganda. meeting, the protocol Nigeria and study instruments have been revised and the revisions approved by the institutional and national authorities as WHO. well as by have intercourse have or use other vaginal products for the dura- expected be cohortwill second the whereas study, the of tion to have at least two acts to the product will of be established by direct Tolerance period. intercourse during the study questioning and colposcopic examinations. This study will also assess the acceptability of the product in terms of its profile. performance general ease of use and its chomonas vaginalis among women at high risk of infection. the investigators, potential and experts with discussions After study design was considered impractical since it would be difficult toobtain adequate information on sexual behaviour or the infection status of the women’s partners. Moreover, randomizing volunteers to exclusively use male Panel Specialist The or acceptable. be to female unlikely was condoms on Epidemiological Research in Reproductive Health there- recommended fore a consultation to in consider which ways information on the efficacy and offemale effectiveness con- doms could be assessed. 94 Annual Technical Report 2001 the infant can get maximum benefit from the breast milk, and ing by HIV-infected mothers can be made safer, so partly that There is an urgent need to explore ways in which breastfeed- families. ance of breastfeeding may not be acceptable avoid-to them or their complete and option an not is this women many for formula and water to prepare the replacement feed. However, infant sustainable and affordable safe, to access have they ing altogether or to breastfeed fortime only, a short provided breastfeed-avoid to advised are infection HIV with Mothers and theavoidance ofbreastfeeding. section caesarean elective load, viral suppress maximally ARVpotent that of regimens achieveduse been the through 2–5% the transmission than rate obtained in developed higher countries, which has far remains rate This 20%. around is regimen, ARV prophylactic short-course a from havingbenefited despite age, of months 18–24 by infected children of proportion the consequence, a months.As 18–24 for fed of 15% transmissionrisk in cases where children are breast- a for responsible is period postpartum The regimens. ARV short-course using 10%, under to 20% roughly from half,by ing. occur viral (ARV) prophylaxis is given. Roughly 5% of transmissions where prolonged breastfeeding and no antiretro- is the norm The rate of MTCT of HIV is approximately 35% in populations andrationaleObjectives prevention ofMTCT ofHIV Combination antiretroviral therapy and and theresultsareexpected 2002. inearly analysis newfor the formsuitable a into compiled been now have dying data final mother The patterns. feeding the different to of according risk the assess to plan analysis and methodology a developed Department the pattern, feeding infant to according transmission of risk the of meta-analysis closely with Working the team (NICHD). which is conducting Developmentan individual record Human and Health Child of Institute National States United the of Branch AIDS nal Study Transmission byPediatric,sponsored the (BIHTS) HIV Mater- and Adolescent, Infant and Breastfeeding the by through database common a transmission into breastfeedingcompiled havebeen HIV of risk the on data available All Progress have completedstudiesonMTCTofHIV. who investigators has of teams with collaboration a and into entered mothers HIV-infected in mortality on information The Department also considered ways to rapidly obtain more by Nduatietal. tion ofthearticle lished in the pub- and Departments HIV/AIDS and (CAH) Development Section3 - Reproductive tract infections andsexually -Reproductive infections transmitted tract infections Section3 and intrapartum transmissions can be reduced be can transmissions intrapartum and utero In , 15% intrapartum and 15% during breastfeed- during 15% and intrapartum 15% utero, in The Lancet in June 2001 soon after the publica- have only a small risk of transmitting HIV to their infants,their to will HIV transmitting of risk havesmall a only Progress Women with high CD4 counts (above 500 cells/mm 500 (above counts CD4 high with Women new protocol stratifies women according to their CD4 counts. among mothers at a more advanced state of the disease, the higher be shownto been has HIV of MTCT of rate the Since by suppressingherviral load. and reducing the risk of HIV transmission through breast milk apy for the mother as a way of both improving her own health ther- ARV providing of effects the studying are teams other No weaning. abrupt of impact the breastfeeding—or mixed with compared milk—exclusive breast through transmission of risk the on patterns feeding infant different of impact the studying are teams Similarly,severalhighest. is be to transmission thought of risk the being when milk is breast infant from the weaned as feeding mixed of period the during or period, breastfeeding the regimens—during prophylactic extended studying are others while prophylaxis, texposure pos- of forms differentby offered protection for potential the infant HIV. acquiring of risk the the reduces studying are groups Some to prophylaxis ARV or immunological providing There is considerable research under way to assess whether fromcollaboratingexperts agencies. and rights, women’s for and (PLWHA) HIV/AIDS with living people foradvocatesinfection, HIV of prevalencerates high with countries developing selected from policy-makers and scientists by attended was questions. meeting standing The an identify out- key addressing to of way sound and ethically and acceptable teams research other of activities the review to area this in research further for need the cussed dis- Group 2001. The December in HIV of MTCT of vention Pre- the on Group Research a convened Department The iie stig, r f h ipc ta cmiain therapymay have onthehealthofmothers. combination that impact the of or settings, limited resource- in HIV of preventingMTCT in ARVtherapy nation combi- of effectiveness and safety the about known is Little themselves. of MTCT of HIV since mothers will perceive a clear benefit for prevention for interventions of uptake the increase nificantly sig- may care effective providing addition, In it. require who mothers those to treatment life-savingproviding consider to possible is it countries, developing in affordable becoming forowntheir disease. Noweffectivethat ARV are treatments support and care require infants—mothers their to infection transmit may that vectors as merely infection HIV with ers moth- consider to questionable ethically who is It infants orphaned. the are for life of quality poor a as well as saved, ARVfewof in therapychildren’smayresult for mothers lives form the in care life-saving provide to failure death, of risk higher at themselves are die mothers whose infants Since may breastfeed theirinfants withminimalrisk. so partly that women who are not able to avoid breastfeeding 3 ), who ), Annual Technical Report 2001 95 NORMS AND TOOLS NORMS AND in utero and intrapartum transmission of HIV from Specific objectives/targets nosis of gonorrhoea and chlamydia among symptomatic STI nosis of gonorrhoea and chlamydia The patients projects are will being commence evaluated. in 2002. In addition to evaluating the performance of the tests, utility using of cost-effectiveness the assess to planned are studies such rapid diagnostic tests in reproductive health care set- tings. The results from these studies will guide national or provincial programme managers to determine the suitability care settings. health in the different diagnostic tests of rapid Development of new norms/tools norms/tools of new Development on infant feeding information Standardized While considerable progress has been made reduce to in regimens prophylactic identifying ARV affordable and practical the risk of an infected mother to her infant, little made in advance has reducing the been risk of transmission milk. In through many breast resource-poor settings, replacement feeding can be a dangerous and expensive option, and socially. being poorly culturally tolerated, in addition to Although the risk of HIV transmission through breastfeeding is well established, the substantial benefits of breastfeeding feed- replacement with Compared documented. well also are ing, breastfeeding has consistently been shown to reduce infant morbidity and mortality associated with infectious dis- In eases. addition to its anti-infective properties, breast milk contains all the nutritional requirements necessary advocating concern about One for life. of months six first the infant’s replacement feeding for infants born to HIV-infected moth- breastfeeding undermineof will promotion this the that is ers among women who are known to be not infected with is HIV, status infection HIV whose women those among as well as not known. Factors associated with an increased risk of HIV transmis- sion through breast milk include high maternal advanced viral stage load, of disease, seroconversion in the mother during breastfeeding, prolonged breastfeeding, high volume pathology breast any of presence the ingested, milk breast of The Department is currently developing tools in two areas main where existing health care services for reproductive health can contribute to the reduction of HIV transmission and to the improved prevention and management of RTIs. While reproductive health care settings opportunity are to not impact on the the HIV only and can interventions the STI which on resource important epidemics, an provide they be based, and are a complement to HIV and STI prevention targeted at specific high-riskgroups. programmes Reproductive tract infections and sexually transmitted infections tract transmitted infectionsReproductive sexually and ) 3 ) require 3 or she has developed AIDS, will be given triple given be will AIDS, developed has she or 3 ARV ARV therapy for the management of their HIV disease and will be provided with a for beyond, and tripleperiod breastfeeding the combination delivery, therapy pregnancy, through as long as they require it. Women with intermediate stage disease (CD4 counts in the range of 200–500 cells/mm will be to either randomized receive a standard short-course prophylaxis with or or ZDV will NVP, receive triple combina- tion therapy for up to 6 months provided that they continue to breastfeed. Any woman who requires therapy during the below fallen has count CD4 her because period,either study cells/mm 200 The Department is participating in evaluating the perform- ance of selected rapid diagnostic tests in collaboration with the Disease Transmitted Sexually Diagnostic Initiative (SDI) within the UNDP/World Bank/WHO Special Programme for for Tests Diseases (TDR). Tropical in Research Training and the diagnosis of syphilis in antenatal care and for the diag- Progress Objective and rationale impor- most the diagnose definitively to capacity current The tant RTIs in women remains limited, especially in resource- Rapid diagnostic tests that are constrained settings. suitable for use without a complex laboratory infrastructure could be RTIs of, management and for, screening the in value great of diag- rapid 40 than More complications. of prevention the and nostic tests are on the market, but little is known about their performance under field conditions and their suitability for countries. use in health care services in developing Simple diagnostic tests for STIs for diagnostic tests Simple be provided with one of the short-courseexisting prophylac- (NVP). or nevirapine (ZDV) such as zidovudine tic regimens, Women with low CD4 counts (below 200 cells/mm The details of the study protocol, the mechanisms and proce- and mechanisms the protocol, study the of details The infra- necessary the and research the implementing for dures structures are being developed. It is planned to initiate the first steps of the research in early 2002. While providing long-term care for women HIV-infected and their partners is beyond the scope Department, and partnerships resources of are the being developed governmental organizations (NGOs), with local care and support non- groups, and public and private health care study sectors sites in the to provide care in inequitable the and possibly unethical not post-study to make provision for period. It is long-term care and access to treatment for the women who to participatevolunteer in the research. therapy. All therapy. women will be given appropriate infant feeding counselling according to WHO recommendations, and free replacement feeding will be provided two to for those followed be who will choose infants their and women All option. this from delivery to assess morbidity years and mortality in both mothers and infants. 96 Annual Technical Report 2001 to be included in future research studies, the minimal timing minimal the studies, research future in included be to questionnaires core of set a transmission, HIV to relevant pathologies breast of description of, a patterns, definitions feeding infant and Thetool for, nomenclature wasaccepted. standard a tool includes the of version final the and 2001 March in Botswana Gaborone, in convened was shop Zimbabwe).and Africa South work- Followinga test pilot the Kenya, India, d’Ivoire, Faso,Côte Burkina (Brazil, countries infant nutrition, and then pilot-tested in eight sites from seven and HIV,breastfeeding on research in experts by reviewed was instrument The drafted. was information essential mal set of common definitions and instruments to record the mini- rhoea, and health and nutrition surveys were reviewed and a amenor- lactational transmission, breastfeeding of studies The methodology and instruments used in recently completed opment in Washington, DC, USA. Devel- Educational for Academy the and Development, and with tion Health Adolescent and Child of WHO’s Department collabora- in done manner.wasstandardized work a This in information record to tool a developed Department the ies, stud- planned and ongoing between breastfeeding through HIV of transmission on data of comparison the facilitate to order In breastfeeding. through transmission of aspects all of meta-analysis comprehensive a or studies between isons and/or infant morbidity. pathology These breast differences severely limit any patterns, compar- feeding infant methodologies record different to slightly used milk breast through transmission HIV of risk the on date to published studies All other research. by confirmed be to yet has result this though breastfeeding, exclusive than transmission HIV of risk higher a carries ing feed- mixed that shown has study One infant. the in thrush oral or nipples,cracked or abscess breast mastitis, as such Section3 - Reproductive tract infections andsexually -Reproductive infections transmitted tract infections Section3 women with HIVinfection Clinical guidesfor themanagementofpregnant norms/tools New work onthedevelopment undertaken of finalized following the field test and disseminated through and disseminated test field the following finalized be will guides The 2002. early in Kenya and Guyana mas, in Ethiopia and Thailand, and will be undertaken in the Baha- completed been has test field the Africa South Soweto, tal, Harare and experts from the Chris Hani Baragwanath Hospi- in (AFRO) Africa for Office Regional WHO the of laboration col- the infection.With HIV with women of care and selling countries, toselected clinical staff and midwives distributed with experience of been coun- has which version field-test a into compiled were reviewers the from comments final The depart- ments tobuild aconsensusonsuchissues. WHO relevant the with way under is nancy.Work preg- in infection most HIV for the testing for and algorithms infection, appropriate HIV with mothers to born infants for schedule immunization optimal the particular, in unclear, has guides are guidance and which policies on the WHO issues highlighted of development The counselling. and ing selling and testing, pregnancy and childbirth, and infant feed- with compatibility existingcoun- for voluntary guides,example, on WHO those ensure to taken been has Care infants. their and HIV-infectedmothers of care Post-pregnancy and women, HIV-infected for care delivery and Labour women, HIV-infectedfor care Antenatal women, pregnant in HIV for booklets: complementary but separate, four into divided been have guides The tion. with experience of managing pregnant women with HIV countries infec- in and WHO in experts by reviewed and 2000, in workshop a to subsequent options.drafted were guides The HIV-infectedthe for mother, giveto and infanton advice feeding support and care appropriate provide to HIV, prevent of to MTCT interventions implement help to guides clinical of series a develop to asked was Department the 1999, In for futureresearchonthistopic. strengths and limitations and the preparation usefulness, of a revisedits tool of review intended the for allow will tool ing way.under currently experience infantthis with feed- Further studies two by used being are data of presentation and ysis newly developed studies and the proposed methods for anal- adopted as the core of the infant feeding instruments by eight 2001, Medicine , in tics P,(Gaillard 2001 FarleyDecember E, in Piwoz TMM, tool was published in a special issue of the of, development and for, rationale the describing article Development.An and Health Adolescent and Child of ment and WHO’sDepart- Department the of sites web the as well as teams research HIV with contacts direct through nated dissemi- and 2001, in published and finalized was tool The for theanalysisandpresentationofdata. categories suggested and collection, data for intervals and 32–55.Te ol a been has tool The 20:3527–3535). Voluntary counselling and testing and counselling Voluntary Statistics in Medicine Statis- Annual Technical Report 2001 97 Bulletin of the World Health Organi- focused focused on STI case management in primary health settings. Studies care on the control of congenital syphilis were undertaken in Bolivia, Kenya and South The Africa. reports were received in 2001. Two of these basis the for FRONTIERS intervention trial to increase male studies formed the involve- initial the through health reproductive in involvement syphilis. antenatal for ment of men in screening The reports underscore the difficulty in integrating services when additional tasks are introduced into existing services, particularly are when aimed they at health goals that are dif- ferent from the existing services. Supervision, financial and required managerialare support, periodicreinforcement and before an additional task can be safely assumed to be inte- grated. Some of the country reports individually are being published in international journals, while a compendium of the reports will be submitted to the zation which is planning a special issue on congenital syph- ilis. The issue will highlight the poor of effectiveness availability the of despite syphilis, congenital control most to efforts affordable and effective tests and Analogies treatments. will be between situation the drawn and above current initiatives fact the is both Underlying HIV. of MTCT of risk the reduce to restrict severely system care health the of limitations the that interventions. evidence-based new, the options to integrate Programme guidance tool on improved RTI RTI on improved tool guidance Programme management The RTI Programme Guidance Tool, developed in partner- ship between the Department and the Population Council’s Reproductive tract infections and sexually transmitted infections tract transmitted infectionsReproductive sexually and In cooperation with the Population Council’s FRONTIERS Project, the Department, case six funded (UNAIDS), together HIV/AIDS on Programme Nations with the Joint United studies on the integration of STI prevention and care reproductive into health services. The objective of the was to document studies programmatic approaches where effective integration has taken place, the lessons learned during their implementation, and the cost in financial and human terms. The Department provided technical support to three studies that specificallyfocused on integration of congenital syphilis control in antenatal care programmes. The other studies Integration of RTI prevention and management in prevention of RTI Integration health settings reproductive The Department is developing a series of materials to pro- their and mothers support psychosocial HIV-infected vide for the of review expert an is materials the for basis The families. support psychosocial providing with experience and literature psychoso- the assess to guide a settings, resource-limited in cial needs of women with HIV infection and their families, a guide on how to provide appropriate psychosocial support, and a tool to evaluate psychosocial support programmes. The Department is working closely with and AFRO with in a local Harare NGO—the Zimbabwean AIDS Prevention and Support Organization (ZAPSO) which is implementing a demonstration project on psychosocial support for infected mothers HIV- and their The families. tools developed in Zimbabwe will be generalized and used developing as generic the tools for basis psychosocial for support in other settings. Psychosocial support mothers and Psychosocial HIV-infected for families The guides will be reviewed basis as new information on the and of prevention MTCT of HIV updated on a WHO policies and guidance are and new becomes available regular issued. WHO Regional and Country Offices, national AIDS control programmes, national and international professional socie- ties and through the Departmental web It site. is planned to translate the guides into French, Spanish and Portuguese of countries. and disseminate them in a wide range 98 Annual Technical Report 2001 will cater for clients who present for advice and counselling and advice for present who clients for cater will guide The services. health child and maternal or planning, health care settings that provide familychild health), primary ductive health care services (family planning or maternal and management of RTIs in women and men presenting to repro- The goal of the ECPG for RTIs is to provide guidance for the care andtheECPGfor family planning. newborn and pregnancy,childbirth for ECPG the to volume in reproductive health care settings. This will be a companion RTI)sexuallyinfectionstransmitted(ECPG and ductive tract repro- of management an the for guide of practice care developmentEssential the 2001, in initiated, Department the Tool,Guidance Programme RTI the of work the on Building infections careEssential practice guidefor reproductive tract New norms/tools initiated funding tobeprovided by theHORIZONSProject. with 2002, developed during be may Ghana and Brazil from year. They will be implemented in 2002. Additional proposals past the during approved and developed been have Latvia cation of the RTI Programme Guidance Tool in Cambodia and appli- the from arose that research operationsfor Proposals rospectively, asintheotherfield-testcountries. mation on the impact of the tool prospectively, rather than ret- infor- collect to opportunity an provide will fifth China in test field This Commission. Planning Family State the through country’s the plan to integrate RTI management into of the providedservices part is This settings. care health different the for services integrated of level appropriate the define to Tool Guidance Programme RTI the of procedures the use will China Ghana). and Latvia Cambodia, (Brazil, field-test countries four the in out carried be consequently will ation evalu- formal a and required, Toolis Guidance Programme RTI the of impact the of evidence Additional implemented. been already have assessment ToolGuidance Programme field-test countries revealed that many key findings of the RTI ance Tool, Guid- follow-up the twoof programmein with Programmemanagers RTI the of impact the for indicators tive Tool is also being designed. While it Guidance is Programmedifficult toRTI define objec- the of evaluation an addition, In in thefirsthalfof2003. distribution and for ready be versionprinting will and friendly user- more simplified, a in Guidance re-written Toolbeing is Programme RTI the trials, field the the from experience of In light context. national their for interventions appropriate ers to identify the information required to decide on the most manag- programme helps and interventions programmatic of range broad a considers management. It and control STI on decisions programmatic to Introduction Technologytive Contracep- for Approach Strategic Programme’s the of tion Latvia in 2000, and in Ghana in 2001. This tool is an adapta- HORIZONS Project, was field-tested in Brazil, Cambodia and Section3 - Reproductive tract infections andsexually -Reproductive infections transmitted tract infections Section3 The field-testing of the ECPG for RTIs will be initiated in beinitiated will RTIs 2002. for ECPG the of field-testing The whererelevant,incorporated, intotheECPGfor RTIs. be settings—will high-prevalence in management cases symptomatic syndromic for of use existing the example, Their management. guides—for case responsible and prevention is STI which for Department HIV/AIDS WHO’s with forECPG the coordinated RTIson closely being work is The of care. in order to select the best alternatives for use at the first point it behaviourssurrounding important RTI/STIthe on and data programme managers to find national and and interpret local efit for their own national or local situation. This guide will help ben- forRTIsformaximum ECPG the use and adapt to how on guidance include will guide manager’s programme level available.facilities second- the The and matters, sexual and sex about norms cultural patterns, behavioursexual charge, dis- vaginal for treatment seeking women in pathogens cal by, determined settings for example, prevalencethe cervi- of different the to tuned approaches and a algorithms include of series will guide first-level The countries. their in tings set- different the in applicable approaches and care of ards stand- the determine who managers programme provincial or national at aimed guide second-level a include also will RTIs for ECPG the Therefore,management. and for diagnosis available resources the and preva- patterns disease resistance of lence, terms clients in to situation offered local the services on and depends advice the of nature The including dualprotection. forreferralpreventioncounselling infection,ner and future of basic principles of provider–client interaction, as well as part- will include not only diagnosis and treatment of RTIs but also guidance This services. care health reproductive in contact of point first the at providersfor guidance include will ECPG treatment. The seeking patients symptomatic for as well as complaints, infection-related with or symptoms any without Asian countries. forforsessions three and French-speaking countries African sessions three countries, African English-speaking for sions ses- three include will 2002. These January–July period the for planned videoconferences nine of series new a has and the Department evaluated the GDLN sessions in March 2001, MTCT, Task on Team Inter-Agency UNAIDS/WHO/UNICEF the of support its of part interventions.As prevention MTCT implementing in experiences and information exchange to countries allowed that videoconferences of series a run and create to (GDLN) Network Learning Distance Global Bank the Worldfacilities of the availedof Department the 2000, In prevention ofMTCT ofHIV DistanceGlobal Learning Network onthe TECHNICAL COOPERATIONTECHNICAL WITH COUNTRIES Annual Technical Report 2001 99 8 5 4 1 3 Totals

50 25 13 38 % of total

4 2 1 3 Number Developed countries Developed

% of total Reproductive tract infections and sexually transmitted infections tract transmitted infectionsReproductive sexually and

Number Countries in transition

50 38 50 % of total

4 3 4 Developing countries Developing Number Mags Beksinska, Reproductive Health Research Unit, Durban, South Africa Health Research Unit, Mags Beksinska, Reproductive Belgium Health, Ghent, Reproductive International Centre for Claeys, Patricia Nigeria Health, Sagamu, Research in Reproductive Dada, Centre for Oluwakayode Belgium Antwerp, Medicine, Tropical Lafort, Institute of Yves USA NY, York, New of Medicine, Academy York The New MaryLatka, Africa Health Research Unit, Durban, South Reproductive Saiqa Mullick, Belgium Antwerp, Medicine, Tropical Institute of Dyck, Van Eddy Abidjan, Côte d’Ivoire Projet RETRO-CI, Vuylsteke, Bea Members Annex 1 Annex THE PREVENTION OF FOR FEMALE CONDOMS OF MALE AND ON EFFECTIVENESS GROUP RESEARCH STIs IN 2001 Members Women from: AFRO AMRO EMRO EURO SEARO WPRO

Maurizio Macaluso, Centers for Disease Control and Prevention, Atlanta, GA, USA Disease Control and Prevention, Centers for Maurizio Macaluso, Collaborating agency scientist Collaborating 100 Annual Technical Report 2001

WPRO SEARO EURO EMRO AMRO AFRO from: Women Members Miriam Rabkin,MTCTplus,Miriam ColumbiaUniversity, New York, NY, USA Ellen Piwoz, Academy for EducationalDevelopment, Washington, DC, USA Lynne Mofenson, National InstitutesofHealth,Rockville, MD, USA Anne Duerr, Centersfor DiseaseControlandPrevention, Atlanta,GA,USA Collaborating scientists agency Philippe Van dePerre, de CentreHospitalierRégionalArnaud Villeneuve, Montpellier, France Margaret Siwale, Lusaka Trust Hospital,Lusaka,Zambia Roger Shapiro, Botswana–Harvard Partnership, Boston,MA,USA John Shao, MedicalCenter, KilimanjaroChristian Moshi,United Republic of Tanzania Sunanda Ray, AIDSInformation, Harare, Africa Zimbabwe Southern Françoise Ndayishimiye, ProjectGIPA, Bujumbura, Burundi Nicolas Meda,CentreMuraz, Bobo-Dioulasso, Faso Burkina Eugénie Kayirangwa, ofHealth,Kigali,Rwanda Ministry Peter Iliff, ZvitamboProject,Harare, Zimbabwe Haverkamp,Geert NationalAIDS Therapy andEvaluation Centre, University ofAmsterdam,theNetherlands Jeanne Gapiya, Association Nationale deSoutienauxSéropositifsetSidéens, Bujumbura, Burundi Raman Gangakhedkar, NationalAIDSResearchInstitute, Pune, India François Dabis, Université Victor SegalenBordeaux2,Bordeaux,France Andrew Agabu, NationalAIDSCommission,Lilongwe, Malawi Isidore Adeyanju, NationalAIDSProgramme, Cotonou, Benin Members RESEARCH GROUP ONMOTHER-TO-CHILD OFHIVIN2001 TRANSMISSION Annex 2 Section3 - Reproductive tract infections andsexually -Reproductive infections transmitted tract infections Section3 Number Developing countries 10 11 1 4

% oftotal 67 73 27 7

Number intransition Countries

% oftotal

Developed countries Number 3 1 4

% oftotal 20 27 7

Totals 10 15 1 3 1 4 Annual Technical Report 2001 101

4 2 2 2 Totals

% of total

Number Developed countries Developed

% of total Reproductive tract infections and sexually transmitted infections tract transmitted infectionsReproductive sexually and

Number Countries transition in

50 50 50 100 % of total

4 2 2 2 Developing countries Developing Number All Women

Other scientists Thailand Ministry Nonthaburi, Anupong, Health, Chitwarakorn of Public BhartiaLalit Bhutani, Sitaram Delhi, India Institute of Science and Research, New Bolivia (USAID), La Paz, International Development United States Agency for Blanco, Stanley USA NC, Park, Triangle Health International, Research Family Florence Carayon, in Reproduction, Mumbai, India Research Institute for Shanta Chitlange, Zimbabwe Harare, Group, Technical National MTCT Inam Chitsike, Egypt Cairo, Office, Technical Cairo El-Shafei, Moshira Heredia, Lima, Peru Cayetano Peruana Health, Universidad Garcia, School of Public Patricia South Africa Johannesburg, Witwatersrand, of University Glenda Gray, Delhi, India New South and East Asia Regional Office, Council Population Hawkes, Sarah Research in Reproduction, Mumbai, India Kamal Hazari, Institute for Canada Victoria, Sidney, of University Liz Lindsey, South Africa Johannesburg, Witwatersrand, of University McIntyre, James Belgium Antwerp, of Antwerp, University Medicine, Epidemiology and Community André Meheus, Zimbabwe Harare, of Zimbabwe, University Mutambirwa, Jane Kampala, Uganda University, Makerere Department of ObstetricsClemensia Nakabiito, and Gynaecology, Senegal Dakar, Institut d’hygiène, N’doye, Ibra Zimbabwe Harare, National AIDS Control Programme, Daisy Nyamukapa, Nigeria Hospital, Sagamu, Teaching Ogun State University Odusoga, DepartmentLawrence of Obstetrics and Gynaecology, and Support Zimbabwe Organization, Harare, AIDS Prevention Zimbabwean Donata Origo, Kampala, Uganda University, Makerere Department of Obstetrics and Gynaecology, Bina Pandey, Fortaleza-Cearà, Brazil Nacional de Saude, Fundaçao Queiroz, Projeto HIV/DST, Telma USA NC, Park, Triangle Health International, Research Robert Family Rice, USA Richard Steen, Durham, NC, Health, Ghent, Belgium Reproductive International Centre for Temmerman, Marleen Wi, Philippine National AIDS Council Secretariat, Department Elvira Santa Cruz, of Health, Manila, the Philippines Teodora USA NC, Park, Triangle Health International, Research Family Yacobson, Irina Beijing, China Medicine, of Preventive Guang Zeng, Chinese Academy Oluwakayode Dada, Centre for Research in Reproductive Health, Ogun State University, Sagamu, Nigeria Sagamu, University, Health, Ogun State Research in Reproductive Dada, Centre for Oluwakayode Thailand Siripon Kanshama, Ministry of Health, Nonthaburi, Kampala, Uganda University, Makerere DepartmentFlorence Mirembe, of Obstetrics and Gynaecology, Mumbai, India Research in Reproduction, Chander Puri, Institute for Principal investigators Principal Annex 3 Annex IN 2001 SCIENTISTS from: AFRO AMRO EMRO EURO SEARO WPRO 102 Annual Technical Report 2001 WPRO SEARO EURO EMRO AMRO AFRO from: SCIENTISTS IN2001 Annex 3(continued)

Women All Section3 - Reproductive tract infections andsexually -Reproductive infections transmitted tract infections Section3 Number Developing countries 10 13 21 2 5 1 3

% oftotal 18 11 36 52 75 7 4

Countries intransition Countries Number

% oftotal

Developed countries Number 2 5 4 7

% oftotal 18 24 25 7

Totals 10 17 28 2 5 2 1 8 Annual Technical Report 2001 103 ica. , 2001, Contraception The Lancet 2001, 358:1096. Reproductive tract infections and sexually transmitted infections tract transmitted infectionsReproductive sexually and Antenatal syphilis screening and management procedure in South Afr and management procedure in Antenatal syphilis screening A case study of Nairobi City Council’s decentralised syphilis screening programme in programme syphilis screening decentralised A case study of Nairobi City Council’s . La Paz, MotherCare Bolivia, MotherCare Bolivia, La Paz, maternal. and congenital syphilis in Bolivia Case study: :32–37. Diseases, 2002, 29 Transmitted Sexually Statistics in Medicine, 2001, 20:3525–3537. WHO Technical Consultation on behalf of the UNFPA/UNICEF/WHO/UNAIDS Inter-Agency Task Team on Team Task Inter-Agency the UNFPA/UNICEF/WHO/UNAIDS Consultation on behalf of Technical WHO . Geneva, World Health World Geneva, of PMTCT. in the context mothers and families Psychosocial support HIV-infected to . Geneva, World Health World Geneva, notes. Technical and use of nevirapine. selection of HIV: of mother-to-child transmission Prevention Organization, 2001 (WHO/RHR/01.21). New data on the prevention of mother-to-child transmission of HIV and their policy implications: conclusions and recom- HIV and their policy implications: of of mother-to-child transmission on the prevention data New mendations. Health Organization, 2001 (WHO/RHR/01.28). World Geneva, of HIV. Transmission Mother-to-Child . Available at: http://www.who.int/reproductive-health/ at: Available 2001. June 7 women. HIV-infected among mortality on breastfeeding of Effect rtis/MTCT/WHO_Statement_on_breast_feeding_June_2001.html Clinical guides for the management of pregnant women with HIV infection. IV. Post-pregnancy care of HIV-infected mothers care of HIV-infected Post-pregnancy IV. with HIV infection. the management of pregnant women Clinical guides for (WHO/RHR/01.26). Health Organization, 2001 World Geneva, version). (field-testing and their infants Clinical guides for the management of pregnant women with HIV infection: III. Labour and delivery care for HIV-infected HIV-infected deliveryLabour and care for III. with HIV infection: the management of pregnant women Clinical guides for (WHO/RHR/01.25). Health Organization, 2001 World Geneva, version). (field-testing women Clinical guides for the management of pregnant women with HIV infection: II. Antenatal care for HIV-infected women (field- women HIV-infected Antenatal care for II. HIV infection: with the management of pregnant women Clinical guides for (WHO/RHR/01.24). Health Organization, 2001 World Geneva, . testing version) Clinical guides for the management of pregnant women with HIV infection: I. Voluntary counselling and testing for HIV in and testing for counselling Voluntary I. HIV infection: with the management of pregnant women Clinical guides for Health Organization, 2001 (WHO/RHR/01.23). World Geneva, . version) (field-testing pregnant women Beksinska ME, Mullick S, Kunene B, Rees H, Deperthes B. A case study of antenatal syphilis screening in South Africa:A case study of antenatal Rees H, Deperthes B, B. Kunene S, Beksinska ME, Mullick successes and challenges. service Assessing the acceptability, A, et al. TMM, Peregoudov Farley Bulut A, Ortayli N, Ringheim K, Cottingham J, Turkey. and in Colombia, Philippines, of the diaphragm and use-effectiveness delivery requirements, mothers. in HIV-1-positive Breastfeeding I, Osborne C. de Zoysa Gaillard P, O, Fontaine T, Farley an assessment tool for of HIV: of mother-to-child transmission in the context practices and replacement feeding Breastfeeding Health Organization, 2001 (WHO/RHR/01.12). World Geneva, research. Durban, Reproductive Health Research Unit, 2000. Durban, Reproductive G. Jové De la Quintana C, Blanco S, 2001. 63:267–275. of mother-to-child in the context feeding on infant information Collection of standardized TMM. E, Farley Piwoz Gaillard P, of HIV. transmission Health, 2001. in Reproductive Council Frontiers Population Washington, antenatal clinics. Maggwa BN, Hagembe B, Homan R. Homan R. BN, Hagembe B, Maggwa Lindsey E. Lindsey Organization, 2001. Beksinska ME, Mullick S, Kunene B, Mosery B, N. Kunene S, Beksinska ME, Mullick Annex 4 Annex IN 2001 PUBLICATIONS 104 Annual Technical Report 2001 Annual Technical Report 2001 105 Section 4 Unsafe abortionUnsafe 106 Annual Technical Report 2001 nae brin suis o eeo ipoe mtos of methods improved develop to studies abortion, unsafe of determinants and context the understand to studies ity, mortal- and morbidity associated its and abortion unsafe of activities Research Group (STAG). Advisory and Technical Scientific held in abortion on August and September 2000, and by the 2001 meeting of consultations the two by identified orities pri- the address to designed are activities Department’s The • • • • isto: unsafe abortion preventingon work Department’s the overallof strategyThe disability. permanent or temporary unsafe suffer of million consequence 5 another a abortion, as year each die who women It safe. is 000 approximately80 to addition abortion in that estimated been has such legal, is abortion where stances circum- in that, ensure to and unsafeabortion of sequences urges countries and organizations to address the health con- which 1994, in held Development(ICPD) Populationand on Conference International the at adopted Action Pro- of the gramme by guided is abortion on work Department’s The Section 4-Unsafe abortion Section

reduce unsafe abortion. reduce unsafe abortion. assist in the development of programmes and policies to safer; and improve technologies and interventions to make abortion translate thatevidence toolsandguidelines; intonorms, eeae cetfcly on eiec on prevalenceand practices of abortion; evidence sound scientifically generate nops dcmnig h goa dimensions global the documenting encompass INTRODUCTION I.H. Shah, H. von Hertzen, I.K. Warriner Unsafe abortion port to countries toimprovecare. tocountries abortion port sup- technical and providers, mid-level other and midwives for guidelines of implementation and development the ices, serv- abortion safe for guidelines managerial and technical of development the are addressed providers.mid-levelAlso fortrainingof the through expanding safeto access abortion evidence the evaluate to study a and abortion, nonsurgical to women in developing countries. may Nonsurgical abortion available be not may providers trained of numbers sufficient procedures, surgical safest the among is provider trained a by aspiration vacuumdramatically. Although rise death infection and injury, of risks the conditions, personnel clinical poor untrained under by out carried are procedures these woman. When the to risk without not are conditions, clinical good under and personnel trainedby out evencarried when developing pregnancy,of of termination forcountries. Invasive procedures needs the on focus special a with methods is ofexisting technologies acceptability and safety abortion efficacy, the improve on to research of aim overall The vided by mid-level providers. pro- abortion of acceptability and safety the as well as tion abor- unsafe to pathways the and abortion of determinants the exploring on focuses morbidity.also and Work mortality data on the incidence of unsafe maintains abortion and abortion-related and compiles it so, doing In consequences. and determinants its investigating and abortion unsafe on data analysing and gathering by abortion unsafe of dimensions global the document to research conducts Department The Specific objectivesSpecific of research RESEARCH ACTIVITIES Annual Technical Report 2001 107 Unsafe abortionUnsafe Assessing attitudes to abortionAssessing phy- of opinions and views the countries, developing many In sicians have a powerful impact on whether and what type of reproductive health services are provided to Argentina, clients. there In is no national family was study planning A programme restrictive. very is abortion regarding law the and completed in this country that explored the perspectives of physicians (obstetricians and gynaecologists) on providing abortion under conditions different and on its depenalization as well as on the quality of care complications provided to from women unsafe with abortion. Data were through a collected, self-administered questionnaire, from 467 physi- cians working at public hospitals that serve a population low-income in Buenos Aires. The response rate was A 84%. majority (79%) of respondents agreed that depenalizing abortion would decrease maternal deaths penal- not should abortion,law the that considered 80% and due to unsafe ize abortion in cases where there was health, risk incest to or rape a and woman’s fetal malformations. Most (77%) abor- assertedunsafe to due complications with women that tion should be always treated with medical competence and without any discrimination. Overall, most of the were in favour providers of depenalizing abortion under a number of circumstances, and only a small (9%) group held the view that abortion be restricted circumstances. should under any non-surgical abortionDetermining optimal regimens for Preceding the discovery of the antiprogestin mifepristone, the Programme tested prostaglandin-alone regimens (sul- at that gemeprost and available meteneprost were prostone, This research, how- terminationtime) for of early pregnancy. ever, did not lead to a practical repeated and high acceptable doses of regimen: these prostaglandins were needed to reach efficacyacceptable rates and the treatment caused most to acceptable not were which side-effects, troublesome mifepristone When studies. these participatedin who women compound new this tested Programme the available, became for termination of but pregnancy, discovered that it was not sufficiently when The effective used Programme then alone. combined mifepristone and a prostaglandin analogue in a sequential regimen, and this approach resulted in a viable alternative to surgical abortion. This sequential regimen Israel, China, countries, European is most in use routine in now Tunisia and the USA. The Programme the develop regimen to make it more has for develop- affordable continued to ing countries. accept- and effective an develop to is objective recent more A able misoprostol-only regimen for early first- aswell as sec- ond-trimester abortions. The benefits of routine priming of the cervix with misoprostol are also being investigated in a new study on whether the safety of the vacuum aspiration procedure can be further improved. Results from two multicentre studies of early medical abor- tion These were published studies during investigated 2001. With support from the Programme, a research project has Bangladesh abortionof dynamics the Matlab, in investigated where an integrated family planning and maternal and child has since been 1977. in operation health (MCH) programme inte- whether examine to was study this of purpose main The increas- by planning with MCH services, i.e. of family gration ing access to has contraceptives, an effect on the incidence previously were project this from findings Several abortion.of reported.New findings emerged have in 2001 on the effects of sex preference on contraceptive use, abortion and fertil- use contraceptive mid-1990s, the to 1980s early the From ity. recourse did as 1993, in 64% to 1983 in 40% from increased to abortion—from an abortion ratio of 16 in 1982–86 to 24 in 1992–95, while fertility declined. Sex preference had an in decline abortion,the to with recourse especially on impact use. contraceptive on not but children, of number desired the There was, however, no evidence to suggest sex-selective abortion. Investigating the dynamics of recourse to induced abortion the dynamics of recourse to Investigating Reliable Reliable data on abortion and unsafe abortion are needed by policy-makers and health planners health needs. to In countries address where public abortion is collecting data induced on abortionlaw, unsafe, restricted and its con- by sequences is a challenging task to access with professionals health Qualified methodologies. and requires innovative abortion cases were interviewed during a study in Colombo District, Sri Lanka and the findingswere madeavailable in Different 2001. of levels estimates were produced based on varying assumptions. The estimate—40 abortions annually per 1000 women of reproductive age—is comparable to the regional-level estimates for South-East Asia and supports the use of this methodology. In interviewing abortion countries is restricted and data are not available, where induced health professionals provides an alternative means of col- lecting these data. Estimating the prevalence of unsafe abortion of unsafe Estimating the prevalence In addition to a number of projects new initiated in 2001, the areas. key of number a in progressed has work Department’s Progress in research is described below; developments are countries in with cooperation technical and tools guidelines, sections. included in the relevant Progress be more appropriate in these circumstances, keeping in mind in keeping circumstances, these in appropriate more be that surgical follow-up procedures are needed in only 5% of meet To cases. this aim of expanding access to safe abor- tion in circumstances where abortion is not against the law, the Department to has carrycontinued out research on non- surgical abortion in order to determine: (i) the lowest effec- (ii) the most dose prostaglandin suitable tive of mifepristone; analogue as well as its dose and and route (iii) the most appropriate regimens at stages different of of administration; pregnancy. 108 Annual Technical Report 2001 (0.5%) were given blood transfusions. The conclusion from conclusion transfusions.The blood given women were (0.5%) six and bleeding heavy to due aspiration vacuum had women of 2.3% all, In dose. higher the with 1.1–2.3) that times CI: (95% 1.6 was mifepristone of dose lower the with abortion complete a have to failure of risk relative The interaction). the for 0.49 = (P significant statistically not was difference the but gemeprost, of dose lower the with greater was mifepristone of respectively.effect groups, The mg 1.0 and mg 0.5 the not in 91.4% was and 88.7% significant: it statistically but efficacy the on gemeprost of effect an was respectively.groups, mg 200 and mg 50 There the in 92.3% and 87.6% wererates abortion complete pristone: crude the of mife- dose the to related was efficacy abortifacient The 325 ineachoftheotherregimens. and regimen unsuccessful this in enrolled were women 249 design, thus that arm of the study was discontinued. A total of study the in rule stopping a as set cut-off predetermined the below be to discovered was gemeprost) mg 0.5 byfollowed the efficacy for the lowest dose regimen (mifepristone 50 mg analysis, interim the During Georgia. Tbilisi, and Hungary; Szeged, Sweden; Stockholm, Singapore; Zambia; Lusaka, hai, KongHong and Tianjin China; SAR, Ljubljana,Slovenia; Shang- Cuba; Havana, Kingdom; United Edinburgh, India; centres in 13 cities: Aberdeen, United Kingdom; Chandigarh, at days<57 period. menstrual last the from included study This abortion medical requesting women 1224 among prost geme- mg 1.0 or mg 0.5 either by followed mifepristone of mg 200 and mg 50 of side-effects and efficacy the compare to out carried was study double-blind randomized, Another Scandinavica, 2001,80:447–451). Gynecologica et Obstetricia (Acta group higher-dose the women in by frequently more reported was which follow-up, one-week at reported nausea of exception the with groups, both in comparable were side-effects of incidence the and 0.9 was dose mg (95% confidence interval 600 [CI]: 0.6–1.4). the The to timing of compared abortion dose mg 200 with the abortion complete a achieve to failure of risk relative 91.7%). The vs (92.4% dose higher the with that to similar was mifepristone of dose lower the with rate abortion plete tion. A total of 896 women in participated the study. The com- days’ 57–63 gesta- at vaginally administered gemeprost mg 1 followedby mifepristone of mg 600 and mg 200 of effects side- and efficacy the Szeged, compare to Georgia) Hungary; Tbilisi, Sweden; Stockholm, Slovenia; Ljubljana, China; Tianjin and Hong Kong Special Administrative Region [SAR], India; Edinburgh, United Kingdom; Havana, Cuba; Shanghai, multinational study was carried out in ten centres (Chandigarh, 1993, Journal, Medical (British pregnancy of days 56 to up istered prostaglandin gemeprost, had similar efficacies when admin- the by later followedhours mg, 48 200 and mg 400 mg, 600 of doses in mifepristone that showed study WHO earlier An costs. reduce to effort an in mg 600 of dose turers’ recommended manufac- the than lower doses mifepristone of efficacy the Section 4-Unsafe abortion Section :532–537). Recently, a double-blind, randomized, double-blind, a Recently,307:532–537). 50 and56days. among women with amenorrhoea of amenorrhoea with women among pared with the V/O group. The differences were not significant com- CI: when 95% 1.0–4.7) the (RR=2.2, groupin V higher CI: 95% [RR]=2.8, (relativeover and risk 1.3–5.8), twotimes Journal Journal of Obstetrics and Gynaecology, seven (British than weeks longer age gestational a with cies mifepristonewith ment was effectivenot pregnan- in enough pretreat- after misoprostol oral of mg 0.4 that demonstrated clearly study previous oral a However, prefer drugs. of women administration many that show studies Acceptability abortion. medical for inadequate is gemeprost of mg 0.5 by followed mifepristone of mg 50 of dose single a that was study this of amenorrhoea with women among abort failingto of risk The CI: 0.8–1.9). tion in the V group compared to the V/O group was 1.2 (95% 1.0–2.2). The relative risk of failure to achieve complete abor- the CI: to (95% compared wasgroupgroup1.5 O/O V/O the in abortion complete achieve to failure of risk relative The started with vaginal that but continued group with the oral misoprostol in (V/O). 94.7% and group (V) vaginal-only the for 93.5% to compared 92.3%, wastinuing: misoprostol of O/O) con- and (starting group oral the in rate abortion complete by end-2001.When considering undetermined cases as failures, completed the crude was efficacy the of analysis The would prefer homeuseshouldthey begiven thechoice. they whether and home, at regimen the using confident feel ions of the regimen, their assessment on whether they would opin- women’s on data collect to study the in included was assessing the efficacy and side-effects, a questionnaire brief to addition Ulaanbaatar,Mongolia). Romania; In and Mures, Targu- Hungary; Szeged, Sweden; Stockholm, Singapore; Norway;Slovenia;Oslo, Ljubljana, Nam; City,Viet Minh Chi Ho Finland; Helsinki, India; Delhi, New and Mumbai digarh, Chan- China; Shanghai, and SAR Kong Hong (Beijing, tres A total of 2219 women were recruited for the study in 15 cen- days; and (iii)57–63days. three categories of amenorrhoea: (i) up to 49 days;the (ii) 50–56 of each for women 750 women, 2250 was target ment daily for 7 days; and (iii) a vaginal dose of 0.8 mg. The twice recruit- mg 0.4 of dose oral an with continued mg 0.8 of dose oral dose of 0.4 mg twice daily for 7 days; (ii) an initial vaginal an with continued mg 0.8 of dose oral initial an (i) pristone: mife- of mg 200 after hours 48 administered regimens ostol misopr- three involved study double-blind randomized, This bleeding were alsoevaluated. postabortion of amount and duration the on regimen this of effects efficacy. The clinical with the improve could pretreatment mifepristone repeated after whether misoprostol test oral to of out administration carried was study a Thus, > 57 days was almost three times higher in the O/O group O/O the in higher times three daysalmost was57 ≤ 49 days and between and days 49 2000, 107:524–530). Annual Technical Report 2001 109 Unsafe abortionUnsafe to limit or space births and The project Lomé. hence will employ both qualitative and affect quantita- fertility levels 4500 in of survey community a including methods, research tive discussions. group in-depth interviews and focus women, Assessing the safety and efficacy of mid-level providers providers Assessing the safety of mid-level and efficacy of abortion In developing countries, access to safe abortion services is pregnancy. unwanted an facing women many for challenge a Of the approximately 55 000 unsafe abortions worldwide 95% every day, of that them take place in occur developing countries. Complications arising from unsafe abortion con- tribute to nearly one-fourth of the maternal deaths in some developing countries. In circumstances where abortion legal, the law is generally restricts the provision of abortion to physicians and, in some cases, requires additional training and Forcertification. avariety of geographical, financial and social reasons, millions of women turn to abortion provided by nonphysicians who may not be clinically trained in abor- tion techniques, including midwives, paramedics and tradi- abortion unsafe of consequences The birth attendants. tional com- lifelong or life-threatening including health, women’s for the to costs significant in result and substantial are plications, health care system and its resources. One approach to reduce unsafe abortions and their conse- quences is to expand the provision of abortion services to include or providers, trained mid-level among nonphysicians those qualified to perform abortions in circumstances where abortion is legal. The terms “nonphysician” and “mid-level providers” refer to a broad range workers including of midwives, nurses, nonphysician clinical officers, health physi- whose among cian train- others, assistants and paramedics, but another countryto one from differ responsibilities and ing in the health of provision care reproductive who are involved or primary health care services. In areas where greatly would servicesabortion decentralizing and expanding the shortage of abortionaccess to safe increase serviceswomen’s and also physicians is severe, help to conserve resources. evidence However, suggesting that trained nonphysicians are able to perform abortions as There anecdotal. often and sparse is physicians as effectively by abortionoutcomes comparing studies rigorous of lack a is for there a is a need Specifically, types of providers. different controlled, trialrandomized to the of investigate safety abor- government-certifiedand trained medically by provided tions mid-level providers compared to those performed by physi- pol- Although settings. sociocultural different several in cians, icy-makers in several developing countries have expressed an interest in expanding the provision of abortion services, many are reluctant to initiate change in the absence of evi- dence indicating that mid-level providers devel- a are in kind its as of first competent the be to is study This physicians. as oping country and will provide policy-makers with the nec- essary data for them to address expanding the provision of abortion services. 57 days of amenorrhoea, and that > Unsafe abortion: global and regional esti- regional and global abortion: Unsafe continuing continuing prostaglandin one for week the improves efficacy of the method but significantly, does not influence the dura- tion of postabortion bleeding. Two priorities Two highlighted during the recent consultations on abortion—(i) documenting the incidence of abortion, and (ii) research on pathways to abortion—are being addressed by The study will measure of the abor- prevalence a new study. tion and its impact on and fertilitystudy the levels, pathways the Currently, Togo. Lomé, in living women among abortion to legislation permits in Togo abortion only when necessary to greater a to declined have levels Fertility life. woman’s a save extent in Lomé than in other parts but increases of Togo, in the prevalence of contraceptive use are too the examine will small investigators The to change. the suffi- explain ciently characteristics and circumstances of women seeking abor- tions, and determine the extent to which abortions are used Estimating the prevalence of abortion in and its role Estimating the prevalence fertility decline The number of unsafe abortions and other abortion-related indicators are among the most difficult reproductive health data to estimate. As part of the Department’s commitment to maintain up-to-date data on unsafe abortion worldwide, document 1998 the mates is being updated. The final product will provide esti- mates of unsafe abortion, globally and maternal by mortality abortion. due to unsafe region, and of Updating abortion unsafe data on worldwide Several Several projects have been initiated following the identifica- tion of research priorities during the meeting and on Needs in Priorities the Area of Unsafe Abortion in August 2000, Consultation the Technical on Abortion in September 2000, and the meeting in of These 2001. STAG include an updat- ing of data on unsafe abortion, a study effectiveness of of abortion the performed safety by and mid-level providers, and research into the prevalence of abortion and pathways clini- multicentre new In addition, several to Togo. abortion in These will launch in for earlycal trials 2002. were developed address the development of misoprostol-only regimens for as well as trimester first early in pregnancy of termination the in the second trimester; the advantages and disadvantages of routine priming of the and cervixa four- with mifepristone; arm study comparing the efficacy of 100 mg and 200 mg of 24 either misoprostol vaginal mg 0.8 by followed mifepristone hours or 48 hours later. New projects initiated during 2000 during projectsNew initiated The study suggests that the vaginal route of misoprostol is more than effective the oral route to complete achieve abor- tion among women with The difference in the median length of bleeding (12–13 days) days) (12–13 bleeding of length median the in difference The was not significant in the three groups. 17 days. more than for bled groups in all three women Also, of the 25% 110 Annual Technical Report 2001 ducted to test whether con- routine preoperative be treatment with will 0.4 study multicentre double-blind, randomized, A withmisoprostol Routine priming ofthecervix one require also will study year. this of phase clinical the that anticipated Nam, is YugoslaviaSweden,Zambia. Viet It and in centres 14 in China, Hungary, Mongolia, Romania, Slovenia, womenSouth Africa, 2100 include will study This ing. bleed- of duration the and side-effects of frequency tation, ges- of length the to relative abortion complete inducing in outcomes—effectiveness main following the to respect with compared be will regimens four period). The menstrual last in women experiencing pregnancy amenorrhoea of up to early 63 days (from of the termination the for used when later, hours 48 or hours 24 either misoprostol administered nally mifepristone, 100 mg and of 200 mg, followed doses by two 0.8 mg compare of vagi- will study abortion medical Another mifepristone andmisoprostol Nonsurgical usingasequentialregimen of abortion phase ofthestudyisexpected tolastone year. side-effects.of occurrence clinical and The acceptability val, inter- induction-to-abortion abortion, complete inducing for effectiveness their of respect in compared be will regimens four intervals. The 12-hour or 3-hour either at or and vaginally sublingually either administered be will which oprostol, mis- of mg 0.8 of doses three receive will groups treatment the all in groups. Women treatment four to allocated domly ran- be will study the join to wish who women Nam. Eligible Cuba, Georgia, India, centres in Mongolia Armenia, and Viet 11 in legal out pregnancy. of carried be termination will study requesting The gestation) of days 63 to (up women nant preg- 2100 involving 2002 early in trial multicentre omized, rand- a launch to out carried were Preparations available. this compound in where countries mifepristone has not been with termination pregnancy for of research method prostaglandin-only of a renaissance a to also and use, its to uted tol compared to other prostaglandin analogues have contrib- misopros- of price low reasonably and availability wide The Nonsurgical withmisoprostol alone abortion between clinicsandcountries. comparability ensure to countries both in clinics (MSI) tional Interna- Stopes Marie in conducted be will cians.study The currently legally performed by both physicians are and nonphysi- abortions first-trimester where and abortions out carry legally can providers mid-level where Nam, Viet and Africa South developingcountries, two in place take will study The performed by physicians. fromabortions those arising from rates complication performed by nonphysicians abortions to them compare and on evidence collect will trial this design, study experimental an Using abortions. from tions variable—complica- outcome one on focus will study This Section 4-Unsafe abortion Section 2002. availablebe of should end byresults the the and months six this study. The recruitment for in the study participate is expected will to Zambia require and Nam Viet Africa, South enia, Slov- India, Hungary, Georgia, Armenia, in Twelve centres mg misoprostol either vaginally or sublingually every 3 hours. 0.4 of doses 5 to up receive to randomized be will Women amenorrhoea). weeks’ (14–20 trimester second the during pregnancy of termination legal requesting women pregnant rand- a omized, fordouble-blind, multicentre developedstudy which will was involve 680 protocol a end, this nancy.To preg- second-trimester of termination fordeveloped be also area of abortion recommended that effective the regimens in should activities Department’s the on consultations two The abortion Misoprostol-alone regimens for second-trimester hs oue agt mdie a pr o te paig and updating the of part as midwives targets module This is anticipated tobepublished and by 2002. April 2001 in Switzerland Geneva, in held meeting nical has been subjected to external peer review of as a part tech- version final revised. The and field-tested been has module material training other developed Ipas.by abortion incomplete of Management The with consistent made and drafted was module the 2001, In manual. and student-notes separate manual a trainers’ complete a of consists material The care. postabortion includes , abortion incomplete of agement modules, new these of workers. One health other and midwives of capacity the strengthen effectively to modules developto years.eral additional important considered was It nal “killers” was developed and distributed over the past sev- mater- major the manage to workers and health mid-level midwives other of competency the increasing at aimed rial The package of incomplete abortion of ontheManagement module Midwifery medical and practitioners policy-makerswith guidelines for improving the quality of care. provide to designed are care postabortion and abortion safe accessing for and abortion unsafe preventing for tools and norms of development The ment isestimatedtocontinue for ayear. Recruit- Nam. Viet and Slovenia Romania, Mongolia, India, Hungary, Cuba, China, Armenia, in centres 14 in recruited be will who pregnancy, of weeks 12 to up women 5000 of evacuation, pelvic infection, etc. This study will include a total incomplete haemorrhage, severe perforation, uterine injury, to vacuum aspiration reduces complications such as cervical prior hours three vaginally administered misoprostol of mg Specific objectivesSpecific Midwifery modules containing training mate- NORMS AND TOOLS Man- Annual Technical Report 2001 111 WHO National Unsafe abortionUnsafe in 2002. References for these for References 2002. in Library Cochrane The TECHNICAL COOPERATION WITH COUNTRIES TECHNICAL COOPERATION Namese. The Namese. Department will also support WHO Regional support to technical specific providing in CountryOffices and opera- or workshops as such processes regional and country tions research, It as will requested. also continue to network with NGOs such as Ipas, the International Women’s Health Coalition (IWHC) and Reproductive Health Alliance Europe (RHAE) in follow-up and dissemination activities related to the monograph. In 1997, the Programme assessment supportedof issues related to abortion and abortion serv- a national strategic ices in Viet This Nam. assessment recommended a variety of actions to reduce recourse to abortion postabortionabortion including of family services, quality the and to improve planning. In response to the assessment, the Viet Namese Ministry of Health began a series of activities to implement com- included and assessment, the of recommendations the mitments to the same in 2001–2010. the for Health Strategy Reproductive recently published In mid-2001, the Department received a proposal submitted by the Ministry of Health for the development of and a testing quality, client-centred abortion care model that be replicated at could all levels of the health system in Viet Nam. This Comprehensive Abortion Care (CAC) project implemented will by the be Ministry of Health, the Institute for the Protection of Mothers and Newborns, Hanoi and the Du Tu The Obstetrics and Gynaecology Hospital, Ho Chi Minh City. project CAC is being jointly The funded Foundation, Ford by Ipas and WHO with technical assistance provided by Ipas WHO. and In the first phase of the WHO project, and Ipas are support- Viet ing of Namese the national development standards and abortion guidelines for service delivery and the development of a service delivery package for improving the quality of New work and progress on systematic reviews of of reviews on systematic and progress work New abortion safe addressing reviews systematic Cochrane three 2001, In abortion were completed. Two reviews evaluate the com- parisons of different surgical methods to evacuate incom- plete abortions and to terminate first-trimester pregnancies. The third systematic review compares surgical and medical The review methods of first-trimester pregnancy termination. on routine antibiotic use for incomplete abortion has been The updated. first two reviews will be included in the Reproductive Health Library 5, No. to be released in March The 2002. third review is currently in press and will be pub- in lished “Implementing best 3 of the chapter are on in Annex reviews practices”. Improving abortion care in Viet Nam: policy and Viet Nam: abortionImproving in care practice Midwifery modules package which remains in high It is anticipated that the document will be useful to a broad health from health, reproductive in working those of spectrum serv- putting for responsible those and managers programme ices in place, to nongovernmental organizations (NGOs) at the service, information and advocacy Over levels. the next biennium, the Department will support the dissemination of Offices Regional WHO the through essentially document the and through collaboration with partner Initial NGOs. support English-language the of translation ensure to provided be will United the of languages official five other the into monograph Russian and Spanish), as French, Chinese, Nations (Arabic, well as into other languages such as Portuguese and Viet Following Following an introductory chapter that provides an overview of aspects three covers document the involved, issues the of “Clini- law. the of limits the within abortioncare safe providing cal care women undergoing the for abortion”clinical reviews abortionhigh-quality providing services,of including aspects selection of and an provision appro- diagnosis of pregnancy, rec- gives and postabortioncare, and abortion method priate ommendations on abortion methods and the characteristics that influence efficacy their and safety, optimal “Putting use. services in place” provides guidance on the essential ele- ments needed to legal put abortiongood quality, services in place, covering topics such as assessment, national norms and standards, elements of care at each level of the health system, and training certification, monitoringevaluation, and and financing. “Legal and policy, and contextual considera- tions” lays out a policy framework to ensure access to safe topics covering abortion services of the law, to the full extent such as the legal grounds for abortion, creating an enabling policy context and removing unnecessary barriers to appro- priate care. In September 2000, the Department convened a Technical Consultation on Safe Abortion as part of a process to elab- orate a technical and policy guidance document Member to assist States and other participants ICPD+5 key to action implement stated in the paragraph stances 63.iii: where “In abortion circum- is not against the law, health sys- tems should train and equip health-service providers should take other and measures to ensure that such abortion is safe and accessible. Additional measures should be taken to safeguard women’s (Key health.” Actions for the Further Implementation of the Programme of Action of ICPD). The background document prepared for the Consultation considerably was reworked during 2001, and a detailed review process has are Final been being revisions undertaken.car- ried out. Technical and policy guidance on safe abortion and policy on safe guidance Technical upgrading upgrading of their skills and those of viders other who require mid-level training in pro- reproductive health, including postabortion care. French and The module module will are be Spanish expected. distributed as part versions of this of the being reprinted.demand, and is currently 112 Annual Technical Report 2001 address strategies to reduce financial barriers for women related tocontraception andabortion. for barriers financial reduce to strategies address potential introduction of medical the abortion. The will report as also well as abortion surgical for technologies improved of introduction the through procedure the of safety the ing Recommendations media. increas- focuson will delivery service abortion forimproving mass of use including paigns cam- communication and education information, planning family of strengthening the and contraception emergency of promotion broader the contraception, in physiciansfamily of training through as well as abortions providing sites at both contraceptives of availability the strengthening through tion abor- to recourse decrease to strategies for ommendations rec- include to expected are These issues. key of number a for recommendations provide and findings the review will report final A sectors. care health private and public the in services abortion of quality the improve to and abortion to appropriate identify to research and order programme interventions in to reduce abortion the recourse to related issues of assessment strategic a conduct to Romania Ministry in Health the of assisted Department the 2001, November In practice care inRomania: Improving abortion and policy delivery.of service levels peripheral more the at utilization for training including will be tested and revised dissemination, to prior their further protocols delivery service and guidelines guidelines. These care based on comprehensivethese standards and abortion Section 4-Unsafe abortion Section more widelyavailable whereitislegal. abortion medical bymaking method abortion of choice mote Medical on Consortium pro- and safeto access increase to abortion be will Abortion International the of mission The objec- tives. and mission its on consensus a reached and tries, developingof needs coun- the focusingon Abortion Medical was a demonstrable need for an on International Consortium there that concluded group broadly.The more abortion cal work together to address the challenges in introducing medi- could organizations different which in ways the considered abortion worldwide, the experiences with its introduction, and reviewed availabilityparticipants the The medical of use and countries, includingtwo staffmembersoftheDepartment. Medical and Abortion was attended by 38 individuals from 12 on Consortium International an establishing feasibilityof the assessed meeting The Cooperation. Development national support from the Wallace Global Fund and the Swedish Inter- ship with the Reproductive Health Technologies Project, with In June 2001, a meeting was organized by RHAE, in partner- Abortion Medical Establishment ofanInternational Consortium on Annual Technical Report 2001 113 Unsafe abortionUnsafe See Annex 1 of “Research on users’ perspectives” in Section 1, “Promoting family planning”. family “Promoting Section 1, in perspectives” “Research on users’ 1 of See Annex Members Annex 1 (a) Annex HEALTH REPRODUCTIVE ON RESEARCH OPERATIONS AND SCIENCE SOCIAL FOR PANEL SPECIALIST IN 2001 114 Annual Technical Report 2001 See Annex 1aof “Research onthedevelopment regulation” ofmethodsfertility in Section1, “Promoting family planning”. Members RESEARCH GROUP ONPOST-OVULATORY REGULATION METHODSFORFERTILITY IN2001 Annex 1(b) Section 4-Unsafe abortion Section Annual Technical Report 2001 115 5 2 1 2 2 Totals Unsafe abortionUnsafe

% of total

Number Developed countries Developed

20 20 % of total

1 1 Countries in transition Number

80 40 20 20 % of total

4 2 2 2 Developing countries Developing Number

All

Women Women from: AFRO AMRO EMRO EURO SEARO WPRO Other scientists Catalin Andrei, Institute of Health Services Management, Bucharest, Romania Bucharest, Romania Radu Beloui, National College of Physicians, Romania Targu-Mures, Health, Cosmina Blai, East European Institute of Reproductive Romania Targu-Mures, Health, East European Institute of Reproductive Ionela Cozos, Health, Bucharest, Romania Reproductive Coalition for Women’s Daniela Draghici, Monica Dunarintu, Marie Bucharest, Romania Stopes, Bucharest, Romania Mihai Horga, Ministry of Health and Family, Viet Nam of Mother and Newborn, the Protection Hanoi, Thi My Huong, Institute for Nguyen Bucharest, Romania Virginia Ionescu, Marie Stopes, Bucharest, Romania and Sexuality, Society of Education and Contraception Borbala Koo, Bucharest, Romania Dan Lazarescu, National College of Physicians, Bucharest, Romania Luminita Marcu, Institute of Mother and Child Care, Bucharest, Romania Doina Ocnaru, Ministry of Health and Family, Bucharest, Romania Society of Obstetrics and Gynaecology, Cristian Posea, Bucharest, Romania Silviu Predoi, Ministry of Health and Family, Romania Targu-Mures, Florina Prundaru, Health, East European Institute of Reproductive Cluj, Romania League, Women’s Lia Rugan, National Bucharest, Romania Youth, for Youth Teodoru, Raluca Bucharest, Romania of Obstetrics Society and Gynaecology, Vaduva, Adrian Tianjin, China Planning, Family Tianjin Municipal Research Institute for Liu Zhifang, Principal investigators Principal Dhaka, Bangladesh Diarrhoeal Disease Research, International Bairagi, Centre for Radheshyam Sri of Ruhuna, Matara, Lanka University Department Geography, of Hewage, Piyadasa Viet Nam Dinh Loan, Department Planning, Hanoi, Nguyen of Maternal and Child Health/Family Viet Nam Thi Phuong Mai, DepartmentMinistry Planning, of Maternal of Health, Hanoi, Health/Family and Child Tran Romania Targu-Mures, Health, East European Institute of Reproductive Mihaela Poenariu, Scientists in 2001 Scientists Annex 2 (a) Annex ABORTION - UNSAFE RESEARCH AND OPERATIONS ON SOCIAL SCIENCE GROUP RESEARCH 116 Annual Technical Report 2001 WPRO SEARO EURO EMRO AMRO AFRO from: Women All Section 4-Unsafe abortion Section Number Developing countries 2 4 2

% oftotal 20 20 10

Number Countries intransition Countries 18 18

% oftotal 90 90

Developed countries Number

% oftotal

Totals 18 20 2 4 Annual Technical Report 2001 117 Unsafe abortionUnsafe Ulaanbaatar, Mongolia Ulaanbaatar, Principal investigators Principal Armenia Yerevan, Armenian Research Centre of MaternalSimon Alexsaniants, Protection, and Child Health Armenia Yerevan, Karine Arustamian, Armenian Research Centre of Maternal Child Health Protection, and Viet Nam Hanoi Obstetric Hanoi, and Gynaecology Hospital, Huy Bao, Nguyen Hungary Szeged, Bártfai, Albert University, Medical György Szent-Györgyi South Africa Hospital, Johannesburg, Chris Hani Baragwanath Heather Brown, Sweden Stockholm, Institute, Marc Bygdeman, Karolinska India Thiruvanathapuram, Hospital, S.A.T. Chacko, Valsamma Region of China Special Administrative Hong Kong, of Hong Kong, University Carina Chan chi wai, Cuba Hospital, Havana, Teaching and ObstetricsGynaecology “Eusebio Hernandez” Cabezas Cruz, Evelio Instruction, China Shanghai, Technical Planning Cheng Linan, Shanghai Institute of Family South Africa Hospital, Johannesburg, Chris Hani Baragwanath Kim Dickson-Tetteh, State Research Centre on Human Reproduction and Maternal and Child Health, Erdenetungalag Radnaabazar, Maternity and Child Health Hospital, Shanghai, China Aihua, International Peace Fang Sweden Stockholm, Institute, Kristina Karolinska Gemzell-Danielsson, Cuba Hospital, Havana, Fajardo’ ‘Cmdte. National Institute of Endocrinology, Gomez Alzugaray, Manuel Chandigarh, India Institute of Medical Education and Research, Gopalan, Postgraduate Sarala Viet Nam the Protection of Mother and Newborn, Hanoi, Duc Hinh, Institute for Nguyen Region of China Special Administrative Hong Kong, of Hong Kong, Chung, University Ho Pak Hospital, Helsinki, Finland Central Helena Honkanen, Helsinki University Romania Mures, Targu Mihai Horga, Medical Research Centre, Viet Nam the Protection of Mother and Newborn, Hanoi, Thi My Huong, Institute for Nguyen Viet Nam Hanoi Obstetric Hospital, Hanoi, and Gynaecology Minh Huyong, To Norway Hospital, Oslo, Ulleval Jerve, Fridtjof Yugoslavia of Republic Serbia, Federal Sad, Sad, Novi Kapamadzija, Clinical Centre Novi Aleksandra Lusaka, Zambia School of Medicine, Hospital, Teaching Christine Kaseba, University Tbilisi, Georgia Institute of Human Reproduction, Zhordania Archil Khomassuridze, Hungary Szeged, Albert Medical University, Szent?Györgyi Laszlo Kovacs, Zhong Shan Hospital, Shanghai, China Cancer Institute, Liver Yinkun, Liu Delhi, India New Suneeta Mittal, All India Institute of Medical Sciences, Viet Nam Hospital, Ho Chi Minh City, Vuong Hung Thi Nhu Ngoc, Nguyen Armenia Yerevan, Armenian Research Centre of Maternal and Child Health Protection, George Okeov, Viet Nam Hospital, Ho Chi Minh City, Du Tu Thi Ngoc Phuong, Nguyen Singapore of Singapore, National University Prasad, R.N.V. Slovenia Ljubljana, Medical Centre, University Alenka Pretnar-Darovec, Health, Cluj Napoca, Romania Rosca, East European Institute of Reproductive Augustin India Research in Reproduction, Mumbai, Rashmi Shah, Institute for Research, Shanghai, China Song Si, Shanghai Institute of Planned Parenthood Viet Nam Biu Suong, Hanoi Obstetric and Gynecology Hospital, Hanoi, Region of China Special Administrative Hong Kong, of Hong Kong, University Tang, Oi-shan Viet Nam Du Hospital, Ho Chi Minh City, Tu Tuyet, Hoang thi Diem Viet Nam the Protection of Mother and Newborn, Hanoi, Institute for Vy, Duc Nguyen Planning, Beijing, China Family Shang-chun, National Research Institute for Wu Scientists in 2001 Scientists Annex 2 (b) Annex ABORTION - UNSAFE FERTILITY METHODS FOR REGULATION ON POST-OVULATORY GROUP RESEARCH 118 Annual Technical Report 2001 WPRO SEARO EURO EMRO AMRO AFRO from: Women Jelka Vukelic, ClinicalCenterNovi Sad,Novi Sad,Serbia,Federal Republic of Yugoslavia Alezandro Velazco, “Eusebio Hernandez” Gynaecology andObstetrics Teaching Hospital,Havana, Cuba Tamar Tsoreteli, ZhordaniaInstituteofHumanReproduction, Tbilissi, Georgia George Tsertsvadze, Zhordania Institute ofHumanReproduction, Tbilissi, Georgia Le Thanh Thuy, andGynecologyHospital,Hanoi, HanoiObstetric Viet Nam Pham Viet Thanh, Tu DuHospital,HoChiMinhCity, Viet Nam Allan Templeton, University ofAberdeen,UnitedKingdom Schaff,Eric University ofRochester, Rochester, NY, USA Janette Rodriguez, “Eusebio Hernandez” Gynaecology andObstetrics Teaching Hospital,Havana, Cuba Helen Rees,HaniBaragwanath Chris Hospital,Johannesburg, SouthAfrica Nair Rajasekharan, S.A.T. Hospital, Thiruvanathapuram, India Miroslava Mirkovic, ClinicalCenterNovi Sad,Novi Sad,Serbia,Federal Republic of Yugoslavia Nguyen Thi NgocKhanh,Institutefor Hanoi, theProtectionofMotherandNewborn, Viet Nam SzentAttila Kereszturi, György MedicalUniversity, Albert Szeged, Hungary Qiao Gen-mei,NationalResearchInstitutefor Family Planning,Beijing,China Constantin Enciulescu,CenterofPublic Health Targu-Mures Targu-Mures, Romania José Carbonell,Mediterrània Médica, València, Spain scientists Other All WPRO SEARO EURO EMRO AMRO AFRO from: Women All Section 4-Unsafe abortion Section Number Number Developing countries Developing countries 19 18 28 4 1 2 1 4 8 4 2 3

% oftotal % oftotal 24 12 24 47 45 10 43 67 6 6 5 7

Number intransition Countries Number Countries intransition Countries 10 10 6 3 6 2

% oftotal % oftotal 35 18 35 24 24 5

Developed countries Developed countries Number Number 2 1 3 4 2 4

% oftotal % oftotal 12 18 10 10 6 5

Totals Totals 17 14 22 42 19 4 1 8 3 1 7 4 2 3 Annual Technical Report 2001 119 Unsafe abortionUnsafe International Family International Family Journal of the Faculty of Journalof the Faculty XIII International of the International Congress Society of Los médicos frente a la anticoncepción y el aborto: una transición una transición y el aborto:Los médicos frente a la anticoncepción . University of Colombo, Working Working of Colombo, University induced abortionsfor having Profile of abortion in Sri and reasons Lanka. seekers Journal of Psychosomatic Obstetrics and Gynecology. Journalof Psychosomatic Obstetrics and Gynecology. Ramos S, Gogna M, Petracci Dominguez M, Durand T, Romero M, Szulik D. Ob-gyn’s opinions towards abortion towards opinions in Ob-gyn’s Romero M, Szulik D. T, Dominguez M, Durand Gogna M, Petracci Ramos S, Argentina. M, Romero M, Szulik D. Gogna M, Petracci Ramos S, , University of Ruhuna, Sri Lanka (in press). Humanities and Social Sciences, University Argentina, 2001:42. Buenos Aires, Psychosomatic Obstetrics Book of abstracts. and Gynecology (ISPOG), de Estado y Sociedad (CEDES), 2001. Centro de Estudios ideológica? Buenos Aires, Bairagi R. Effects of sex preference on contraceptive use, abortion Bangladesh. use, and fertility in Matlab, on contraceptive preference of sex Effects R. Bairagi Cases of induced abortion reported district. in Colombo to the health professionals P. Hewage Publications in 2001 Publications series (in press). Papers Annex 3 Annex ABORTION - UNSAFE RESEARCH AND OPERATIONS ON SOCIAL SCIENCES GROUP RESEARCH P. Hewage Bairagi R, Datta AK. Demographic transition in Bangladesh: what happened in the twentieth century and what happens next. centurywhat happened in the twentieth and what happens next. in Bangladesh: transition Demographic R, Datta AK. Bairagi JournalPopulation , 2001 (in press). Asia-Pacific , 2001, 27:137–143. Planning Perspectives 120 Annual Technical Report 2001 abortion: abortion: a randomized controlledtrial. tion, Task Force on Post-ovulatory Methods of Regulation. Fertility Lowering the doses of mifepristone and gemeprost for early UNDP/UNFPA/WHO/World BankSpecialProgramme ofResearch,Development andResearch Training inHumanReproduc- 2001, 80:447–451. lower doseofmifepristone andgemeprost: a randomized controlledtrial. etGynecologicaScandinavicaActa Obstetricia , tion, Task Force onPost-ovulatory Regulation. MethodsofFertility at57to63days’ Medical abortion gestation witha UNDP/UNFPA/WHO/World BankSpecialProgramme ofResearch,Development andResearch Training inHumanReproduc- emergency contraception. Regulation. Methods ofFertility oflowWHO multicentre trial dosemifepristone andtwo regimensoflevonorgestrel for von H,PiaggioG,DingJ, Hertzen ChenSiSong J, G,NgE,etal. Bártfai for the WHO ResearchGrouponPost-ovulatory Placenta (submitted). metalloproteinase-1(TIMP-1),plasminogenactivators humanfetalinhibitor ofmatrix andinhibitorsinterm membranes. Ockleford CD, Feng Q,Ny T, HuZY, S, d’Lacey Byrnes C, etal. metalloproteinase(MT-MMP),Expression ofmatrix tissue administered fumagillinintherhesusmonkey. Lalitkumar PGL,SenguptaJ, Dhawan DN,Lasley BL,Overstreet L,Sharma JW, etal. effectAnti-nidatory ofvaginally pregnancywithin28days ofearly period. ofmissedmenstrual termination (mifepristone) singledosefollowed by either5mg9-methylene PGE Indian CouncilofMedicalResearch Task Force. A multicentre randomised comparative of200mgRU486 clinicaltrial Honkanen H,vonH. inFinland. Hertzen Acceptability ofmedicalabortion administered (Ala8,13,18)-magaininIIamideintherhesusmonkey. Dhawan L,GhoshD, DN,Lasley BL,Overstreet LalitkumarPGL,Sharma JW, etal. effectAnti-nidatory ofvaginally Publications in2001 RESEARCH GROUP ONPOST-OVULATORY REGULATION METHODSOFFERTILITY -UNSAFEABORTION Annex 4 Section 4-Unsafe abortion Section The Lancet(submitted). British Journal of Obstetrics andGynaecology, ofObstetrics Journal British 2001,108:738–742. Contraception, 2000,62:155–159. Contraception, 2000,62:39–43. 2 gel(meteneprost)or600µgoral PGE Contraception (submitted). Contraception, 2000,62:125–130. 1 (misoprostol)for Annual Technical Report 2001 121 Section 5 of adolescents Promoting sexual and reproductive health and reproductive sexual Promoting 122 Annual Technical Report 2001 the uniqueneeds ofadolescents. health in the population at large are also designed to address developed advocacymaterials and for tools reproductive rial dis- to manage- and and technical time, findings. same seminate the At capacity research strengthen to intended are that activities related and services, information and of health provision optimal the on research intervention includes This adolescents. of needs and situation health sexual the evidencethe enhancing and research promoting on on base is focus main The relationships. responsible and equitable forcapacity the enhancing developmentand maturation and with the objective of enabling the experience of healthy sexual gaps, these addressing on concentrates reproductivehealth The Department’s on work promoting adolescent sexual and into adulthood. develop they as lives people’s for consequences reaching far- have adolescence during behaviours reproductive and this population has major implications forof the future, since sexual Neglect world. the of parts most in served or stood under- poorly remain ways,which and important in adults of those from differ that needs health reproductive and sexual tive health and behaviour. Thus, as a group, adolescents have marriage,childbearing, but also for their sexual and reproduc- implicationsnotonlyfor adolescents’ education,employment, enormous have changes life.These adult for prepare must peopleyoungwhich inways thechangingrapidly forcesare context.cultural Moreover,and social, economic politicaland region class, status, marital sex, age, by adolescencevary of Experiences adulthood. of responsibilities roles, and privileges the assume immediately not do but puberty, lowing fol- changes experience people young which during hood, adult- to childhood from transition of time a isAdolescence Section 5-Promoting sexualSection andreproductive healthofadolescents Promoting sexual andreproductive health INTRODUCTION OBJECTIVES S. Jejeebhoy, H. Bathija, I.H. Shah, I.K. Warriner of adolescents sexual andreproductive health scienceSocial research initiative onadolescent idns rm w suis hd ih o rsy n rarely and risky on light shed studies two from Findings Initial study findings are given below. of care and provider perspectives. Some findings preliminary and consequences; and (ii) health-seeking behaviour, quality correlates their behaviours, risk sexual (i) are: investigation under themes the reports, earlier in described earlier. As or 2000 in approved were projects ongoing settings. These try developingdifferentcoun- in health reproductive and sexual adolescent of continued aspects behavioural and countries social 24 the study in to projects research 33 2001, In research initiative onthetopic. science social ongoing the by supported largely operations, and science social both research, behavioural on is focus Consequently,countries. developingthe in interventions ate appropri- by influenced out- be can that those especially comes, health reproductive and sexual positive to contribute that factors addresses that research support to is aim The ductive healthissues. repro- and sexual adolescent on work WHO’s coordinating Health Adolescent and in Child of out Department carried the is with collaboration area this in Department the of work The n Dvlpet te eatet epnil for responsible department the Development, and SPECIFIC OBJECTIVESOFRESEARCH RESEARCH ACTIVITIES PROGRESS Annual Technical Report 2001 123 l Brazi aleza, Fort , tion) abor h, rt e-bi y (liv tics of ado- the two groups similar, were relatively more were pregnancy the continued who lescents likely to drop out of school than those who opted for abortion. Yet, those who underwent induced abortion of self- reported levels significantly lower esteem, a difference attributed in part to the cir- pregnancy unwanted the surrounding cumstances and abortion-seeking in a setting where abortion is legally restricted. While these differences con- tinued to be manifested at one they had post narrowed pregnancy, considerably: and five years about three-fifths ofyoungwomen in bothgroups reported high self-esteem, and about one-third still students (Figure 5.2). were environ- service the explored have studies Several ment, including the obstacles young people face in acquiring contraceptive and other sexual and reproductive health services, and the perspec- 2001

, Bruno Promoting sexual and reproductive health of adolescents health reproductive and sexual Promoting Z. tively, tively, reported the experience of forced sex. The perpetrators leading of sexual coercion reported by females a were boyfriend or a known (or at least identifiable) adult male residing in the Adolescent community. males also reported coercion by adult males in the cases a community boyfriend), and (and some reported in unwanted touching some a girlfriend peer. by or female A prospective study in Fortaleza, Brazil, explored the con- sequences of pregnancy in adolescence by comparing two groups of adolescents attending a group health facility—one receiving for antenatal care and the second postabortionfor The up adolescents at were one followed and year five care. years following the pregnancy. Preliminary findings related to differences in self-esteem and schooling status, although employment, relationships with partners, and contraception and subsequent fertility experiences will also be explored. Findings suggest that while sociodemographic characteris- P. Bayley, Bayley, P. ource: status of resolution of pregnanc S test if a boy is 2001

A. Source: Source: Ajuwon, researched researched sexual behaviours adolescents—sex for gifts among or money and among study qualitative a In sex. coerced out-of-school adolescents in the United Republic of Tanzania, both females and males acknowledged the practice of pro- viding gifts and money to female sexual young males reported Typically, partners. that they were able to convince partners to engage in sex only through promises They perceived money, of money or gifts. and not to romance, be the primary moti- vation underlying the consent to sex by although out-of-school Interestingly, girls. several females in the study edged that recent encounters sexual had acknowl- material they gain, by accompanied been prac- this to meaning different a attributed she reportedthat female single a Not tice. had consented to sexual intercourse out of material motivation. Rather, in group clar- participants female interviews, in-depth and discussions ified thatexchange of gifts did not necessarily entail a quid pro quo for sexual but favours, was a symbol of a partner’s love and gifts commitment; were sought to “.. A study on sexual coercion of adolescents in-school and in apprenticed Ibadan, Nigeria highlights of the a occurrence range of unwanted sex forced of experience and experiences, sex unwanted attempted touch, including unwanted among both female and male adolescents. As reported and worst apprentices clearly fared female in Figure 5.1 below, female students only slightly better, with about 40% expe- riencing unwanted touch, and 19% and 11%, respectively, reporting coerced sex. Notably, young males, albeit fewer, also reported the experience of unwanted sexual advances and 9% and 7% of male students and apprentices, respec- serious with his sexual proposal”, as a “..to strategy test if a her”. really loves boy 124 Annual Technical Report 2001 • • to members’ suggestions, have included: ers. Network activities, with the objective of being responsive research- individual to support technical providing of means forum for the exchange of ideas and information, as well as a a initiate to done was 2000. This in established reproductive was health and sexual adolescent on initiative research A network of researchers under supported the social science activities Network ambiva- youth. unmarried lence aboutserving an revealed perceptions and attitudes their ever, How- youth. unmarried to services other and contraceptive provideto and need information,counselling, the and norms sexual changing the theory, in recognized, settings four all and MyanmarThailand. in Laos, Providers countries: China, Asian four in studies from providers of perspectives the on findings selected summarizes 5.1 Table providers. of tives Section 5-Promoting sexualSection andreproductive healthofadolescents

phy ofrelevant materials; bibliogra- annotated the and initiative this by supported research ongoing of synopsis the both of updating the the maintenance of a limited documentation centre and centre documentation limited a of maintenance the Nort Lao a Republic nd province P hern eople's Democratic : Vi Thailand entiane pref ec

t ure

students uni adolescents ("..difficulttodealwithunmarriedboys w " b e u r better Providers in overnonf and one-third of formal discom Y r i t unmarried andareunwillingtospendtimeinde their tendenc mportant obstacles to their caremportant as facility-leve eported difficulty ineported discussing contraception with Unmarried f Unmarried appor hreatening provider attitudes. Providers experienc o mbarrassment as well as to a lack of cooperation from nmarried y nmarried ecause they do not listen to the advice. After getting ant to tell the truth"). ung clients' "confusion" about their own problems, ve rsity students , they return to their old beha t withy f ort . indealingwiththesexualissuesof outh, emale adolescentsaresh • attended by: and conducted were workshops analysis three bymid-2001, stage analysis the reached had researchers most As ings. find- of dissemination the and report-writing for plans, ysis stages of critical their anal- research to discuss and sharpen One goal of the network was to bring together researchers at workshopsAnalysis • • y o

to "lie" about events are perceived to be as ung clients. and acceptability; cultural and research their of focus matic the- the to according adapt to researchers for intended sexualbehavioursforadolescent naire) of study risk the question- survey a and guides interview in-depth sion, discus- group (focus instruments core of finalization the three resource persons in Jakarta, Indonesia; three resource personsinJakarta, with along coercion, sexual studying investigators three in investigators with, selected countries. meetings and to, visits project are unable toaccess; they material any with researchers provide to facilities

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Annual Technical Report 2001 125 ment. These These studies ment. were supported through the 1990s reported been earlier. and have the core instruments, the annotated bibliography, Paper Occasional the and research ongoing of synopsis the web Department’s the on available (all above mentioned site); DepartmentWHO’s of Child and Adolescent Health and Development published the proceedings of a meeting held in 2000 on the health and development needs of male adolescents and young men, including from the Department’s research initiative findings on adolescent health. and reproductive sexual Promoting sexual and reproductive health of adolescents health reproductive and sexual Promoting

Other reports and documents that were completed and dis- seminated in 2001 include: Operations research on improving reproductive reproductive on improving research Operations in French- health services adolescents for speaking countries African As described in earlier health services reproductive and improve project to evaluate reports, an operations research for adolescents has been ongoing in several French-speak- include to designed is project The countries. sub-Saharan ing three phases: (i) a baseline survey of adolescent users of health services and the quality of the of findings servicesthe from developed be to strategy intervention offered; (ii) an baseline survey to address the information needs of adoles- cents, train service providers or in modify order to existing make them more services youth-friendly; and (iii) a post- intervention survey to evaluate the intervention. While the • • In addition, a volume under preparation synthesizes most of the 45 major and presentations panel discussions at the international conference entitled “Adolescent Reproductive Health: Evidence and Programme Implications 2000. held in Mumbai, India in November Asia” for South The Department Health Research session: for Global Forum Forum Global the of meeting 2001 the at session a organized for Health Research that addressed adolescent sexual and reproductive health. The objective of this session, entitled “Preventing risky sexual behaviour among young findings from social and people: behavioural research”,was to high- light the evidence from hypothesized to developing play an important role countries in enhancing sexual on factors Presentations people. among young health and reproductive stand- double gender overcoming as issues such addressed ards and power imbalances, understanding young people’s lives and factors that constrain and facilitate sexual health, imparting of programmes skills and sexual- life effectiveness health- appropriate and timely to obstacles and education, ity seeking among young people. Presentations summarized the situation, identified gaps, and made recommendations attended well The session was and policies. programmes for discussion. a lively and generated African Journal of Reproductive Reproductive Health Matters: (i) the per- A synthesis of the findings of studies onyoung people was published as an Occasional Paper of the Depart- Findings from a study of dual-risk adolescents low-income in Jakarta, Indonesia pre- were perception among sented at a dissemination workshop by the researcher herself as well as by members of the team. youth research Reproductive Health. Reproductive presented were studies American Latin two from Findings at the Conference of the Scientific International Study ofPopulation, Union Salvador, Brazil,August for the 2001, and the International Conference on Unwanted Pregnancy and Induced Abortion Latin AmericaImplications for and the Caribbean, Cuer- and Public Health navaca, Mexico, November 2001. One study explored the perceptions of pregnancy among adolescents of dif- second the while Mexico, in status socioeconomic ferent adolescence in pregnancy of consequences the explored in Brazil. women young for The findings offour studies aswell as anoverview on young males in Africa, commissioned by ment, the Depart- have been published in the spectives spectives of adolescent boys on the risks of unwanted pregnancy and sexually transmitted infections in (STIs) Kenya; (ii) the perspectives of and adolescent males females on sexual coercion in Ibadan, sexual Nigeria; behaviour and contraceptive (iii) use among unmar- ried, young migrant women in China; and (iv) the views unmar- servicesfor contraception on parents Chinese of ried youth. The following findings from published four in studies been have fifteen Latin American researchers, as well as nine grant- nine as well as researchers, American Latin fifteen ees of The Ford Foundation (this workshop was ducted con- in Spanish and Portuguese Brazil); resource persons from and included 12 nineteen Asian, African and European researchers, and nine resource persons (this workshop was coorganized with the Institute for Population and Social Thailand). Research, in Bangkok, Mahidol University

• • • • • Findings of studies supported by the social science research science social the supported studies by of Findings jour- peer-reviewed in published being to addition In : initiative nals (Annex 3), findings from several projects supportedby this research initiative have been disseminated at seminars are as follows: Some highlights and conferences. Dissemination • • The above workshops were conducted with the support of The MacArthur Foundation, The Ford Foundation’s Jakarta Trust. Wellcome The and offices, and Rio de Janeiro 126 Annual Technical Report 2001 regulation”). fertility of methods of development the on “Research on ter chap- (forcontraceptionthe details,see anyhormonal using not women of group comparison a density,with mass bone on contraceptives oral combined and (NET-EN) enanthate of impact the on depot-medroxyprogesterone acetate (DMPA), years) norethisterone (42–49 women older and years) (15–19 young among study, longitudinal five-year a is This life.later in osteoporosis of risk greater potentially at women young put achievedand mass bone peak depress may tion, 15–19 acquisi- mass at bone for critical is that contraception period a age, of years hormonal of the use explores which Africa, to South extent Durban, in study ongoing An Study on bone mass and hormonal contraception assistance visitsfromstudycoordinators. technical included research. also activities Capacity-building the conducting in representativesengaged These then were Department. the by organized teams research for courses training research the in participated organizations youth of representatives example, For project. research operations this of principle underlying the been has building Capacity for French-speaking countries. ment and the local study team. Depart- These tools are now this available with collaboration in Development and Health Adolescent and were Child of workshops Department WHO’s by training conducted related and tools activities, of these development for the to contributed also project The of school-based family-life implementation educationprogrammes. the supporting and designing and lors; counsel- peer for activities of, development issues; and in, health training adolescent on personnel health of training interventions: of types three in engaged was team study the reports. earlier in presented were findings Selected youth.for services health reproductive of study a in Mexico) and Kenya Bangladesh, with (along Health” Reproductive in “FRONTIERS project USAID-funded the in included was Senegal in centre the collaboration, Programme’s the With preparation inCôted’Ivoire andGuinea. under been have interventions levels, national and local at and the dissemination of findings from the formative research 2000 in surveys baseline of eroon. completion Followingthe In 2001,researchactivitieswere initiatedinBeninandCam- each. teams and the active of participation youth representatives in unique feature is the constitution of multidisciplinary research ing, funding for project each is country being raised locally. A strengthen- capacity research for support provides and tive Programme is facilitating and coordinating this regional initia- Section 5-Promoting sexualSection andreproductive healthofadolescents In 2001, In sexual andreproductive health scienceSocial research initiative onadolescent sexual activity. mortality, low contraceptive prevalence, and early initiation of infantand maternal levelsKenyaof high byof characterized area an in females adolescent among abortion, induced ing behaviour in the context of pregnancy and outcomes, includ- health-seeking explores study Another females. adolescent sexualto reproductiveand unmarried among health-seeking this is a study in Brazil north-east that explores the obstacles marriage. Complementing early by marked setting a ladesh, Bang- Dhaka, of slums the in conducted study a exploredin are adaptations programmatic special for implications females and adolescent married of needs health-seeking The ity toexercise choice. abil- behavioursthe and risk-taking upon nerabilityimpinges protectivecontextualwaysfactors,and vul- which the in and risk the explore will studies Both Africa. South in conflict of parts of Colombia in 1999, and those growing up in situations vulnerable settings: those displaced by an earthquake that hit Twofocusbehavioursstudies in other adolescents of risk on sexual also experience sexual andthecorrelatesofrisky behaviour. but health, sexual surrounding norms and of, awareness only boys,not adolescent of study munity-based second in the Islamic Republic of Iran that explores, in a com- secondary school-going female and male adolescents; and a among correlates their and attitudes and awareness,norms health reproductive explores that Republic Arab Syrian the Eastern WHO in the initiated—one be will Region. TwoMediterraneanstudies in conducted been have adolescents Few studies on sexual and reproductive health issues among ture ontheother. cul- youth and popular the and hand, one the on leadership sexualityoffered conservativebythe and church political the on messages conflicting the with deal adolescents which in ways the examine will Poland in earlier Investigatorsadolescence. in observed factors situational the by explained can be follow-up the at observed behaviours which to extent the behaviours,and risk their explores and period 18-month an over years 12–16 aged adolescents young follows that study prospective a conduct will India Goa, in researchers severalinclude features.studies unique These Forexample, A total of nine new projects were supported in nine countries. cratic Republic, Myanmar, Thailand and Viet Nam. This ini- Nam. This Viet and Myanmar,Thailand Republic, cratic Demo- People’s Lao the (YunnanProvince), China namely, region, Mekong Greater the of countries five city the of major each in one in ongoing is initiative research regional A Mekong region health needsofyoung migrants intheGreater Regional research initiative onreproductive NEW PROJECTSNEW INITIATED DURING2001 Annual Technical Report 2001 127 Condom standards and standards Condom Transforming health systems: gender systems: health Transforming Guidelines Guidelines on the medical eligibility criteria planning for family provide guidance on the adolescents, as do other issues tools in family planning, advo- specificto unwanted of prevention the on guidelines materials, cacy pregnancies and unsafe abortions, and technical and abortionof management com- on managerial guidelines plications. Guidelines on the management of management STIs of STI cases address and devote a the section to the special needs of adolescents. developed Departmentalso The specifications and guidelines on condom programming, with particular on the needs of adolescents. emphasis Promoting sexual and reproductive health of adolescents health reproductive and sexual Promoting LINKS WITH THE WHO DEPARTMENT OF CHILD WHO DEPARTMENT THE WITH LINKS

AND ADOLESCENT HEALTH AND DEVELOPMENT AND ADOLESCENT HEALTH The Department continues to interact with WHO’s Depart- ment of Child and Adolescent Health and Development in several activities. There is continuous dialogue towards a consensus on research and other Department priorities.participated in a priority-setting meeting organ- Staff of this ized by the Department of Child and Adolescent Health and to Development obtain the perspectives of WHO all relevant Departments, and provided extensive comments and sug- gestions on the documents produced on adolescent sexual and Once reproductive health again, issues. there has been collaboration in many areas—on the operations project research assessing reproductive health services for adoles- cents in French-speaking sub-Saharan countries, identification on of the general research prioritiesthe review of proposals as and well selection of as in specific research • • • The training curriculum training The and rights in reproductive health, in developed collaboration with partners, provides support for sup- This adolescent sexual levels. national at programming and health reproductive port includes the presentation of case lescent sexual examples and of reproductive ado- health issues in sensitize order participants to to address being currently is adolescent course The services. needs and programmes their within run annually in five countries/regions and the curriculum is into Chinese and Spanish. being translated A guide policy-makers pocket and for programme managers This is pocket guide under draws on development. the over- view document entitled motherhood safe Advancing through man- national-level assist will and 2001) (WHO rights human agers to address the key rights issues for adolescents and other special groups. of appropri- health education, provision sexual for Strategies health sexual age-appropriate and services health sexual ate addressed, be will strategies communication and information in an upcoming consultation and subsequent health”. “Promoting sexual publication, all women who are, or NORMS AND TOOLS NORMS AND Neisseria gonorrhoeae, Chlamydia trachomatis, Tri- trachomatis, Chlamydia gonorrhoeae, Neisseria Essential care practice guides relating to maternal and newborn health describe a minimum set tions for of antenatal, interven- delivery, newborn, postpartum and postabortion care, in normal complications situations, and basic emergency Although care. this for common material (chart booklets, job aids, eventually manuals and training material) targets recently have been, pregnant, they devote specific atten- specific devote they pregnant, been, have recently tion to the needs of adolescents. These field-tested in 2001. guides were

Specific objectives • Every tool developed by the Department for the promotion of promotion the Departmentthe for by developed tool Every health reproductive includes a special section on the unique example: For needs of adolescents. Tools developed Tools In the of development norms and tools intended to enhance the reproductive health of individuals in general, it is recog- nized that adolescents are not only more likely than adults to experience risky outcomes, but may also require different approaches in terms of service and care provision. These issues are highlighted in the guidelines and other tools for programming and capacity-building that have been devel- oped by the Department. Other norms and tools relating to adolescent sexual and reproductive health needs are devel- DepartmentWHO’s oped of by Child and Adolescent Health and Development. Studies are being undertaken in Mongolia in reports response from to providers about the unusually lower high genital tract levels infection among of pre-adolescents. Symp- toms may have been observed the explores study by One mothers. their the by perceived or adolescents selves, them- perceptions of about 500 mothers of these pre-adolescents concerning vaginal discharge in general and their ter’s daugh- complaint in particular. A and second discharge of presence the for study pre-adolescents 500 about will examine any signs of lower genital tract infection, and screen speci- for mens and anaerobes. Candida spp. chomonas vaginalis, Research on pre-adolescent girls reporting girls on pre-adolescent Research symptoms vaginal tiative tiative aims to assess the reproductive health needs growing but vulnerable and marginalized of subpopulation, i.e. a The young study migrants. explores risk and health-seeking addi- In needs. information and service as well as behaviours tion to enhancing knowledge about young migrants in this region, this intends initiative to strengthen research capacity networking. through intraregional 128 Annual Technical Report 2001 n ohr udlns f h Integrated the of guidelines other and care newborn and ing the includ- tools and developmentthe norms on of and projects, Section 5-Promoting sexualSection andreproductive healthofadolescents Essential care practice guide for pregnancy, childhood management andcareofadolescents. the special measures that health workers need to take in the incorporate Childbirth—to and Pregnancy of Management Annual Technical Report 2001 129 Promoting sexual and reproductive health of adolescents health reproductive and sexual Promoting See Annex 1 of the “Research on users’ perspectives” in Section 1 “Promoting family planning”. “Promoting family in Section 1 perspectives” “Research on users’ 1 of the See Annex Annex 1 Annex HEALTH REPRODUCTIVE ON RESEARCH AND OPERATIONS FOR SOCIAL SCIENCE PANEL SPECIALIST IN 2001 130 Annual Technical Report 2001 Zulaela, DrSardjitoGeneral Hospital,GadjahMada University, Yogyakarta, Indonesia Zheng Zhenzhen,Instituteof Population Research, Peking University, Beijing,China Zhang Liying,NationalResearchInstitutefor Family Planning, Beijing,China Shi-Zhong Wu, SichuanFamily PlanningResearchInstitute, Chengdu,China Mino Ariel Worobiej, (CERI),Asunción,Paraguay CentrodeEstudiosRurales Interdisciplinarios Supra DrSardjitoGeneral Hospital,GadjahMadaUniversity,Wimbarti, Yogyakarta, Indonesia of Health, Nilar ofHealth,Ministry Tin, Department Yangon, Myanmar Arunrat Tangmunkongvorakul, The Centerfor Public HealthResearch,ChiangMaiUniversity, ChiangMai, Thailand Anand Tamang, Centrefor ResearchonEnvironmental HealthandPopulation Activities(CREHPA), Kathmandu,Nepal Vanphanom Sychareun,Faculty ofMedicalSciences, NationalUniversity ofLaos, Vientiane, LaoPeople’s Democratic CentrodeEstudiosSociologicos, ElColegio deMexico,Claudio Stern, Mexico City, Mexico R Savithri, MamtaHealthInstitutefor MotherandChild, New Delhi,India Marcela SanchezBuitrago, PROFAMILIA, Bogotá,Colombia Ramiro, andSciencesClinicalEpidemiologyUnit,UniversityLaurie ofthePhilippines, CollegeofArts Manila,the Susan Pick, InstitutoMexicano deInvestigacion deFamilia yPoblación, Mexico, DF, Mexico PeredaCristian Feliu, University ofChile, Santiago, Chile Manuela dela Pena Vega, deInvestigacion Asociacion Multidisciplinaria yDocenciaenPoblación (AMIDEP),Lima,Peru Sevkat BaharOzvans, HacettepeUniversity MedicalFaculty, Ankara, Turkey ofSociology, Nzioka,Department Charles University ofNairobi,Kenya Nnko,Soori NationalInstitutefor MedicalResearch,Mwanza, UnitedRepublic of Tanzania Alejandro AndresMoyano, CentrodeEstudiosPoblación (CENEP),BuenosAires, Argentina Laurike Moeliono, Centrefor SocietalDevelopment Studies(CSDS),AtmaJaya CatholicUniversity ofIndonesia,Jakarta, Patricia Merlo, InstitutoMexicano deInvestigacion deFamilia yPoblación, AC, Mexico, DF, Mexico Sunil Mehra, Mamta HealthInstitutefor MotherandChild,New Delhi,India Maung Toe, ofMedicalResearch, Department Yangon, Myanmar Cecilia McCallum,Federal University of Bahia,Salvador, Brazil Chaohua Lou,ShanghaiInstituteofPlannedParenthood Research,Shanghai,China Ko Ko Zaw, ofMedicalResearch, Department Yangon, Myanmar Elena Hurtado, CEISAR,GuatemalaCity, Guatemala Amir Hodzic, Centerfor EducationandCounsellingof Women (CESI),Zagreb, Croatia Caridad Teresita Gracia-Alvarez, NationalInstituteofEndocrinology, HospitalFajardo, Havana, Cuba Gonzalez Ana Cristina Velez, SISMA-MUJER,Bogotá,Colombia Helen Gonçalves, Universidade Federal dePelotas, RioGrande doSul,Brazil GomesDosAnjos,José Carlos Universidade Federal doRioGrande doSul,Porto Alegre, Brazil Gao Ersheng,ShanghaiInstituteofPlannedParenthood Research,Shanghai,China Ana Paula dosReis, Federal University ofBahia,Salvador, Brazil Cui Nian,SichuanFamily PlanningResearchInstitute, Chengdu,China Zenilda Brazil Fortaleza, Vieira Bruno,EscolaAssisChateaubriand, Maternidade deMedicinaSocial,UniversidadeDominique Behague, Federal Departamento dePelotas, RioGrande doSul,Brazil Patsy Bailey, Family Research HealthInternational, Triangle Park, NC, USA Luisa Alvarez Vazquez, National InstituteofEndocrinology, Havana, Cuba Ayse Akin,HacettepeUniversity MedicalFaculty, Ankara, Turkey Ademola J. RegionalHealthEducationCentre,Ajuwon, African University ofIbadan,Nigeria Akosua Adomako Ampofo, Studies, InstituteofAfrican University ofGhana,Legon,Ghana Health Principal investigators for science thesocial research initiative onAdolescent Sexual andReproductive SCIENTISTS IN2001 Annex 2 Section 5-Promoting sexualSection andreproductive healthofadolescents Republic Philippines Indonesia Annual Technical Report 2001 131 3 8 50 29 10 19 10 Totals

2 2 2 % of total

1 1 1 Number Developed countries Developed , Argentina

Promoting sexual and reproductive health of adolescents health reproductive and sexual Promoting % of total

Countries in transition Number

6 98 56 20 36 20 16 % of total

3 8 49 28 10 18 10 Developing countries Developing Number

All Women from: AFRO AMRO EMRO EURO SEARO WPRO

Philip Guest, The Population Council, Bangkok, Thailand Council, Bangkok, The Population Philip Guest, Brazil Rio de Janeiro, Maria do Estado do Rio de Janeiro, Luiza Heilborn, Universidade Delhi, India Council, New The Population Dale Huntington, Brazil Rio de Janeiro, Foundation, The Ford Leal, Ondina Fachel Health International United Kingdom (Europe), Edinburgh, Erin McNeill, Family Orleans, LA, USA New Medicine, Tropical Health and School of Public University Tulane Bob Magnani, Brazil Rio de Janeiro, do Rio de Janeiro, Federal Cecilia de Mello e Souza, Universidade Argentina Buenos Aires, Centro de Estudio de Población, Edith Pantelides, India Pune, Pelto, Pertti Thailand Nakorn Prathom, and Social Research, Mahidol University, Population Institute for Chai Podhisita, Cuba Havana, Vascular, Instituto Nacional de Angiologia y Cirugia Seuc, Armando H. Brazil Rio de Janeiro, Foundation, The Ford Luiza Souza, USA DC, Washington, Council, The Population Project, The FRONTIERS Townsend, John Australia Canberra, National University, The Australian Varga, Christine Thailand Nakorn Prathom, and Social Research, Mahidol University, Population Institute for Yoddumnern-Attig, Bencha Wendy Baldwin, National Institutes of Health, Bethesda, MD, USA National Institutes of Health, Bethesda, MD, Baldwin, Wendy USA California, Bott, Los Angeles, Sarah Jakarta, Indonesia Foundation, Meiwitta Budharsana, Ford Niteroi, Brazil Fluminense, Federal Universidade Zairo Cheibub, London, United Kingdom Medicine, Tropical John Cleland, London School of Hygiene and Council, Nairobi, Kenya The Population Annabel Erulkar, Mexico DF, Mexico, El Colegio de Mexico, y de Desarrollo Urbano, Brigida Garcia, Centro de Estudios Demograficos Monica Gogna, Centro des Estudios de Estado y Sociedad, Buenos Aires Other scientists Mariame Ba, University Hospital “Le Dantec”, Dakar, Senegal Dakar, “Le Dantec”, Hospital Mariame Ba, University Guinea “Donka”, Conakry, Hospital University Mamadou Baldé, Cotonou, Benin CERRHUD, Virgile Capo-Chichi, Senegal Dakar, dans le scoutisme, Coordonnateur du projet EVF Diallo, Ibrahima Abidjan, Côte d’Ivoire Health, Public National Institute of Diomandé Gondo, Cameroon Yaoundé, I, Yaoundé of University Robinson Mbu, Principal investigators for the Team on Technical Support Countries to Technical on Team the for investigators Principal Annex 2 (continued) Annex IN 2001 SCIENTISTS 132 Annual Technical Report 2001 WPRO SEARO EURO EMRO AMRO AFRO from: Women All Section 5-Promoting sexualSection andreproductive healthofadolescents Number Developing countries 10 16 6 9 1

% oftotal 26 39 43 70 4

Number Countries intransition Countries

% oftotal

Developed countries Number 4 1 2 4 7

% oftotal 17 17 30 4 9

Totals 13 14 23 6 1 2 1 Annual Technical Report 2001 133 Population Research, Population Reproductive Health Reproductive African Journal Health of Reproductive Promoting sexual and reproductive health of adolescents health reproductive and sexual Promoting Chinese Journal of Population Science, 2001, 2:67–72. Chinese Journal of Population , Salvador- Conference Population XXIV General Book of abstracts. Reproductive Health Matters, 2001, 9:118–127. Reproductive Sexual relations among young people in developing countries: evidence from evidence countries: people in developing among young relations Sexual African Journal Health (in press). of Reproductive African Journal Health (in press). of Reproductive , 2001, 3:24–29. Information Population African Journal Health (in press). of Reproductive Chinese Journal of Family Planning, 2001, 9:223–225. Chinese Journal of Family AfricanHealth (in press). Journal of Reproductive , 2001, 1:19–25. Information Population Reproductive Health Matters, 2001, 9:128–136. Reproductive Tu X, Peng M, Lou C, Gao E. Attitudes of family planning workers toward providing contraceptive services for unmarried young unmarriedyoung services for contraceptive providing toward workers planning family of Attitudes E. Gao C, Lou M, Peng X, Tu adults in 8 settings in China. and focused on boys health research and programs and reproductive of sexual a review fifty percent: The forgotten C. Varga Africa. in sub-Saharan men young use among unmarried, young and contraceptive behaviour Sexual et al. Lou C, Zhao D, Y, Yang Zheng L, Y, Zheng Z, Zhou cities in China. in five workers migrant women Cui N, Li M, Gao E. Views of Chinese parents on the provision of contraception to unmarried youth. to unmarried of contraception youth. of Chinese parents on the provision Views Cui N, Li M, Gao E. migratory workers. female health status and needs of urban young Reproductive Gao E. Zhao S, Lou C, of men and women. perspectives protection: Obstacles to negotiating dual P. Maharaj among out-of-school adolescents in Magu District: behaviour Pre-marital sexual M. G, Urassa Mwaluko Chiduo B, S, Nnko patterns and meaning. motives, some among adolescents: infections transmitted pregnancy and sexually Dealing with the risks of unwanted Nzioka C. from Kenya. experiences of Nepal. men in border towns and risk perceptions among young behaviour Sexual Puri M, Shrestha D. A, Nepal B, Tamang 195–200. Population Journal, 2001, 16: Asia-Pacific Brown AD, Jejeebhoy SJ, Shah I, Yount KM. Yount Shah I, SJ, Jejeebhoy AD, Brown WHO/RHRR/01.8. 4, 2001, Occasional Paper WHO case studies. Matters, 2001, 9:137–145. 2001, 25:61–64. (in press). Kenya. infections: transmitted on the risks pregnancy and sexually of unwanted of adolescent boys Perspectives Nzioka C. Health Matters, 2001, 9:108–117. Reproductive and adolescent pregnancy in the lives relations, sexual Gender stereotypes, Y. A, Rodriguez Garcia E, Pereda Stern C, in Mexico. groups sociocultural of different of youngsters 219 p. 2001, IUSSP, 18–24 August Bahia, Brazil, and induced behavior and opinion on premarital sexual attitude toward planning workers’ Family X, Gao E. Tu Lou C, B, Wang abortion. of urban and practice knowledge contraceptive behaviour, Sexual et al. Lou C, Zhao D, Y, Yang Zheng L, Y, Zheng Z, Zhou cities in China. in five workers migrant unmarried, female service about the contraception planning workers delivery Analysis on the attitude of the family X, Gao E. Tu B, Wang Zhou L, to the unmarried youth. Bayley P, Bruno Z. Consecuencias del embarazo y aborto entre las adolescentes del nordeste de Brasil: 1 año y 5 años y abortoConsecuencias del embarazo adolescentes del nordeste de Brasil: entre las Bruno Z. P, Bayley Pregnancy and Induced Abortion on Unwanted Health Presented at the International and Public Conference después. Mexico. 2001, Cuernavaca, Latin America and the Caribbean, 12–14 November Implications for Ajuwon AJ, Oladapo Olley B, Akin-Jimoh I, Akintola O. Experiences of sexual coercion among adolescents in Ibadan, Nigeria. coercion among Experiences of sexual Akin-Jimoh I, Akintola O. B, Oladapo Olley AJ, Ajuwon AfricanHealth (in press). Journal of Reproductive Ajuwon AJ, Akin-Jimoh I, Oladapo Olley B, Akintola O. Perceptions of sexual coercion: learning people in Ibadan, young from coercion: of sexual Perceptions Akintola O. B, Akin-Jimoh I, Oladapo Olley AJ, Ajuwon Nigeria. Adomako Ampofo A. “When men speak women listen”; gender socialisation and young adolescents’ attitudes to sexual and attitudes to sexual adolescents’ and young gender socialisation listen”; “When men speak women A. Ampofo Adomako issues. reproductive Annex 3 Annex IN 2001 PUBLICATIONS 134 Annual Technical Report 2001 Annual Technical Report 2001 135 Section 6 reproductive health reproductive Gender and reproductive rights in rights Gender and reproductive 136 Annual Technical Report 2001 • inthisareaaimsto: oftheDepartment The work Objectives mote genderequityandreproductive rights. pro- to projects specific of the number a out carries goals,Department these to explicitly contribute to order In g). 107 paragraph (Beijing+5 services health women’s of delivery the in standards gender-sensitive and to professional conform ethical, workers and services health all that ensure to mechanisms, enforcement and regulatory strengthening or forexample,establishingbyrights, human of promotion and protection the 40); and paragraph (ICPD+5 women of rights human the of protection and promotion the for indicators on bodies Nations United relevant of work the in issues health reproductive and sexual of incorporation the 39); paragraph (ICPD+5 manner comprehensive and systematic a in equity and equality gender achieving and promoting at aimed ures respectively.2000, included: meas- future Keyforthe issues in the five-year reviews of both conferences held in 1999 and reinforced were agreements rights. These human of tection pro- and promotion the as programmes,well and as policies health reproductive in equality and equity gender promoting on Conference WorldWomen (FWCW, 1995) Fourth both clearly emphasized the need for the and 1994) (ICPD, ment Develop- and Population on Conference International The Section 6 - Gender andreproductive 6-Gender rights inreproductiveSection health

cal support; techni- and programming research, health reproductive nisms mecha- for promoting gender equality and human rights in and strategies evaluate and develop identify, INTRODUCTION Gender andreproductiveGender rights in reproductive health J. Cottingham, A. Hilber,Martin M. Colombini from different disciplinesandregions. experts external independent, of group a (GAP), Panel sory Advi- Gender the by work this in guided is Department The n waee pbi hat itreto i big proposed, being is intervention health public whatever ing surround- policies and laws the through protected are rights people’s that ensure to action concrete taking corollary, the negativeshownto contributebeen to outcomes. health Thus also women—has against violence of perpetrators of nation condem- social and femalepunishment mutilation,of genital and policies which protect human rights—such as prohibition deaths. maternal Geneva, WHO, 1989). The absence of lawsS, Armstrong and E (Royston health on impact negative a nondiscrimination—have to right their violating thus childbirth, and pregnancy forto example,relating those need, women only which services health to access of tion laws which violate human rights—such as the specific restric- that show to evidence explicitly.is or There implicitly either if national achievedlaws and be policies reflect a only recognition of these can rights, health reproductive and sexual to The respect, protection and fulfilment of humanrights related • • Specific objectivesSpecific

ASSESSMENT OFLAWS ANDPOLICIESIMPACT- n hmn ihs rnils r itgae it the into integrated are Department’s work. principles rights human and equality and equity gender of promotion the that ensure andpromotegenderequityequality; rights and human fulfil and protect respect, policies and grammes countries support to ensure that reproductive health pro- ING REPRODUCTIVE HEALTH Preventing Annual Technical Report 2001 137 Gender and reproductive rights in reproductive health in reproductive rights Gender reproductive and AND RIGHTS IN REPRODUCTIVE HEALTH IN REPRODUCTIVE AND RIGHTS NORMS AND TOOLS FOR ADDRESSING GENDER TOOLS NORMS AND Specific objectives/targets Mozambique, Mozambique, an assessment tool has been developed to assist a national multistakeholder team to review laws, pol- icies and health system considerations against the health outcome Organized indicators. by internationally major rec- ognized human rights bodies such as the Right to Health, the maternaltool frames and perinatal mortality and morbid- ity issues in terms of the country’s past its performance plans and to respect, protect and fulfil itsto treatyensure, for instance, the obligations right to access basic and emer- gency obstetric care services. In addition to the review and and use the for developed been has methodology a analysis, analysis. implementation of the The assessment tool will be applied in Mozambique in the next biennium. National and provincial workshops held will to discuss the findings and identifykey be interventions to be undertaken. The process will also assist the Ministry can in that indicators of use the institutionalizing and identifying better measure its efforts to respect, protect and fulfil their human rights obligations associated with maternal and peri- natal mortality reduction. In this area of work, the Department focuses on tools which will provide guidance for: (i) understanding repro- the and sexual to relate they as depth rights human of challenge and ductive health, including specific toolsequity related and equality, to gender and (ii) specific gender- and rights- Growing Growing out of the pilot project in Mozambique is the need to develop ways of evaluating the added value of using rights-based approach, a beyond the moral In imperative. the short run, it is unlikely that this approach can demonstrate there are any impact on health outcomes However, as such. extent the as such measured, be could that dimensions other to which processes are participatory, ensure nondiscrimina- of all accountability, for mechanisms by governed are or tion, which are necessary under human rights principles. The Department has convened a small and repro- sexual such measurements for order to elaborate working group in ductive health. This group will review measuring sexual and the reproductive human rights approaches and iden- to tify selected and specificrepro- into rights indicators human integrating forof success the measuring use evaluating/ in ductive health. The deliberations of this working group will be fed into the broader WHO wide-level discussion on indi- cators for the right to health, and further, into a larger meet- rights partfirst the reproductive on 2002 of for scheduled ing within the and Family Community Health (FCH) cluster as a whole. Indicators for measuring/evaluating rights-based rights-based measuring/evaluating for Indicators approaches develop develop evaluation mechanisms including indicators for measuring the impact of integrating human rights-based approach). rights (a elaborate elaborate and implement a methodology for integrating human rights into aspects of reproductive health inter- and country through ventions pilot-projects;

In order to bring a human rights perspective into the goals and objectives of the Making Pregnancy Safer initiative in In 2001, the WHO Making Mozambique sought to a integrate human rights perspective Pregnancy Safer initiative in into the national maternal and perinatal mortality and mor- bidity reduction strategy and Through operational con- plan. Safer Pregnancy Making WHO the partnership, and sultation succeeded in securing the commitment of the Ministry Team of Health and the interest of its principal implementing part- ners in reproductive and family health—the United Nations Population Fund (UNFPA), the United Nations Fund (UNICEF), Children’s the World Bank and a number of bilateral and agencies—to the improve review legal, policy and regu- latory aspects of the operational plan from a human rights perspective. This interest and commitment translated into a Making Pregnancy Safer national workplan that will use human rights methods to identify, support and develop as necessary, the principles of the Making at countryglobal initiative level. Pregnancy Safer The Making Pregnancy Safer and human rightshuman pilot-project, and Safer Pregnancy Making The in conceived collaboration with the Harvard School of Public Health’s François Xavier Bagnoud Center for Human Health Rights, is an and effort to bring human rights principles into maternal and perinatal mortality reduction activities on a national The scale. hypothesis is that the value added by such efforts at the national level will be an increased multi- maternalto commitment political and understanding sectoral and perinatal mortality improved by reduction, demonstrated legal and normative standards access for and care preg- for nant women and newborns. At the provincial level, adding human rights help may to better target marginalized popula- tions with specific interventions and services more appropri- more equitably. ately and, ultimately, Integrating human rights into Making into human rights Pregnancy Integrating a pilot project in Mozambique Safer: Progress • • could be expected to have This is a one important reason to use positive an explicit rights-based impact on health. approach to health The interventions. Department is there- fore working both at the country and the international level to integrate human rights and examine laws related to and different aspects policies of reproductive health, in order to help identify areas where and such policies laws might be The health. sexual and reproductive improve help to adapted this area of work of are as follows: objectives 138 Annual Technical Report 2001 fessionals. pro- health of sexuality:training human the in treatment and entitled WHO a Technical in Report 1975 to back dates health” of “sexual definition official existing only The Technical monograph onsexual health development New work onnorms/tools under undertaken currently inpreparation andwillbepublished in2002. user-friendly,a one, technical “pocket-guide”-style is version the and lengthy a of is document many the Since for area. the document in activities reference a as used being is and Department, the of partners the all to distributed been has It motherhood. safe of cause the advance to approach logues on the development and application of a human rights human rights principles, and to national and international dia- with compliance promote to initiatives national to contribute can be applied to advance safe motherhood. It is intended to treaties rights human international and laws national other and constitutional national in established long rights, human how explore to is document discussion this of purpose The Department. the by Paper Occasional an as Canada, published was Toronto, Toronto, of University the from lawyers rights human international four by prepared document, This Advancing through safe motherhood humanrights Norms/tools developed health. reproductive and sexual to rights human of application the monitoring for system rights human UN the with laboration col- on focuses also health. sexualIt as such issues related Section 6 - Gender andreproductive 6-Gender rights inreproductiveSection health Education abortion, abortion, HIV/AIDS and sexually transmitted infections unsafe mortality,(STIs), maternal particular, in and, health ductive Rights Cultural repro- in indicators and trends and global on focusing (CESCR), Social to Economic, one on and Committee (HRC) the Committee Rights Human the to one 2001, in sessions briefing two held OHCHR, within working UNFPA-secondedthe with officer together Department, The information onspecificcountries. pertinent of provision timely the and health, sexual and reproductive in on key issues UNFPA sessions and briefing of form WHO the in Bodies, Treaty between collaboration closer things, and sexual health. The meeting recommended, among other andstrengtheningofreproductivezations), inthemonitoring organi- nongovernmental and agencies (UN actors relevant other with conjunction in TreatyBodies,by used be to gies meeting in 1996, and to discuss further measures and strate- previous the since progress the assess to was purpose The and sexual health”, organized jointly by UNFPA and OHCHR. reproductive to rights human of application “The on meeting a to substantially contributed Department the 2001, June In tees. commit- rights human various the by up taken adequately are health sexual and reproductive that ensure to (OHCHR) Rights Human for Commissioner High the of Office UN the with closely worked has year,Department past the the Over rights framework norms andstandards withinthehuman support UN HumanRights Treaty Bodies: collaboration to ment willprovide feasible technicalsupport. Depart- the biennium, next the health. Oversexual promote to strategies of content regional to appropriate activities the regional elaborate of series a to lead to likely are ment docu- the of finalization and consultation international The health withinthesector. sexual of health and on definition effective a strategies for on promoting sexual reached be will consensus it that hoped where is 2002, January in consultation international an at debated be will document draft Offices. The Regional with WHO 2001 in held discussions round-table regional four at debated and raised issues key with along monograph, draft commissioned of a into incorporated being series is backgrounddocuments regional a from Information Sexology. of Association Worldthe with collaboration in health sexual on monograph new a elaborating therefore is Department The developments. technical and strategic document that would well reflectglobal these new a for need urgent an clearly is functions—there dys- sexual some overcome to medications and regulation, fertility and contraception of methods safe and effective of development the violence, sexual including violence of tion 25 years—the emergence of the HIV pandemic, the recogni- past the over developments major the of view in However, Annual Technical Report 2001 139 Gender and reproductive rights in reproductive health in reproductive rights Gender reproductive and encourage and give technical support to the centre in the in centre the to support technical give and encourage coun- for course the runcountry to other one and Sudan tries of their region; already centres those to support technical continued give and running as requested; the course, develop short-course adaptations for use with specific countries or organizations (as described below).

Women’s Women’s Health Project (South Africa) ran its fifth were course, courses three All curriculum. revised the using time this support technical to partgive As to plans its of received. well new regional centres, the Department sponsored three staff from University in the Khartoum,Women’s Afhad the Sudan to participate in the southern African course. It is possible that the course will be run in southern African countries over the next biennium. CEDES and YRHRA both expect to run the course in 2002. The curriculum will be disseminated in a targeted manner through WHO Regional Offices, collaborating centres and other training institutions who have already year. the during distributed brochure a expressed to response in interest an A summary of the contents, including the module briefs, will site. web be put on the Department’s biennium the Department the next plans to: Over The Department is being increasingly solicited for technical support to short courses in gender issues and training rights one-day a 2001, In health. reproductive and sexual to related workshop was conducted with the International Confedera- Zimbabwe. Harare, in Congress Africa (ICM) Midwives of tion ICM will continue this series and host another ence workshop on violence in 2002. pre-confer- • • • in on gender and rights Short courses training health reproductive work with the Department of Child and Adolescent Health Adolescent and Child of Department the with work and to Development introduce issues related to adoles- cent sexual and reproductive health into their training activities on the Convention on the Rights of the Child, WHO Regional Offices. which are being run with conduct briefing sessions sexualon Bodies; and reproductive Treaty the other health for fea- the Offices Country and Regional WHO with explore sibility of supporting specific countries in implementing Treaty from CESCR or “concluding other comments” the and Bodies; continue continue to coordinate with other relevant departments in WHO, the to WHO UNFPA and Offices Country and Health Regional WHO point, and Human Rights focal ensure provision of information about sexual and repro- ductive health for a few selected countries reporting to CESCR; TECHNICAL COOPERATION WITH COUNTRIES TECHNICAL COOPERATION

In 2001, the Key Centre (KCWHS, and Australia) for the Centre for African Stud- Family Women’s Health The time. third in the for course the ran Society each Kenya), (CAFS, ies During 2001, the 490-page training curriculum was reviewed reviewed curriculumDuring training 490-page the was 2001, by independent experts, refined, CD-ROM A edited 2001. of andend the at finalized. published The was version English version will also be made Mandarin available. and Spanish versions are being translated and adapted regional by collaborating institutions, two the Reproductive Yunnan of Centre the the and China) (YRHRA, Association Research Health for the Study of State respectively. These and translations Society are (CEDES, being Argentina), financiallyThe sup- portedDepartment,by the China) of case the (in by and Foundation. Ford The initiative to elaborate this 3-week training curriculum is a curriculumis training 3-week this elaborate to initiative The collaborative effort WHO, the between Xavier François Bag- noud Center for Health and Human Rights (Harvard School Health Women’s the and USA), MA, Boston, Health, Public of Project at the University of Witwatersrand (Johannesburg, South Africa). theBriefly, initiative aims tobuild institutional capacity in training centres around the world to offer region- ally-appropriate, high-quality training in gender and rights in reproductive health, covering aspects of research, service delivery and policy development. • • • • Over the next biennium, the Department biennium, the the next will: Over adolescent adolescent sexual and reproductive elaborate to agreement an in health, resulted These women. against and violence years. two next the over to be taken specific actions Training curriculum on gender and rights in and rights on gender curriculum Training health reproductive 140 Annual Technical Report 2001 ic 20, h Dprmn hs en mme o the of member of rights and health reproductive a and sexual on group study been has Department the 2000, Since for plans now are training coursesatthenationallevel.similar short There contribute. to invited was ment Depart- The countries”. developing in position the to ence refer- special with services, health reproductive providing and sexual to approach rights-based and ethical an moting rights—pro- human and ethics “Medical on associations ical conducted a consultation for representatives of national med- (CMA) Association Medical Commonwealth the October, In Section 6 - Gender andreproductive 6-Gender rights inreproductiveSection health gender and rights inreproductivegender andrights andsexual health. on courses training national-levelshort of running and ment develop- the on FIGO and CMA ICM, to support technical Over the next will continue biennium, the to Department give projects andregionalworkshops. country-level to support technical provided has and (FIGO) Obstetrics and Gynaecology of Federation International the Annual Technical Report 2001 141 7 2 2 2 2 2 10 Totals

20 20 10 10 % of total

2 2 1 1 Number Developed countries Developed Gender and reproductive rights in reproductive health in reproductive rights Gender reproductive and

10 10 10 % of total

1 1 1 Countries in transition Number

70 40 20 10 20 20 % of total

7 4 2 1 2 2 Number Developing countries Developing Members

Women Women

) (Chairwoman London, United Kingdom Health Matters, Reproductive Marge Berer, Chile (ICMER), Santiago, Medicine Institute of Reproductive Soledad Diaz, Chilean Myanmar Yangon, Ministry of Health, Department of Health, Thein Htay, Thein India Udaipur, Health (ARTH), for Training Research and Action Iyengar, Sharad Poland Warsaw, Planning, and Family Women for Federation Nowicka, Wanda Kenya Nairobi, Ipas, Khama Rogo, MA, USA Florence, Schrater, Angeline Faye Malaysia Kelantan, Malaysia, of Sains University Rashidah Shuib, South Africa Johannesburg, Ipas, Makhosazana Xaba, China (YRHRA), Kunming, Health Research Association Reproductive Yunnan Zhang Kaining, Annex 1 Annex IN 2001 PANEL ADVISORY THE GENDER OF MEMBERS from: AFRO AMRO EMRO EURO SEARO WPRO 142 Annual Technical Report 2001 Sofia Gruskin, Sofia Gruskin, François Xavier BagnoudCenter for HealthandHumanRights, SchoolofPublic Harvard Health,Boston, SCIENTIST IN2001 Annex 2 Section 6 - Gender andreproductive 6-Gender rights inreproductiveSection health MA, USA Annual Technical Report 2001 143 :267–275. , 2001, 63 Contraception Gender and reproductive rights in reproductive health in reproductive rights Gender reproductive and . Geneva, World Health Health World Geneva, through human rights motherhood . safe Advancing Transforming health systems: gender and rights in reproductive health. A training curriculum for curriculumA training for health. gender and rights in reproductive health systems: Transforming Bulut A, Ortayli N, Ringheim K, Cottingham J, Farley TMM, Peregoudov A, et al. Assessing the acceptability, service delivery Assessing the acceptability, A, et al. TMM, Peregoudov Farley Bulut A, Ortayli N, Ringheim K, Cottingham J, Turkey. Colombia, Philippines and in of the diaphragm and use-effectiveness requirements, Annex 3 Annex IN 2001 PUBLICATIONS Ravindran Sundari TK, ed. Sundari Ravindran Cook R, Dickens B, Wilson AO, Scarrow S. S. Scarrow Wilson AO, B, Cook R, Dickens (WHO/RHR/01.5). Organization, 2001 Organization, 2001 (WHO/RHR/01.29). Health World Geneva, . managers health programme 144 Annual Technical Report 2001 Annual Technical Report 2001 145 Section 7 Technical cooperation with countries cooperation Technical 146 Annual Technical Report 2001 • Highlights ofachievements in2001 • • • • improving reproductive health. Specifically, theaimsare: at aimed activities programmatic and research regional and national to implement and develop countries to assist capacity their to enhance is countries with cooperation nical tech- on work its in Department the of objective main The Section 7- Section Technical cooperation withcountries

eeomn (SI) ad h Pplto Council’s Population the and (USAID), Development International for Agency States United the the Department, between Memo- signed the (MoU) Understanding of of context randum the within 2001 December in Geneva in organized was consultation international An reproductive healthprogrammes andoutcomes. policies and initiatives related to health sector reforms on of effects the monitoring in countries with collaborate to and research; to health reproductive of results countries the apply and developing disseminate to to and capacity, research their strengthen assistance provide to essential for improving reproductive health; and the adaptation and application of practice guidelines technologies health reproductive of introduction the ing includ- programming, and planning national support to health reproductive address needs; to required is research where areas identify to countries developing assist to OVERVIEW OFACTIVITIES IN TECHNICAL COOPERATION WITHCOUNTRIES A. Ntabona, M. Mbizvo Overview • •

tred integrated services. client-cen- for tools and models strategies, operational and health; reproductive in adults young and lescents ado- (VIA); involvementmale acid the of acetic with tion scaling-up of cancer cervical screening by visual inspec- health; maternal on interventions community-based ple, operational rangewide a issues,on of research forincluding, exam- promote to efforts regional supporting on Collaboration with WHO Regional Offices focused mainly tional research. opera- through services health reproductive integrated of models appropriate of testing and development the in researchers and managers policy-makers, between collaboration improve to need the stressed also They Regions. the in systems health national strengthen to reproductive of efforts role ongoing the in pivotalservices and programmes health the to visibility more for the call strong and a made Mediterranean.Participants Africa Eastern of Regions WHO the for 2001 tember Kenya,Nairobi, in washeld institutions research Sep- in of directors and managers programme for symposia policy-makers, regional ofplanned series a of first The ing inthedeveloping Europe. andEastern world train- and research health reproductiveinvolved in tions organiza- regional and local and agencies international from representatives including participants, 77 together operations.programmebrought health meeting tive The reproduc- improve to research use and demand to ers manag- programme of capacity developthe to need the and research, basic and normative complements research that focused programmatically for rec- need the ognized on based is MoU This project. FRONTIERS Annual Technical Report 2001 147 Overview TION WITH REGIONAL OFFICES WITH REGIONAL TION Technical Technical Advisory Group of (STAG), impact initial the examine to funding order in 2002/2003 was for approved the systems and organizational changes brought about by health sector reform initiatives on the utilization and quality of reproductive health services.this To effect, a proposal a for three-year research initiative was submit- ted The to MacArthur Foundation and was for approved 2002. will commence in This initiative partial funding. INTERREGIONAL ACTIVITIES AND COLLABORA- INTERREGIONAL ACTIVITIES Several research and programmatic activities were supported were activities programmatic and research Several jointly in selected countries by different thematic teams and These Department.the within team cooperation technical the activities served as an entry strengthening and point programme development in for the areas of research capacity fertility regulation; maternal and perinatal health, HIV of (MTCT) including transmission mother-to-child of prevention the medicine evidence-based tools; new of field-testing infection; support interagency to and practices; best implementing and planning and evaluation. programme The Department continued to make significant contributions to the capacity of countries to health address needs their through reproductive fostering interregional was work research programmatic and Research and cooperation. technical institu- service and research academic, national by out carried Offices, Country and Regional WHO with cooperation in tions governments, nongovernmental organizations (NGOs) and other partners. regional on countries with cooperate to is objective main The Activ- priorities. programme and research health reproductive ities that are undertaken are based on the assessments of regional experts who advise on priorities for research, strengthen- and capacity technical and research the for strategies selected of implementation and testing the includes This ing. from research evidence. interventions that are derived activities in interregional of progress Highlights 2001 during programme symposium policy-makers, for Regional directors managers and research At its February recommended, 2000 among meeting, STAG would findings research of utilization greater that things, other be achieved by including to efforts other policy-makers and advocacy in managers and programme health reproductive In line presen- disseminate with research the results. above, tations on the Department’s efforts research towards capac- Regional Commonwealth the at made were strengthening ity Health Ministers Conference in October 2000 in Swaziland. launched with a serieswas of symposia an initiative Further, for policy-makers, programme managers and directors of Introduction Following Following advice from the Department’s Scientific and Support was provided to action interventions (Stage research II) in Bolivia, for China, Ethiopia, Lao testing People’s Democratic Republic, Myanmar and Zambia. Scaling-up of tested interventions (Stage Adaptations Zambia. and III) Nam Viet Brazil, Bolivia, is in way under of the strategic planning process continued in additional tract reproductive including health, reproductive of areas infections (RTIs), maternal and newborn health, abor- cer- and prevention HIV/AIDS to related issues and tion, vical cancer. The field guide for implementing strategic the assess- ment (Stage I) was published, and web pages on overview the of the Strategic Approach, experiences and links to publications relevant are avail- related country site. web Department’s on the able The first meeting of the Regional AdvisoryPanel (RAP) for Eastern Europe, the Newly Independent States and Central held Asian was in Republics September 2001 in Panel‘s the of approval following Denmark Copenhagen, Coordina- and Policy Programme’s the by establishment reviewed Panel the things, other Among Committee. tion and endorsed the strategy paper prepared by the WHO Regional Officefor This Europe. paper covered sexual and health reproductive the for Region, and related pro- grammes supported by the WHO Regional Europe Office for on maternal and neonatal health, sexual and adolescent reproductive health, gender mainstreaming projects. and other ongoing research and training With support from the Programme international sources, and up to 379 research projects national have and been initiated or are ongoing in these institutions and a total of 524 research articles were thermore, published. 388 Fur- congress abstracts were presented national, regional at and international scientific events to disseminate the research results. Overall Overall 14 Long-term Institutional Development (LID) Grants and 12 Resource Maintenance Grants (RMGs) were awarded to the network of collaborating research also were (RTGs) Grants Training Research institutions. awarded to 35 scientists from these institutions, most of whom received their training within their respective regions.

• • • • • • Continued Continued support for research, research capacity strength- activ- development programme health reproductive and ening ities was provided to selected countries in each of the as follows: WHO Regions, six The Department continued to provide support to national- level decision-making for improving the quality of reproduc- process three-stage the through services and care health tive Approach”: “Strategic of the 148 Annual Technical Report 2001 ductive health and population programmes.activities population Future and health ductive repro- national supporting in CSTs as such bodies technical of functions of effectiveness the maximizing for strategies on, recommendations make and review, further to (iii) and governments; advising in activities their from learned sons Community Health Cluster; (ii) to share experiences and les- and Family the and Department the within units different of be to (i) functions objectivesand directions,strategic the concerned: on updated experts the enabled It years. four of gap a after 2001, December in held was staff Headquarters WHO (UNFPA)and Fund Population Nations (CSTs) United teams the of support country the on working health tive reproduc- in between consultation annualexperts The WHO in reproductive health team specialists programme/country support advisory consultationAgency for UNFPA-funded technical in available be 2002. will meeting the of report full The tiatives. for closer inter-agency collaborationthe ini- to jointly support areas suggested also participants research. The operations in centres training potential of ing; needs assistance the and train- research operations from benefit will who researchers operations research in reproductive health; priority a the profiles of managers and and needs to of issues came the they on consensus shared, experiences on Based Europe. trainingdevelopingand the research in Eastern in and world health reproductive in involved organizations local regional and and agencies international from representatives ing includ- participants, 77 together brought meeting tions. The opera- programme health reproductive improve to research need to develop the capacity of programme managers to use the to and research, basic and formative complements that to research focused programmatically for need respond recognized the to organized was It project. FRONTIERS cil’s PopulationCoun- the USAID, and Department, the between 2001 December within the context in of a memorandum Genevaof understanding signed in held was consultation This research capacity building Consultation onreproductive healthoperations ing willbepublished in2002. findings into programme activities. The full report of the meet- building and provide guidelines capacity for the translation research of research to support its increase should WHO (iii) and regions; the in problems health reproductive future and current both to respond should agenda research the ing; (ii) utilization, and should make a greater commitment to its its and fund- research health reproductive to priority greater give should managers programme and policy-makers (i) were: recommendations levels.Other national at meetings similar having recommended Health and Initiative this welcomed Mediterranean. Ministers Eastern WHO the the and for Africa of 2001 Regions September in Kenya Nairobi, in held was symposium first The Programme. the from grants ing research institutions receiving research capacity-strengthen- Section 7- Section Technical cooperation withcountries Collaboration with WHO Regional Offices Reproductive Health”. on Reforms Sector Health of on Impact be “The will meeting the meeting will be published in 2002. The theme for the of 2002 Recommendations health. reproductive in men including at aimed programmes and policy for implications and learnt lessons models, case region-specific designs, programme entations embraced regional experiences, research findings, infectionswomen.ted against violence and (STIs)/HIV Pres- transmit- sexually of prevention health, maternal improving and Health” Reproductive planning, family of promotion of areas thematic the included in Involvement Male for ming “Program- was meeting this of theme (PAHO).The zation the and Department was Health hosted by the Pan-American ReproductiveHealth Organi- in Advisers Regional WHO betweenmeetings goal-oriented of series the of second The Regional Advisers inReproductive meeting Health • planned. Other plannedactivitiesinclude: been have Pacific Western and Asia WHO South-East of the Regions in and Americas the of Region WHO the in tors direc- research and managers programme ministers, health pro- and ministers of regions.respective Meetings the from managers gramme health into of take will recommendations activities account interregional for plans future The Planned Activities officially designated,alsocollaborated withtheDepartment. not although centres, 26 Another Reproduction. Human in Technicaland Cooperation Research for Centres laborating Col- WHO designated officially 53 were there 2001, During WHO Collaborating Centres on otherfollow-on activities. continuingintroduced. wasdeveloped and Work application were forms relevant the and grant each on brochures tion Informa- 2000-2001. in undertaken Strengthening Capacity Research of Review In-depth WHO the to follow-up the a as Regions across undertaken were activities of number A Research capacity strengthening Regional Officesin2001. 7. 1 provides of a collaborativesummary activities with WHO ductive health and other operations research activities. Table men’s health, repro- in maternal roles of areas the in Offices Regional WHO with collaboration in undertaken was Work uig f h UFAspotd ehia Avsr Pro- Advisory Technicalgramme (TAP) currentlyinprogress. UNFPA-supported the of turing within this context will depend on the outcome of the restruc-

agement and translation of research findings into coun- into findings research of translation and agement man- programme research on workshops interregional Annual Technical Report 2001 149 r o

f

y Overview

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Medicine e v ng pregnanc health in ti i e k male genital v r client-friendl ti o f health of male r ma e o vices f v ti entions health ser e aining in Reproduc r v T ti s on improving adolescent reproduc adolescent improving on s an approach to promote maternal and and maternal promote to approach an : s e ioural changes in relation to to fe relation in changes ioural tion of guidelines on medical eligibility criteria tion of guidelines on medical eligibility v Biology and in operations research Biology and in operations research e v h ti s role and participation and role s reproduc in ' e use and other guidelines on family planning and e use and other guidelines on family n t to courses on Research elopment of an operational model and tools elopment of an operational er tal Quality Management ev entral America America entral ystematic introduc ystematic o ntegrated response to sexual and reproduc and sexual to response ntegrated C S T I D and Reproduc community- and facility-based interv facility-based and community- contraceptiv integrated sexual and reproduc and sexual integrated —Suppor —

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adolescents and young adults in Latin America adolescents and — acific Eastern Mediterranean Europe Americas Asia and the P the and Asia collaborative research with WHO Regional Offices; and WHO Regional Offices; research with collaborative an interregional consultation on the impact health. on reproductive sector reforms of health try and policy; programmes

• • 150 Annual Technical Report 2001 Reproductive Health,RegionalOffice (PAHO),for theAmericas Washington, USA,5–7September2001 (inpress). tion. UNDP/UNFPA/WHO World BankSpecialProgramme ofResearch,Development andResearch Training inHumanReproduc- Health Organization,Geneva, Switzerland,21–24August 2000(inpress). programmes inreproductive health. basedonthemeeting of A report WHORegionalAdvisersinReproductive Health, World tion. UNDP/UNFPA/WHO/World BankSpecialProgramme ofResearch,Development andResearch Training inHumanReproduc- and HumanResearch,2001,23 Rivera R,Ezcurra E. Composition andoperation ofselectedresearchethicsreview committeesinLatinAmerica. PUBLICATIONS IN2001 Annex 1 Section 7- Section Technical cooperation withcountries Programming for maleinvolvement inreproductive health. basedonthemeeting of WHO RegionalAdvisersin A report A framework inthedevelopment toassistcountries healthplansand andstrengtheningofnationaldistrict :9–12. IRB: Ethics Annual Technical Report 2001 151 Policy and programme issues programme and Policy MAIN AREAS OF WORK MAIN AREAS OF The purpose of Stage III to research is action II Stage the to in generated findings disseminate research and apply the policy development and planning for wider implementation. Based on an of evaluation the Stage II research experience and findings, decisions are made onof the appropriateness expanding method introduction and/or replicating other tested interventions on a larger scale. The main areas of work on the Strategic Approach included the dissemination and support Approach Strategic the of adaptation countries, by Approach for use of the to other Strategic areas of reproductive health, and scaling-up. replication and With regard to its application to introduction of tives, contracep- sufficientexperience has been gained in the assess- ment and Stage II testing of Thus, interventions. efforts are focusing on dissemination and the promotion of use of the Strategic Approach by countries, as well as the testing and synthesizing of lessons learned in the Stage III scaling-up process. A second area of activity testing is of the the application of adaptation the and methodology to other spe- cific areas new- and maternal HIV/AIDS, of reproductiveincluding (RTIs) infections tract health, such as reproductive born health, abortion and cervical cancer. Here, the is focused work on the adaptation and development of tools for Stage I strategic assessments, as well as Stage II projects servicesof care of quality the improve to interventions test to in these specific reproductive health areas. As these activi- ties to move Stage III, they are to expected contribute to the further of development knowledge and provide guidance for programme managers on successful scaling-up of stream lessons related closely third A interventions. pilot from learned P. Fajans, M.A. Broderick M.A. Fajans, P. Policy and programme issues and programme Policy INTRODUCTION A strategic assessment risegives to a variety of recommen- strength- the policies, health reproductive concerning dations ening of the quality of care in service delivery, the service delivery infrastructure and the management of programmes and activities. Stage II research is a means of a testing, limited scale, on the recommendations concerning the intro- duction of technologies or other interventions the to improve quality of care in service delivery. Stage I employs a systems perspective to assess: existing contraceptive (i) method mix, the other options for fertility health reproductive future possible and current and regulation interventions; (ii) the extent of the coverage, quality of care and capabilities of the service delivery system; and (iii) the needs and perspectives of current and potential The users. assessments of the need for contraceptive introduction are designed to assist programmes in deciding whether there is a need to introduce one or more new methods, to expand the use of existing and perhaps underutilized methods, or inappropriateany to withdraw and technologies, deciding on improved. be could services of care of quality overall the how The assessments use a qualitative methodology and a par- ticipatory approach programme involving managers, service researchers and others with an interest providers, in improv- organi- youth and women’s including health, reproductive ing organizations (NGOs). zations and other nongovernmental The Department has been developing, testing and refining a “Strategic Approach” to improve the reproductive health quality services. Although originally of developed care of to address contraceptive introduction, the methodology has serv- health reproductive of range a address to adapted been This Approach has three stages. ices. 152 Annual Technical Report 2001 guay. Regional workshops for countries in Africa and Asia will proposals for strategic assessments in Chile, Cuba and Para- and plans of development the in participants the to support continuing providing is Project, Reprolatina the with ration collabo- in Department, the and below), (described temala that subsequently conducted a strategic assessment in team Gua- the led workshop this from Participants Council. tion Popula-(PAHO)the Organization and Health Pan-American Bolivia, Chile, Cuba, Guatemala and Paraguay, as well as the representatives from NGOs and women’s organizations from included Participants senior 2001. country policy-makers and programme managers, during and Bolivia in Reprolatina (NGO) organization nongovenmental the by implemented in the experts implementation of strategic assessments, was national train to and Approach Strategic the of utilization for advocate to intended workshops, regional three of first The health. nal andnewborn field guide for use in strategic assessments related to mater- in the of adaptation the on began be published work addition, 2002. In early will guide field The Romania. and temala quality of care has continued with field-testingfurther in Gua- improve and choice contraceptive broaden to assessments sions about contraceptive introduction: a guide for conducting During 2001, work on a draft field guide entitled Dissemination, building andcapacity advocacy comprehensive strategic assessments). (i.e. conducting issues health reproductive of range broad a addressing simultaneously in methodology the of use the is Section 7- Section Technical cooperation withcountries Figure 7.1. C o untries implementing by the Strategic Approach (supported Making deci- n h WO ein f h Esen eierna. Other Mediterranean. Republic,Dominican the China, in made were presentations Eastern the of countries Region WHO nine the from in participants by attended and Center tion and Development programme at the Cairo Demographic Popula-in Partners organizedReproductivebythe Health in Program Leadership Global the at given was a presentation example, For 2001. during workshops international and national of number a at made were Approach Strategic the list of publications at the end of this chapter. Presentations on the in included are Approach Strategic the with experiences country concerning articles Other Nam. Viet and Myanmar PDR), (Lao RepublicPeople’s Democratic Lao the in zation utili- its with experience the presenting papers individual as well as Approach, Strategic the of overview an giving article lead a with Approach Strategic of use the to devoted issue the 2001, In mechanisms. of variety a through disseminated and mented docu- be to continued have Approach Strategic the of tion implementa- with experiences country years,previous in As countries. ess inneighbouring for promoting and providing technical assistance to the proc- ticipated in Strategic Approach activities, as resource people to efforts build regional ongoing capacity by using the the individuals who have par- to contribute will workshops These port TeamsPopulationNations United the (UNFPA).of Fund Sup- Country and Offices Regional WHO respective the as Programmes Population (ICOMP) of and the Population Council, Nairobi, Kenya, as well Management the for Council International the including partners regional WHO with tion collabora- in implemented 2002, of half first the in held be published an published of Population Asia-Pacific Journal WHO andotherpar tners)

Annual Technical Report 2001 153 Policy and programme issues programme and Policy COUNTRY EXPERIENCES DURING 2001 EXPERIENCES COUNTRY Ongoing activities in Africa Ethiopia In addition, a larger conference was planned to examine and examine to planned was conference larger a addition, In synthesize existing knowledge about how to enhance scal- ing-up of service delivery research for broader policy programme and development. This conference is scheduled to take place in September 2002. These efforts are expected the documenting papers scientific (i) outputs: two produce to utiliza- the on experience and research learnedfrom lessons policy for innovations servicedelivery evidence-based of tion and programme development; and (ii) a practical guide for technical researchers, managers, programme policy-makers, experts and donors intended to facilitate the scaling-up of small-scale service innovations. The first of Stage several II activities has been the develop- ment of a project to investigate strategies to expand access to coitally-dependent methods of contraception protection and for youth. dual The two-year project is mented being by the imple- Family Guidance Association active of sexually Ethiopia that assessment in the from findings to response youths were not interested in using routine contraceptives, but desired coitally-dependent The methods. study is using the introduction of the female condom and emergency con- traception, as well as the reintroduction of the male condom and vaginal foaming tablets, as the overall a quality of youth-centred means services. The project for is enhancing strengthening providers’ and peer educators’ knowledge of all contraceptive methods, increasing knowledge of and prevention STI for options and planning youth family regarding emphasizing dual protection. The study is funded by the A proposal for a series of activities on the topic of scaling-up A proposal for of health interventions, titled “From pilot projects to policies in scaling health up strategies for innovations and programs: service delivery”, was submitted to The Rockefeller Foun- dation. This proposal requested support for two team resi- dencies and a conference intended to develop strategies to facilitate more effective use of small-scale testing of repro- ductive health service The innovations. first team residency The purpose of this residency took place in December 2001. was to discuss two reviews of the social science and devel- opment literature related to scaling-up of pilot projects, as well as the experience and lessons learned to date with the Approach. Strategic the of III and II Stages of implementation Stage III: replication and scaling-up replication III: Stage There is a growing recognition of the need for a methodology a for need the of recognition growing a is There and tools to assist countries in strategic planning and pro- gramming for comprehensive reproductive health services. In recent years, experience with the adaptation of the stra- tegic assessments to address broader reproductive health concerns has been gained in Ethiopia, Myanmar and, most recently, in Lao PDR. ICOMP, Population Council, in Bangkok and collaboration the with Department, will the testing further be modifications of thefor methodology compre- hensive reproductive health assessments China in Yunnan, and Rajasthan, India in 2002. Adaptation of the Strategic Approach of the Strategic Adaptation Work is continuing on Approach to address other the reproductive health The issues. Coun- adaptation Population the with working continued of has Department the Strategic cil’s HORIZONS Project on an adaptation of the Strategic Approach to address issues related to sexually transmitted assess- strategic a 2001, In RTIs. other and (STIs) infections ment of abortion-related issues was conducted in Romania, and an assessment related to both family planning was conducted in The Guatemala. maternal Strategic health and Approach is being adapted by other partners as example, well. For EngenderHealth is assisting Bolivia methodology to address issues to related to the screening and use the treatment of cervical cancer, while the office of thelation Council, Popu- Brazil supported an assessment of HIV pre- vention in the border regions of in Technology Brazil. Appropriate for Program the with collaboration In addition, future method- the of utilization support to planned is (PATH) Health ology to address the introduction of a range of reproductive health technologies. The Department’s web site now contains web pages devoted devoted pages web contains now site web Department’s The expe- country of description a with Approach, Strategic the to riences, and links to publications including country assess- ment reports and the field guide aswell as to theweb sites partners.of collaborating India, Guatemala, Kenya, Romania, Uganda and the USA, Switzerland. as in internationalas well meetings in Geneva, 154 Annual Technical Report 2001 health centres, located in three districts in the rural Copper- rural the in districts three in located centres, health rural eleven in Zambia in care of quality and choice ceptive contra- enhance to interventions tested has study II Stage A Zambia egy. an exercise to develop a National Reproductive Health Strat- of Health in to the Ministry robi will provide technical support Nai- Council, Population the and Department the 2002, In report. the from recommendations key implement to steps is Health taking of Ministry the and kits, Norplant for orders new placed the have USAID on and UNFPA evaluation, Based the care. of results of quality appropriate with provided being was Norplant ensure to interventions critical mended recom- and supported, be should Norplant of introduction further that evaluationNorplant. concluded The of curement pro- further regarding this decisions making to conduct prior evaluation, and design to WHO and Council Population the from assistance technical requested the Health and of UNFPA Ministry Norplant. introduce previous to of Ethiopia evaluation in an efforts was 2001 in activity second A and theDepartment. Council Population the by provided support technical with United States Agency for International Development (USAID) Section 7- Section Technical cooperation withcountries r Figure 7.2. improv Clients reported eproduc tiv e healthser v ices at healthproject centre ed satisfa c t ion with s

otaetv pout aalbe ih ead o ihr the quality oftheir manufacture safety. either and/ortheirlong-term to regard with available products contraceptive the of number a review to (iv) and services; health planning family of context the in RTIs of management and diagnosis the strengthen to removal;(iii) and insertion both to related care of aspects improve to and programme national the in provided IUDs of types of number the reduce to (ii) care; of ity to provide all contraceptive methods with improved quality themes included the need: (i) to strengthen providers’ capac- the key of Some emerged. recommendations and findings important Numerous programme. planning family national the availablein technologies IUD on emphasis an with tion, introduc- contraceptive of issue the address to China Chong- qing, in assessment strategic a conduct to the Department from support requested Commission State Planning the Family of Technology and Science of Department The China inAsia Ongoing activities contraceptive. emergency an as efficacy its evaluate to Postinor-2 of tion of Ministry Health is now reviewing the data, prior to registra- inadequate. remained The clients to provided information of quality ages.However, the all of clients urban for traception con- emergency of supplies and information both of source popular most the were pharmacists that showed study This completed. also was contraception emergency the of provision for sources alternative investigating study separate A Department. the and Council Population the by provided be will support region. Copperbelt the in districts the of all in centres health all in learned lessons the and strategy the replicate to developed was project III Stage a workshop, project final the Following line andthecontrolsites. base- to compared as broadened, has centres intervention the in mix method the and month each doubles acceptors new of number the result, centres.a control As the in viders pro- with comparison in or baseline at did they than clients, with interacting time more spend and clients to information information, use to communicationprovideand materials, education (IEC) more likely more are skills, technical better project evaluation showed that providers in project sites have end-of- centres.An health and districts participating among to newsletters share management interventions and and successful innovations providers, for manuals self-training of (STDs). eases bydevelopment the supported been has This dis- transmitted sexually of management syndromic the in trained also were Providers (IUDs). devices intrauterine of all of provision available methods, the including field-based training for insertion in providers train to offered as well as progesterone acetate (DMPA) and emergency contraception, depot-medroxy- contraceptive injectable the introduced has belt region. Following a baseline situation analysis, the project Funding is being provided by USAID and technical and USAID by provided being is Funding Annual Technical Report 2001 155 Policy and programme issues programme and Policy Viet Nam Viet A Stage II study assisted the Government of Viet develop Nam a strategy to for introducing DMPA and, at the same time, strengthen the quality of family planning ductive This health project service and train- developed delivery. repro- ing curricula and materials for providers, planning improved IEC materials, family and trained providers and commu- nity-level workers, emphasizing counselling and provision of balanced information, in addition to technical information on all available contraceptive methods. worked The on approaches to project strengthen management of serv- also of supervision tools. including the development ices, interventions the up scale and replicate to project III Stage A tested initially in three provinces in Stage II is The is introduction being of implemented DMPA in under 21 of the way. 53 provinces in Viet Nam where government or donor sup- avail- already is delivery service health strengthening portfor As in Stage II, the Stage III project is being undertaken able. as a collaborative effort between the Ministry of Health, the National Committee and for Planning Population Family and the Viet Nam Women’s Union. It is jointly funded, primarily Zusammenarbeit Technische für Gesellschaft German the by (GTZ) with and the UNFPA, Department providing technical support through ICOMP. Myanmar model district-level a developing is project research II Stage A improving the for quality of care of planning family and other the (i) include: activities Project services.health reproductive communica- and education information, new of development sector public for training (ii) activities; and materials (IEC) tion basic health staff, private general practitioners, private drug shop staff, township- and community-level members Mater- Myanmar the organization, nongovernmental national of a community a (iii) (MCWA); Association Welfare Child and nal man- the strengthen effortsto (iv) and component; advocacy agement capabilities related to planning, supervision and health centre staff. logistics of township-level and The project is being implemented in two districts with differ- reproduc- and composition ethnic conditions, geographic ing health needs. tive During 2001, the provider training curriculum developed by the project was utilized by the Ministry of Health in the train- ing of health staff throughout Myanmar and the IEC materi- for UNFPA by adopted being are project the by developed als use in project activities in 120 districts. In late 2001, a mid- project evaluation was conducted. Initial review of the data and knowledge skills of as indicates providers well improved as motivation to provide quality services. However, it also suggests necessary modifications to the content of provider infor- community of efforts area increased the and in training mation. y . Follow-up Follow-up activities Planning. ople's Democratic Republic e P A 14-year-old mother of two in Samoua Lao rovince, rovince, Figure 7.3. Figure P Chinese Journal of Family Implementation of a Stage II project has been delayed, so as to integrate this research with other through activities WHO’s planned Making Pregnancy Safer (MPS) initiative. This project sought to strengthen the availability and utiliza- tion of essential obstetric care at the district and community levels, to test the approaches to strengthening outreach by community- and centre health the to staff health district-level health services. reproductive level Lao People’s Democratic Republic Democratic People’s Lao The findings, conclusions and recommendationswere pre- sented at a dissemination workshop held in Chongqing and at a second workshop national-level which brought together national stakeholders to discuss prioritiesplans for interventions and and further research formulate to address the The report recommendations. is being published in Chinese in published be will report the of summary a and English, and the are beginning with a review of the safety and efficacy of IUDs of efficacy and safety the of review a with beginning are and hormonal contraceptive methods provided through the national family planning programme, with the goal of select- pro- the in provision for products effective more and fewer ing service technical new of development the Following gramme. delivery guidelines, a process being supported by the Con- sortium for Implementing Best Practices, a Stage II project will test a package of interventions choice and quality of care. informed recommended assessment to improve by the 156 Annual Technical Report 2001 improve access to and quality of family planning and mater- and planning family of quality and to improveaccess would that interventions priority identify to assessment tegic stra- a implement to Department the with collaborated mala Guate- of WelfareSocial and Health Public of Ministry The Guatemala tion Council,Brazil. NGO Reprolatina, the University of Michigan and the Popula- funded by the Bill and Melinda Gates Foundation through the are try continuing through the Reprolatina Project, an activity coun- the of south and north the in municipalities additional to approaches and activities replicate and expand to Efforts municipalities. additional four in activities of replicability tested the project III Stage The constraints. resource existing within level municipal the at occur of can expansion choice reproductive that demonstrated had project II Stage The Brazil and theNGOReprolatina. Brazil Council, Population the by provided assistance nical for Department DevelopmentInternational (DFID), with tech- wide introduction of DMPA bysupported the United Kingdom country- the in Health of Ministry the by used being now are Lessons learned and materials developed through the project to thosenotinvolved intheproject. centres,health compared as participating in higher matically dra- was acceptors new of number the and accessible more have become services familyplanning that documented tion evalua- final delivery.A service guiding in participation nity commu- of development the and services, of management focused Interventions providerthe on training,strengthening DMPAing Bolivia. Cruz, PazSanta La Cyclofem,and in and introduc- while delivery, service health reproductive related A Stage II study attempted to strengthen family planning and Bolivia inLatin America Ongoing activities abortion”. Romania. This activity is in described the chapter on “Unsafe in 2001 November in conducted was services abortion and familyplanning of care of quality the improving and abortion to recourse the reducing to related assessment strategic A Romania inEastern EuropeOngoing activities “Unsafe abortion”. of care of services. abortion on chapter the in described is project This quality the improving and abortion to recourse strategic second a of assessment which focused on issues related to reducing the recommendations the up follow to The Ministry of Health has also begun implementing a project Section 7- Section Technical cooperation withcountries quality, effectiveness, efficiency and financial soundness. financial and efficiency effectiveness, quality, equity, in improvements including systems, health of tives objec- the of manyachieving of means a as promoted been and international donors in recent years. Health reforms have governments by implemented and designed reforms health by promoted been have systems health in changes Major on therecommendationsofassessment. based interventions for plans identify and priorities discuss will stakeholders key other and agencies donor sentatives, NGOrepre- ofHealth, Ministry the from officials local and national with along members, team The 2002. February in national ata dissemination workshop to be bediscussed held in Guatemala will City recommendations and findings The ods. meth- contraceptive available the among choices informed better make can they that so users to counselling and tion need to expand IEC campaigns and a to provide is more informa- there (iv) and referral; strengthen to and sites delivery service peripheral more the to services to expandaccess to provided, services of pharmacies, quality the improve to private need a is and there clinics NGO and public through provided are methods planning family of range broad tively at referral centres outside the capital city; (iii) although a rela- as well as to improve the quality of emergency care obstetric areas rural from emergencies forobstetric mechanisms port trans- emergency and referral functioning develop to need urgent an is there (ii) areas, populations; indigenous for rural especially in services heath maternal accessing to riers from the emerged assessment. Key findings include: (i) there recommendations remain major bar- and findings Many 2001 infive “departments”ofGuatemala. October in conducted was assessment strategic The care. obstetric emergency on emphasis with services, health nal THE IMPACT OFHEALTH SECTOR REFORMSON Figure 7.4. Guatemalaassessmentt REPRODUCTIVE HEALTH eam membersplanfieldwork Annual Technical Report 2001 157 Policy and programme issues programme and Policy STAG stressed STAG the importance of examining the interaction between health reforms and the impact of these initiatives on the utilization and quality of health reproductive services. Thus, initial funding was approved for the 2002–2003 bien- research three-year a for developed was proposal a and nium This initiative. was submitted to The MacArthur Foundation commence to expected is initiative the and funding, partial for in 2002. Generally, the Generally, reforms have involved significant changes in health of regulation and organization payments, financing, the systems. These broad system changes are likely to important influences on sexual and have reproductivehealth pro- grammes and gender related-issues, and pose challenges to the future development of interventions to promote and ensure reproductive health. To date, there has been little reliable very and convincing research on the impact of gen- eral system reforms on reproductive health services, repro- ductive health outcomes or on the sexual and reproductive health rights of individuals. Most of the current literature on knowledge. the scarcity of concrete the issue emphasizes 158 Annual Technical Report 2001 All WPRO SEARO EURO EMRO AMRO AFRO from: Women Miguel Marroqin, Ministry ofPublic Health andSocial Miguel Marroqin, Ministry Welfare, Guatemala Tran ofHealth,Hanoi, Thi PhuongMai,Ministry Viet Nam Tran ofHealth,Hanoi, Thi Luong,Ministry Viet Nam ofHealth(MCH/FP),Hanoi, Nguyen DinhLoan,Ministry Viet Nam Nu Aye andChild Khin,Maternal Welfare Association, Yangon, Myanmar Edgar Kestler, EpidemiologicalResearch CentreinSexual andReproductive Health,GuatemalaCity, Guatemala Cheng Jieshan,Family PlanningResearchInstitute, Chongqing,China Michele Gardner, The Population Council, Yangon, Myanmar Anibal Faundes, CEMICAMP, Campinas, Brazil Rodica Fagarasan, EastEuropean InstituteofReproductive Health, Targu-Mures, Romania Constantin Enciulescu,EastEuropeanInstituteofReproductive Health, Targu-Mures, Romania Do Thi Thanh Nhan, Viet Nam Women’s Union,Hanoi, Viet Nam Francois Deniaud,Paris, France APROFAM,Dalila delaCruz, Guatemala Epidemiological ResearchCentreinSexual Cipriani, Carlos andReproductive Health,GuatemalaCity, Guatemala Chajal,APROFAM,Marta Guatemala Cardona,President’sMiriam Office for Women, GuatemalaCity, Guatemala DoloresCastro,Maria LaPaz, Bolivia Trinh DinhCan,NationalCommitteefor Population andFamily Planning,Hanoi, Viet Nam Francisco Cabral deOliveira, CEMICAMP, Campinas, Brazil Marc Bygdeman,KarolinskaHospital,Stockholm, Sweden SchoolofPublic Harvard Health,Boston,MA,USA Thomas Bossert, Tracy Baird,Ipas, Carrboro, NC, USA scientists Other Jay CouncilonManagementofPopulation Satia,International Programmes, Kuala Lumpur, Malaysia Lee SouaKou, andChildInstitute, Maternal Vientiane, LaoPeople’s Democratic Republic Fang Ke-juan, ShanghaiInstituteofPlannedParenthood Research,Shanghai, China Thein Thein Htay, ofHealth, Department Yangon, Myanmar ofHealth,Bucharest,Romania Mihai Horga,Ministry Philip Guest, The Population Council,Bangkok, Thailand Diaz,Reprolatina,Campinas,Margarita Brazil Ayo Ajayi, The Population Council,Nairobi,Kenya Principal investigators SCIENTISTS IN2001 Annex 1 Section 7- Section Technical cooperation withcountries Number Developing countries 7 3 2 1 1 2

% oftotal 88 38 25 13 13 25

Number Countries intransition Countries 1 1

% oftotal 13 13

Developed countries Number

% oftotal

Totals 1 8 3 2 1 1 2 Annual Technical Report 2001 159 4 6 2 18 42 26 12 Totals

5 7 10 14 % of total Policy and programme issues programme and Policy

2 4 6 3 Number Developed countries Developed

7 10 10 % of total

4 4 3 Countries in transition Number

5 29 10 33 76 48 % of total

4 2 12 14 32 20 Number Developing countries Developing Chongqing, China Chongqing, WPRO SEARO EMRO EURO AMRO All Women from: AFRO

Mi Guoqing, Division of Technical Instruction, Department of Science and Technology, State Family Planning Commission, Planning Commission, State Family Instruction,Technology, Department and of Science Technical Division of Mi Guoqing, Jorge Monroy, Guatemalan Association of Sexual Education, La Paz, Guatemala Education, La Paz, of Sexual Guatemalan Association Jorge Monroy, Myanmar Yangon, Theing Myint, Department of Health, USA MD, Park, Takoma Nancy Newton, Guatemala Women, Guatemala City, for Office Lidia Ortiz, President’s Romania Targu-Mures, Health, East European Institute of Reproductive Mihaela Poenariu, Guatemala Health, Guatemala City, and Reproductive Research Centre in Sexual Lilian Ramirez, Epidemiological Guatemala Guatemala City, Education, Guatemalan Association of Sexual Claudia Rosales, MI, USA Ann Arbor, of Michigan, University Ruth Simmons, Council, Nairobi, Kenya The Population John Skibiak, Romania Targu-Mures, Health, Reproductive East European Institute of Bela Szabo, Guatemala Council, Guatemala City, The Population Vielman, Liza Beijing, China Family Planning Commission, State Institute, Shangchun, Scientific Research Wu Planning Commission, Beijing, China State Family Technology, Department Xiao Shaobo, of Science and Beijing, China Centre, Research and Information Xie Zhenming, Population Mary Zama, Ministry of Health, Lusaka, Zambia Planning Commission, Beijing, China State Family Zhang Minghua, Division of Science Research, Shanghai, China Research, Parenthood Institute of Planned Weijin, Zhou Myanmar Yangon, Thet Zin, Department of Health, Thet 160 Annual Technical Report 2001 2001, 15:63–86. toimproveas anopportunity qualityofcarefor allcontraceptive methodsin Viet Nam. Thom NT, HieuDT, Nhan VQ, NhanDT, Whittaker M,Fajans P, etal. The strategic approach totheintroductionofDMPA time hascome. Simmons R, Brown JW, Diaz M. Facilitating large scale transition to quality of care in family planning programs: an idea whose Population, 2001,15 Journal Satia J, Fajans P, EliasC, Whittaker M. A strategic approachtoreproductive healthprogramme development. Democratic Republic. Sananikhom P, I,Fajans Reerink P, EliasC, SatiaJ. A strategic assessmentofreproductive healthintheLaoPeople’s Studies inFamily Planning,2001,32 (inpress). Penteado LG,Cabral F, DiazM,J, GhironL,SimmonsR. Organizing apublic sectorvasectomy program inBrazil. providers inPyayservice andKalaw townships inMyanmar . Bangkok, Population Council,2001. ofHealthandPopulationMyanmar Department Council. Myanmar. Htay TT, GardnerM,Ba-Thike K, Wai KM, Wai KT, KhinNA. Population, 2001,15 Journal Htay TT, Ba-Thike K,GardnerM,EliasC, Fajans P. A strategy for advancing reproductive healthinMyanmar. Population Council,UnitedNationsPopulation Fund, World HealthOrganization,AddisAbaba,2001. ofHealth. Ethiopia Ministry reproductive healthandfamily planning. New York, The Population CouncilPress, 2001(inpress). reproductive healthcarereforms: the SantaBarbara Project.RespondingtoCairo: case studiesofchangedpractice in Diaz M,SimmonsR,J, Cabral F, Bossemeyer D, MakuchMY, etal. PUBLICATIONS IN2001 Annex 2 Section 7- Section Technical cooperation withcountries Social ScienceandMedicine(submitted). Studies inFamily specialvolume). Planning,2002(forthcoming Asia-Pacific , 2001, 15Population Journal An evaluation of Norplant insertion andremoval inEthiopia.IncollaborationAn evaluation withthe insertion services ofNorplant :5–20. :39–62. Perceptions ofreproductive morbidityamongwomen, menand Perceptions ofreproductive tract morbidityintwo townships in :21–38. Involving aBrazilian municipality initsown Asia-Pacific , Population Journal Asia-Pacific Asia-Pacific Annual Technical Report 2001 161 RESEARCH ACTIVITIES RESEARCH promoting “targeted” research on major and on the needs of LDCs. health problems reproductive The WHO Regions of Africa and the Eastern Mediterranean Eastern and the of Africa Regions WHO The

Overall research output research Overall The eight centres supported or Resource Maintenance (LID) Grants Grants with Development Long-term Institutional (RMGs) in are projects involved which address regional and national reproductive health priorities. From a studies, three total projects (6%) were implemented with support of 48 from the Programme’s capacity-building grants (LID, RMG and Re-entry Grants). Six projects (13%) were carried out at the centres with support from national The sources. par- ticipation of the regional centres in the global research effort is exemplifiedby thefour projects (8%) conducted in these collaborating institutions with supportThematic Groups from of the Department. Likewise, the institutional strengthening efforts deployed by the Programme in its regional centres have enhanced their capacities for fundraising from international other agencies, to address topics of global or local relevance. Thirty-five projects (73%) carried regional centres out received support in these from international agen- WHO. cies other than Thirty-one per cent of the projects were mainly logical epidemio- or social science projects, another 31% were clinical stud- science basic were projects) (12 25% projects, research ies and 13% (six projects) focused on operations research designs. All thematic areas were studied, but HIV/AIDS maternal(10), on health were projects of numbers the highest (9) and family planning Many (9). projects dealt with several thematic areas concurrently. • H. Bathija, D. Chikamata, A. Fahmy A. Chikamata, D. Bathija, H. Eastern Mediterranean Eastern The WHO Regions of Africa and the and Regions of Africa WHO The INTRODUCTION promotion of resource research mobilization capabil- for Regions; ity-strengthening activities in the two and strengthening research skills in the social sciences; promotion of intraregional training; promotion of intraregional stimulation of interest in sexual and reproductive health Easternthe Africaand French-speaking LDCs, in issues Region; Mediterranean promotion of networks through “South-to-South” links; “South-to-North” and research development, protocol research of improvement management and scientific writing; development development of subregional “Centres of which Excellence”, are capable of assisting weaker centres, espe- countries (LDCs); cially those in least developed

• • • • • • • The main elements of the strategy are: The main elements of the strategy The strategy continued to focus on selected institutions and the the stimulation of interest in strengthening repro- of countries. health research in various ductive The main objective of the area Department’s is to strengthen the research activities capacity of institutions in in this the WHO Regions of Africa and the Eastern Mediterranean to enhance their potential to implement reproductive health facili- to and needs regional and national to relevant research tate their participation in the global research effort. 162 Annual Technical Report 2001 tribution of the different types of FGM among the volunteers the among FGM of types different the of tribution dis- the shows 7.5 Figure phase. pilot the in recruited were ber 2000 and the end of February 2001. Overall, 1919 women The pilot phase of the study was conducted between Decem- information.ing thewomen andgathering tions are expected on the part of the staff, apart from examin- activeinterven- no and nature, in observational is study The measures oftheirinfants born. tion is also obtained regarding the health and anthropometric Informa- hospital. from discharge their after weeks six until up delivery and labour followedthrough are study the to ted delivery.to admit- Womenprior status FGM their determine into the study and those recruited undergo an examination to ticipating centres for are delivery approached for recruitment par- the to admitted pregnancies singleton with women All tions inwomen withFGM. complica- obstetric of treatment and prevention the to vant rele- information clinical obtain to is objective subsidiary A complications. obstetric and FGM differentbetweenof types relationship evaluatethe to and hospital in birth giving FGM estimate with women among complications to obstetric of incidence the are objectives primary The FGM. of quences conse- health the aims regarding information It reliable Sudan. provide to the and Senegal Nigeria, Kenya, Ghana, Faso, Burkina in departments obstetric and units maternity of number a at study,based cohort prospective multicentre, The research on obstetric sequelae of FGM is a multicountry, of FGM. aspects various into research for tools disseminate and test develop, to as well as programming and advocacy improve to order in FGM, of consequences health reproductive of the frequency the on particularly knowledge, increase objective to is The practice. the of context sociocultural the wellas as FGM, of sequelae obstetric mutilation the on focuses genital (FGM) female on work Department-supported Research onfemale genitalmutilation Regional research initiatives Section 7- Section Technical cooperation withcountries Figure 7.5.study) (pilot types FGM of Distribution required sample size.sample required provideques- will the Department The continuehave the to order in months additional six for will collection data Senegal in centres participating It was that Senegal. agreed in Office Country WHO the by funded be will centres sites. three nine additional of The total a include The Senegal team decided to extend the study nationally and be extended to15monthsinsomeorallof thecentres. to needs collection data if see to months six after reviewed 18 from shortened was months, as originally phase planned, to 12 months. Progress will be main the of duration The Senegal (6)andtheSudan(4). (7), Nigeria Kenya(3), (3), Ghana Faso(5), Burkina in sites 28 in conducted be will study the respec- of phase tively. subjects, main The 6000 and 9000 recruit should countries these FGM, III type of cases sufficient have to order in that calculated was it Sudan, the and Faso Burkina in centrated recruiting a total of 20 000 women. Since FGM type III were is con- phase main the byreviewed.met be objectivescould the that decided was It for requirements size sample The Fasotion ofcasesinBurkina andtheSudan. propor- large a represented and Nigeria, except centres all foundwashospital. in III in type time FGM the to study main the follow-upin infants.the limit to decided was Therefore,it in put efforts the place to justify ensure that the mothers came for to follow-up with their enough large not was infants, and mothers of follow-up 6-week possible the on during complications phase pilot the from derived information The the meeting. the pilot-phase study. The following were the key outcomes of of experience the to according instruments and procedures phase. The meeting critically reviewed and amended all study tions; and (iii) to outline the implementation plan for the main solu- and/or alternatives suggest and difficulties identify to (ii) study; the of phase pilot the assess to (i) were: meeting the of objectives main The Switzerland. Geneva, in 2001 April in place took consultants study the and phase pilot the in participated who investigators principal the of meeting A ateachstudysite.recruited for theextension. facilities management data and tionnaires ed o a i-et suy o understand to study in-depth an for need a therefore, is, There sources. secondary from and fragmentary is it of much FGM, on information growing is there Although all sitesinNovember 2001. at started Pro- collection Data Review(SERG). Group Ethical the and and Scientific gramme’s Health Reproductive in Research Epidemiological in Panel cialist Spe- approvedwerethe by study main the for budget and plan implementation The Annual Technical Report 2001 163 WHO laboratory DEVELOPMENT OF HUMAN RESOURCES OF DEVELOPMENT The WHO Regions of Africa and the Eastern Mediterranean Eastern and the of Africa Regions WHO The including the use of antenatal care visits for preparing birth plans for pregnant women and exploring ways of assuring the study As a special feature, skilled attendance at delivery. would look at the role The issue of community in involvement maternal of health had men in maternal been identified health in theFebruary 2000 care. joint planning meeting between the Regional Office for Africa (AFRO) that interest Headquarterscommon of projects the of one as WHO and should be developed. A prototype protocol, developed by the Department in col- with laboration African has AFRO been researchers, sent by to several countries for review and South Nigeria, in prepared adaptation. being are protocols adapted these Currently, Africa and Uganda, and the projects are to expected start in 2002. The fifth semenologyworkshop was held in December 2001 at the University of Stellenbosch, Cape South Town, Africa for ten participants from Ethiopia, Kenya, Nigeria, Tunisia, South Africa and Zimbabwe. All participants successfully completed both the theoretical and practical examinations. The objective of the workshop was to nationally establish accepted an standard inter- for the evaluation of semen as human described in the WHO manual, sperm–cer- and semen human of examination the for manual A randomized, double-blind study to compare two compare to double-blind study A randomized, in emergency of levonorgestrel regimens in Nigeria contraception emer- of area the in Programme the by carriedout Research gency contraception has aimed at finding agents thatmore effective are and/or have fewer side-effects than the hor- present the of objective The use. in presently methods monal project is to compare the efficacy andtreatments: side-effects(i) levonorgestrel administered two of in two doses of 0.75 mg at a 24-hour interval;and (ii) admin- levonorgestrel istered in one dose of 1.5 mg. It would be a dose, major single practical one in given be could levonorgestrel if advantage because this would simplify the treatment and increase the The study will be conducted in compliance and acceptability. centres in Nigeria. seven In addition, the project will serve as a training ground in clin- ical research conducted in accordance with cen- of network a developing Good in role a play will Clinical it and Practice tres for clinical research in Nigeria. Finally, the project will of emergency contribute contracep- to spreading awareness tion in various areas in Nigeria, and to data on collecting the use of national levonorgestrel for emergency contracep- tion. Workshops and short courses Workshops workshop semenology international WHO-sponsored The Regional Advisory Panel (RAP) for the African and East- and African the for (RAP) Panel Advisory Regional The ern Mediterranean Regions had, in its in previous meetings 1998 and 1999, agreed that research a multicountry study operations on maternal health should examine the be perceptions of initiated pregnant women, to communities and health personnel on pregnancy complications. Ensuing action would focus on developing appropriate strategies, Studies on community involvement in improving in improving Studies on community involvement care of maternal continuation More details on this work are given in the chapter on “Pro- health of adolescents”. and reproductive moting sexual In response to the recommendations workshop on needs adolescents’ and of perspectives in repro- the intercountry ductive Easternhealth WHO’s in Mediterranean Region, the Department has collaborated with the Regional Office since 2000 to provide technical support for the research proposals development in of the Islamic Republic of Iran, Oman, and the Syrian Republic. Arab Adolescent reproductive health in the WHO Region of WHO Region health in the reproductive Adolescent Mediterranean the Eastern More details on this project in are “Pro- the given chapter on health of adolescents”. and reproductive moting sexual In Senegal, the Programme is collaborating with the FRON- TIERS in Reproductive Health Project funded by the United States Agency for International The (USAID). Development Project FRONTIERS has assumed the entire funding the for research and interventions in Senegal, within one of its own This FRONTIERS-supported projects. project has a broader and Kenya Bangladesh, in out carried being also is and focus Mexico. In 2001, the operations research project health servicesreproductive adolescents contin- improve for to evaluate and ued in fiveFrench-speaking sub-Saharan countries: Benin, Cameroon, Côte d’Ivoire, Guinea and Senegal. and coordinating is this facilitating gramme regional initiative The Pro- and is providing support for the research capacity strength- ening aspects of the the project. However, funding for each country project is being raised A locally. characteristic fea- ture of the project is its implementation by multidisciplinary research teams and the active participation of youth repre- in each team. sentatives Operations research on improving reproductive health reproductive on improving research Operations services adolescents for the sociocultural diversity and complexity of FGM consequences, in and order to design its culturally meaningful and workable programmes towards advocacy and these examining studies intervention for development Protocol strategies. be will proposals and 2001 in continued aspects sociocultural initiated. 164 Annual Technical Report 2001 included reproductive health researchers, programme man- programme researchers, health reproductive included participants research. Programme-relatedThe or supported the MediterraneanEastern Region, in collaborating in Programme- Yemen) and Tunisia Republic, Arab Syrian Sudan, Lebanon, the Arabia, Saudi Pakistan, Oman, (Egypt, Iran, of Republic Islamic countries ten in institutions partic- from 37 ipants were There infection. HIV and diseases mitted fertility regulation, infertility, sexual behaviour, sexually trans- ing human subjects, covering such areas as maternal health, medical, social science and epidemiological research involv- bio- includes context this in research health Reproductive research. health reproductive in practices ethical encourage and on discussion stimulate to was workshop Cairo the of Programme.the with collaborating tres purpose general The tion. These workshops are intended for participants from cen- reproduc- human of field the in subjects human on research devotedworkshops and practice to the principles of ethics in ReviewEthical Programmethe that Group organize regional and Scientific Programme’s the by response recommendation the in to was This Egypt. Cairo, in 2001 November in held was subject this on workshop fourth Department’s The reproductive health Regional workshop onethical issuesinresearch in and reproductive inreproductive rights health”. “Gender on chapter the in given are courses the of Details Africa. South and Kenya in conducted were courses These Courses ongenderandreproductive health Guinea and Tunisia. further tested during training workshops held in Côte d’Ivoire, been have manual training the of modules various whereby 2001, during continued manual a such of development the French.to in manual the trainingSupport standardized a of lack was approach this to constraints the of one However, level.national at training the duplicate could who trainers of training the for need the to pointed evaluation post-training the of results 1997, In implementation. research and tocols pro- research developingfor skills necessary the acquire to French- order in from 1993 since course professionalsthis taken have Africa speaking health 120 than more 2000, Department’s the in indicated As in Africa Regional training course for French-speaking countries Stellenbosch. of University the by coordinated programme Control Quality ticipants have been subsequently enrolled in the Continuous a total of 49 persons have in participated this course. All par- existing. inAfrica semenqualitycontrolnetwork extendthe to was workshop the objectiveof trials. second A clinical WHO-sponsored of results the enhancing to tribute reliablecon- also will and analyses semen human on results morphology. sperm describe repeatableensure will and This that centre the publicationsfrom and interactionmucus vical Section 7- Section Technical cooperation withcountries Annual technical report report technical Annual Since1997, • • robi, Kenya. The objectives are: oftheworkshop Nai- in 2002 early in place take will workshop the and 2001 ondary levels of health care. Preparations were completed in sec- and primary the at management infertility on research operational of study multicountry a of development workshop the for a recommended RAP Regions, Mediterranean Eastern and African the in issue priority a is infertility Since management Regional workshop oninfertility accepted for the2001–2002 academicyear. been have students foreign ten and countries African other completed the course. The course now attracts students from successfully students eight 2000–2001, year academic the In resources. library and facilities computer enhancing and staff academic the strengthen to support building capacity Programme’sincludes The Africa. in groups research ical M.Sc. an Nigeria, which Ibadan, trains professional biostatisticians for biomed- Ibadan, supported of University the has at biostatistics in Programme course the 1999, Since Ibadan, Nigeria M.Sc. course inbiostatistics, University ofIbadan, sity ofIbadan,Nigeria. who is to start a Master’s course in biostatistics at the Univer- in Demography Studies (INED), Paris, of France; Institute and one National from Cameroon, the at Cameroon from one andrology; in forstudies Kingdom, United Edinburgh,burgh, health systems research; on one from Nigeria at the University course of Edin- a for Belgium Brussels, Brussels, of sity Univer- Free the at d’Ivoire Côte from one research; health sexual and reproductive in course Master’s a for Kingdom United London, Hygiene, and Medicine Tropical of School London the at Uganda and Nigeria from each gramme:one Pro- the from awardedgrantswere researchers six 2001, In Research training grants (RTGs) Research Training • countries inthe countries Mediterranean Region. WHO Eastern committees. Three of the six faculty members were also from review ethical national or local of members potential or rent of women’s groups and other individuals who were either cur- agers or planners, representatives of consumers’ groups and

with limitedresources; and countries in infertility of management improved the for blueprint a up draw and future the for perspectives line out- practices, best identify experiences, past review to levels; andsecondary both primary at setting limited-resource a in infertility of management tothe solutions formulate and practices best define to Regions. preventiveformulatea to twothe strategy forin infertility Annual Technical Report 2001 165 There is an supportoverwhelming the for establishment of the Regional Network. and national institutions, of number a are there Although reproductive of field the in working networks subregional there AfricanRegion, the in training and research health The institutions. these links that network regionwide no is Net- Training and Research Health Reproductive African work would serve to link and any in strengthen involved been not have that institutions and existing works net- such Establishing efforts. a regional reproductive health network would be a good way to ensure that best prac- tices and the lessons learnt are shared. to conduct a regional workshop for dissemination of infor- of dissemination for workshop regional a conduct to include should workshop this participantsin mation—the and programmers; researchers policy-makers, to mimeograph the collected database through a lead- team and task investigators principal includes that force ers of the targeted countries; health research directory the reproductive for to develop all countries of the Eastern Mediterranean Region and and update it regularly; to explore funding sources for the development of the health research directory. reproductive The WHO Regions of Africa and the Eastern Mediterranean Eastern and the of Africa Regions WHO The

dinators of Egypt, Islamic Republic of Iran, Lebanon, Saudi Arabia and the Syrian Arab Republic, a representative each Headquar- and Secretariat WHO EMRO from and UNFPA of consultation were: Major recommendations of the ters. • • • • • • Health Research Reproductive African The Network In 2000, the Regional Advisory Panel reviewed a proposal from the Reproductive Health Research Unit (RHRU), Chris Hani Baragwanath Hospital, Soweto, South Africa, for the establishment of an African Regional Reproductive Health Research and Training Network. The feasibility study was funded by The RHRU. objectives of this network would be to forge partnerships, and to develop, improve and support health reproductive research, research training and capacity South- promote to help would It Region. African the in building to-South collaboration, and strengthen linkages research institutions within between the Region. It would also serve as a channel to share information and disseminate research findings and lessons learnt. In 2001, the proposal and 14 a centres questionnaire in five were countries (Kenya, sent Mozambique, Nigeria, to to made were site-visits addition, In Zimbabwe). and Uganda all these countries and consultations held with the directors The study feasibility of health reproductive research centres. report concluded that: OTHER ACTIVITIES OTHER SUMMARY OF COUNTRY ACTIVITIES OF COUNTRY SUMMARY DISSEMINATION OF RESEARCH FINDINGS OF RESEARCH DISSEMINATION An informal consultation for a reproductive health research directory in the Eastern Mediterranean in Region WHO’s was Regional held Officecoor- country the for by attended was It the2001. August in (EMRO) Eastern Mediterranean Data collection for a reproductive health research directory for for directory research health reproductive a for collection Data the French-speaking African countries was initiated in 2001 by the African Network of Reproductive workshop held training to the a follow-up This was Health (RESAR). Research in November 2000 in Ouagadougou, Burkina Faso for par- ticipants of 12 French-speaking African countries. The pur- pose of this initiative is (i) twofold: to improve dissemination of research findings; and (ii) to promotedirectory is expected networking.to be The widely disseminated through the Internet and CD-ROMs. During 2001, the Department collaborated with 35 institu- tions or research groups in 23 countries of the African and Eastern Mediterranean Regions. A brief description of 7.2. the Table in is given at country level main developments During the reporting period, a total of 27 research articles (25 articles research 27 of total a period,reporting the During original papers and articles) two review were and published seven books or book chapters were authored by staff from the eight centres receiving capacity strengthening support. Likewise, 11 presentations were made at national, regional events. or international scientific The dissemination of relevant research findings isrequisite to their a pre- adaptation and utilization by reproductive health programmes and services. Research results have to be shared internationalwith, and and validated local by, sci- entific communities, and the most direct mechanism is their publication in peer-reviewed journals and presentations at events. scientific Training provided by the centres by provided Training abroad of Training staff from Programme-supported centres was complemented by the training programmes organized by the centres themselves for professional staff and from national technical institutions, including service providers. The eight centres receiving research capacity strengthening support have provided individual formal in participated training fellows Forty-five to institutions. local 11 other staff from courses while 878 persons attended short, group-learning activities such as seminars and workshops these centres. organized by Regional directories of reproductive health Regional directories of reproductive 166 Annual Technical Report 2001 Section 7- Section Technical cooperation withcountries Egypt Beni Ethiopi Cameroon Cô Burk voire te n ina F d’ I a aso includes allUniv an affiliateoftheEgyptianMedicalAssociationanditsresearchnetwork Gynaecolog w

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activities. network’sthe of 1998. in part compiled wasbe will This the African Reproductive Health Research Directory that There is an urgent need to update, expand and maintain Zimbabwe MATIC ISSUES Resource Maintenance Gr Z T · · heDepart imbabwe, Harare 3 ongoing research projec has 2 ment ofObstetricsandGynaecolog

ant • the following mainlinesofwork: Activities planned for the next year can be summarized under • •

Department in order to enable them to undertake undertake health needsandpriorities; to them enable to research projects relevant to their identified reproductive order the in with Department collaborating currently institutions maintain and support grants, development institutional through by theDepartment. promote dissemination and utilization of tools developed cal cancer; and maternal HIV/AIDS, cervi- and as FGM health, reproductive adolescent health, such issues key networks on research working regional strengthen and promote ts and22publications PLANNED ACTIVITIESPLANNED y , Univ e rsity of of rsity ;

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tions r (MPS c e health e f fe tiv ing Group t in y sa ork W vical cancer and e trac y tiv r reproduc o y f ment collaboration with genc ng pregnanc G) tilit r W llaboration with other UN e aki f A echnical cooperation with nter-A ncluding cer ncluding countries T Depart I (I in refugee situations Planning and programming in programming and Planning AFRO collaboration with M Reproduc i agencies Co in 172 Annual Technical Report 2001 Marie-Hélène Bouvier-Coll, FrenchMarie-Hélène NationalInstituteofHealthandMedicalResearch(INSERM),Paris, France Collaborating scientist agency Christiane Welffens-Ekra, andGynaecology, ofObstetrics Department University Hospital Yopougon, Abidjan,Côted’Ivoire andGynaecology, ofObstetrics Sekadde-Kigondu,Department Christine University ofNairobi,Kenyatta NationalHospital, Babatunde Osotimehin, The SocialScienceandReproductive University HealthNetwork, CollegeHospital,Ibadan,Nigeria Boniface (SAGO), Gynaecologists andObstetricians Nasah,SocietyofAfrican Buea,Cameroon of andChildHealth(IMCH),Department Women’s Maternal SectionofInternational Gunilla Lindmark, andChildren’s Health, Bailah Leigh,NationalAIDSControlProgramme, ofHealthandSanitation,Freetown, Ministry Sierra Leone Reproductive HealthProgramme, ofPublic Lebanon Mohammed Kanaan,SocialHealthDepartment, Health,Beirut, Ministry Alex Ezeh,Population African andHealthResearchCentre, Nairobi,Kenya Faysal University Faculty El-Kak,American ofBeirut, ofHealthSciences, Lebanon Beirut, Kim Dickson-Tetteh, andGynaecology, ofObstetrics Reproductive HealthResearchUnit,Department HaniBaragwa- Chris Hyam Bashour, ofCommunity Medicine, Faculty Department ofMedicine, DamascusUniversity, Damascus,Arab Syrian andGynaecology, ofObstetrics Hassan Ba’aqeel,Department KingKhalidNationalGuardHospital,Jeddah,SaudiArabia andGynaecology, ofObstetrics Ba,Department Mariame University ofDakar, Dakar, Senegal ofHealth,Muscat,SultanateOman Asya ofResearchandStudies, Ministry Al-Riyami, Department REGIONAL ADVISORY PANEL AND FORAFRICA IN2001 THE EASTERNMEDITERRANEAN Annex 1 Women All EURO EMRO AMRO AFRO from: SEARO WPRO Section 7- Section Technical cooperation withcountries Nairobi, Kenya Uppsala University, Uppsala, Sweden nath Hospital,Johannesburg, SouthAfrica Republic ) (Chairman Number Developing countries 13 6 5 8

% oftotal 93 43 36 57

Number Countries intransition Countries

% oftotal

Developed countries Number 1 1 1

% oftotal 7 7 7

Totals 14 7 5 8 1 Annual Technical Report 2001 173 National University of Benin, Cotonou, National University raphy, National University of Benin, Cotonou, of Benin, Cotonou, University National raphy, raphy, raphy, The WHO Regions of Africa and the Eastern Mediterranean Eastern and the of Africa Regions WHO The Islamic Republic of Iran Islamic Republic Benin Benin NigeriaState, d’Ivoire Eastern Mediterranean Region Mediterranean Eastern Pakistan National Research Institute of Fertility Control, Karachi, Badar Uddin Abbasi, Tunisia Tunis, Population, Family and for National Office Human Reproduction, Rim Ben Aissa, Research Centre for Egypt Cairo, States, Project, League of Arab PAPFAM Samia Charchour, Egypt Cairo, American University, Social Research Centre, Sahar El-Tawila, of Khartoum, University Khartoum, Department the Sudan Abdulazis Gerais, of Obstetrics and Gynaecology, Egypt Cairo, The Egyptian Fertility Care Society, Hassan, Ezzeldin Islamabad, Pakistan DepartmentSamina Jalali, Qaid-i-Azam University, of Biological Sciences, Egypt Cairo, States, Research Unit, League of Arab Khaled Louhichi, Population of Khartoum, University Khartoum, of Medicine, the Sudan Saad, Faculty Mohamed El Fadil Maternity Egypt Shatby Hospital, Alexandria, Sami Said, Department of Obstetrics and Gynaecology, Tehran, Planning, Ministry of Health and Medical Education, National Research Centre in Family Tehrani, Ramezani Fahimeh Mamadou Baldé, University Hospital of Donka, Conakry, Guinea Donka, Conakry, Hospital of University Mamadou Baldé, Mozambique Maputo, Hospital, Maputo Central Department of ObstetricsAntonio Bugalho, and Gynaecology, and Demog Centre of Research in Human Reproduction Virgile Capo-Chichi, Zimbabwe Harare, Zimbabwe, of University Department Chirenje, of Obstetrics and Gynaecology, Zvavahera Nigeria Sagamu, Ogun State University, of Health Sciences, Dada, College Olukayode Senegal Dakar, of Dakar, University of Medicine and Pharmacy, Diadhiou, Faculty Fadel Senegal Dakar, Cheikh Anta Diop de Dakar, de Médecine et de Pharmacie, Université Faculté Djibril Diallo, Nigeria Lagos, of Lagos, University College of Medicine, Osato Giwa-Osagie, Nairobi, Kenya National Hospital Campus, Kenyatta of Nairobi, College of Health Sciences, University Jaldesa, Guyo Kenya Nairobi, National Hospital Campus, Kenyatta College of Health Sciences, of Nairobi, University Joseph Karanja, of Zambia, Lusaka, Zambia University Christine Kaseba, Department of Obstetrics Gynaecology, and Ethiopia of Addis Ababa, Addis Ababa, University Kassahun Kiros, Nigeria Abuja, and Children, Women National Hospital for Mairo Mandara, Kampala, Uganda University, Makerere DepartmentFlorence Mirembe, of Obstetrics and Gynaecology, Nairobi, Kenya Institute of Primate Mwenda, Research, National Museums of Kenya, Jason Ghana Bolgatanga, Help Integrated, Rural Odoi-Agyarko, Kwasi of Ibadan, Ibadan, Nigeria University DepartmentOladosu Ojengbede, of Obstetrics and Gynaecology, Nigeria Hospital, Benin City, Teaching of Benin University Department Okonofua, of Obstetrics and Gynaecology, Friday Nigeria Benin, Benin City, of University Department Orhue, of ObstetricsAugustin and Gynaecology, Plateau Hospital, Jos, Teaching Jos University of Jos, University DepartmentJoseph Otubu, Obstetrics of Gynaecology, and of Nairobi, Nairobi, Kenya University Department Oyieke, of Obstetrics and Gynaecology, James Cotonou, Benin Health Research, African Network of Reproductive René Perrin, Cameroon Yaoundé, Health Research, African Network of Reproductive Tantchou, Justine Health, Abidjan, Côte Health, National Institute of Public National Research Cellule of Reproductive Bonle, Te Marguerite of Nairobi, Nairobi, Kenya Biology Unit, University Reproductive Wango, Emmanuel Nairobi, Kenya Medical Research Institute, Research, Kenya Clinical Centre for Wasunna, Monique K. Michel Akotionga, Maternité du Centre Hospitalier National Yalgado Ouedraogo, Ouagadougou, Burkina Ouagadougou, Faso Ouedraogo, Yalgado MaternitéMichel Akotionga, Hospitalier National du Centre and Demog of Research in Human Reproduction Eusebe Alihonou, Centre African Region African Annex 2 Annex IN 2001 COLLABORATING SCIENTISTS 174 Annual Technical Report 2001 described inthefollowingdescribed section. are strategies these under implemented activities main The • • • The following strategies were selected for attaining this goal: dissemination andutilizationofrelevant researchfindings. regional reproductive health problems; and (ii) to promote the relevanttopics in projects research designed and national to cas, by promoting and supporting the implementation of Ameri- well- the of Region WHO the in institutions collaborating Programme-supported in continue capacity to research (i) were: strengthening biennium 2000–2001 the for (RAP) Panel Advisory Regional the byestablished goals main The intheglobalresearcheffort. itate theirparticipation health reproductive research relevant to implement national and regional needs, and to to facil- potential further their to undertaken enhance was Americas the of the Region in WHO institutions of capacity research the Strengthening Section 7- Section Technical cooperation withcountries

health programmes andservices. reproductive in utilization and adaptation their facilitate to results research relevant of dissemination increased and resources; human of strengthening and development sciences; reproductive biology, clinical/epidemiological basic investigations and social in networks research national and regional of strengthening the through particularly effort, research global the in reproductive participation and research health national and regional of implementation INTRODUCTION The WHO RegionoftheAmericas E. Ezcurra o h Isiuo e eiia Booi Eprmna de Experimental Biologia y Buenos Aires, Argentina is centered on Medicina the project: “Epididy- de Instituto the to The Long-term Institutional Development (LID) Grant awarded grantscapacity-strengthening with research supported Projects directly of 10%overnearly the1999figures. increase an projects, science social or epidemiological were (36%) 48 studies, research 132 the from that, noting research address worth is it approaches, methodological different to from issues developed capacity to respect With from international agencies other than WHO. regionalreceivedcentresthesesupport in outcarried (38%) projects 51relevance. 2000,local Duringor global of topics address to agencies international other from fundraising for gramme in its regional Pro- centres have the enhanced bytheir capacities deployed efforts strengthening institutional the Department.fromtheThematic supportAlso, ofGroupswith institutions collaborating these in conducted (14%) projects exemplified19 the is researcheffortglobalby the incentres support from national sources. The participation of the withcentresregional the at out carriedwere Fifty-two(39%)projects Grants).Development,Re-entryMaintenance Resourceand Programme’scapacity-building grants (Long-term Institutional ble), 10 projects (8%) were implemented with support from the during2000 (the last year for which complete data are availa- and national priorities. From the overall number of 132 regionalstudies address which projects involved in were grants ing Thecentres11 supported withresearch capacity-strengthen- Overall research output RESEARCH ACTIVITIES Annual Technical Report 2001 175 The WHO Region of the Americas Region of WHO The DEVELOPMENT OF HUMAN RESOURCES OF DEVELOPMENT the four final country reports are readyfor review, and the remaining two should be completed by the end of the year. Preliminary results and methodological issues related to the study have been disseminated in presentations international events. and seven national local teams in two made by Projects covering all areas of reproductive health of reproductive all areas covering Projects Resource Maintenance Grants were also awarded to research five institutions in Brazil, Chile (2), Cuba and Peru to assist in the implementation of comprehensive reproductive health research programmes. Basic reproductive immunol- ogy, contraception, maternal and child health, reproductive tract infections and adolescent reproductive some of health the topics were covered. The scientific output five institutionsof these in 2000 (data on 2001 are not yet available) amounts to 72 original articles published in 38 national and 34 international journals. In 2001, 14 scientists from regional centres received grants to undergo training in the areas of reproductive epidemiol- reproductive ogy, medicine, the social sciences and molec- ular biology. In addition to grants directly Brazil (3), Argentina from women) (5 awarded fellows six Programme, by the (1), Costa Rica (1) and Nicaragua (1) received grants from to undertake within the Region. training PLACIRH Resources for Training Grants continued to be awarded to the Institute of Nutrition in Mexico City and to the National Institute of Public Health, Cuernavaca, Mexico to regional support postgraduate courses in reproductive biology and respectively. epidemiology, reproductive 7.4 Table summarizes the overall number of training grants awarded in the 2000–2001 biennium. Nineteen fellows (10 women) received grants for short- and long-term mostly (11) in centres located in Latin America. training, Progress of research programmes mostly programmes of research Progress other sources by cofunded neonatal health research and on maternal Projects A Resource Maintenance Grant (RMG) was awarded to the Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina to facilitate the coordination and the implementa- tion of regional research in maternal and and Only supportbasic, its role as a regional centre. neonatal training health core support was provided—neither specific training activities projects were funded. During the nor 2000–2001 bien- nium, CREP completed seven research projects and seminated their dis- results in ten originaltraining, to respect articles With published journals. in peer-reviewed international, medicine evidence-based 14 organized Centre the from staff and Argentina within locations different in offered 12 courses, abroad. two and from a of review Bulletin The second main task of CNEP is the coordination “Reality and beliefs research regional, project multicentre on of the in the sexual and reproductive perceptions men’s and which behaviour” includes social decision-making sci- process: of ence groups from Two Argentina, Bolivia, Cuba and Peru. The third recipient of a LID Grant is the Centre for Population Population for Centre the is Grant LID a of recipient third The Studies (CENEP) in Buenos Aires, Argentina which coordi- The network has nates the regional social sciences network. social on information disseminates it First, purpose. twofold a sciences research relevant to reproductive health, on train- ing opportunities, scientific meetings, In etc. the 2000–2001 bul- four and newsletters 21 published network the biennium, letins; a web page was designed and made operational in Furthermore, CENEP 2001. prepared a November librarians CD-ROM with a bibliography on the from Social information Aspects of incorporating Human (1990–2001), Reproduction the network’s holdings, library’s the to 2002 January in available be will CD-ROM The journals. network. the of members The Guatemalan Research Research is the second Centre recipient of the three awarded during on the The LID biennium. Centre’s activities during Grants Epidemiologic this period focused on the project to “Strategic identify priority assessment interventions that would improve access to and quality of family planning, care in Guatemala”. maternal A background paper and was produced by neonatal the Centre and discussed at the planning workshop held in August 2001, in which a wide representation of national key car- was assessment strategic The participated. stakeholders ried out in October 2001 in five departments ofGuatemala, char- social and ethnic cultural, nation’s the of representative Furtheracteristics. details on the strategic assessment may issues”. and programme in the report“Policy be found on mal proteins that participate in gamete interaction and their potential use for male fertility regulation”. The first specific aim of the project (Aim A) was to study the potential contra- ceptive use of an already identified epididymal protein (pro- three first the During fusion. gamete mediates which DE) tein years of the grant, protein DE was cloned, sequenced and expressed as a functional protein in a prokaryotic system. Recent evidence that revealed DE has significant homology with a human epididymal protein also involved The fusion. in tissue specificity gamete and immunogenicity of DE, its role in fertilization, the possibility of producing the antigen in large amounts by recombinant DNA technology, and the existence of its functional homologue in humans, strongly support the potential use of this epididymal protein for the future development of immunocontraceptives suitable Considering that human no use. single antigen provoke may for the immune response required for a contraceptive method, the second aim of this project (Aim B) was to identify characterize and novel epididymal proteins involved in gamete interaction. The recent development of a cDNA expression library towards human epididymis will allow further charac- terization of the proteins at a molecular level. 176 Annual Technical Report 2001 tives completed in the present biennium: (i) acceptability initia- research regional two the to related activities tion are the information dissemina- importance Of particular research initiatives Dissemination ofresults from regional andmeetings. journals regional andinternational national/ in presentations dis- and publications the of shows tribution 7.6 Figure agencies. and international and authorities national to presented were reports official 28 and events scientific international or regional national, in made were presentations 286 Furthermore, staff support. capacity-strengthening byreceiving centres from authored were chapters book and books 56 and published, were reviewarticles) 23 and papers nal origi- (174 articles research 197 of total a 2000, During centres receivingresearchcapacity-strengtheningsupport. organizedby workshops the and seminars as such activities group-learning short, attended 1480 and courses formal in from other local institutions. A total of 216 fellows participated staff 76 to training individual provided centres 11 the 2000, technical and providers. institutions,national from staff service including In professional for themselves centres the by was centres supported organized programmes extensivetraining by complemented the from staff of abroad Training Scientific publications Section 7- Section Technical cooperation withcountries DISSEMINATION OFRESEARCH FINDINGS R C W W W Ph.D. course Short R T ourse T orksho orksho orksho G G course p p p Programme Ev C Reproductive P Biology ofImplantation Molecular Biology E S ublic Health ommunicatio pidemiology ocial Sciences ocial Health aluation n

sive, particularly inChile(seeBoxsive, 7.1). particularly advocacyand havedissemination information of inten- been investigators—activities of teams three the by undertaken publications scientific five and activities training and demic aca- events—four scientific in presentations nine the to tion disseminated. addi- widely In havebeen study the of results the contraception, emergency on study the to respect With Cuba andPeru, mentionedabove. reproductive health: a multicentre study in Argentina, Bolivia, (ii) the role of men in the decision-making process that affects Mexico;and Chile Brazil, in contraception emergency of and 1 3 1 2 3 3 1 2 2 1 2 1 1 1 1 1 2 2 2 Annual Technical Report 2001 177

t

the , e t in numerous rnmental e v estigators and v The WHO Region of the Americas Region of WHO The nongo t's in The opinions and views

. iced through the mass er rape was prepared as a spin-off spin-off a as prepared was rape er the projec t nistries of Health and Justic i M y 2001, e Medicine (ICMER) took par ention af tiv Two institutions in Santiago continued to receive support: the support: receive to continued Santiago in institutions Two Chilean Institute of Medicine Reproductive (ICMER) and the Catho- the at Development and Biology Reproductive of Unit These lic centres University of also Chile. participate in Pro- gramme-supported institutional development activities and centres. act as regional training Bolivia Bolivian investigators associated with the Centre for Social Research, Appropriate Technology and Training (CISTAC), La participatedPaz in the four-country research initiative on decision-mak- of respect in behaviour and perceptions men’s ing processes affecting sexual and The reproductive health. final countryJanuary report in 2002. expected to be ready is Brazil The Campinas Research Centre and for Control of Maternal Campi- of University the of (CEMICAMP) Disease Infant and nas has been the main recipient of Programme support in the Grants cover work undertaken the on country. training in epidemiol- clinical in research on and methodology research intro- contraceptive to relevant issues science social and ogy duction and other aspects of women’s reproductive health. stud- sciences social and clinical the in part took CEMICAMP is and trial section caesarean regional the with concerned ies implementing a Programme-supported study on counselling services. planning in family Chile ices, parliamentarians, parliamentarians, ices, v ebruar radio and in the written press legal medical ser y and STI/HIV/AIDS prev icipated in the project were sought and vo projectand the in sought were icipated t ed on television, television, on ed t

contraception (EC) in Chile in F in Chile in (EC) contraception etc. s who par , y t c omen's Secretariat, omen's W COUNTRY REPORTS COUNTRY r emergenc o National In view of the public controversy caused by the attempted registration of a dedicated produc dedicated a of registration attempted the by controversy caused public the of view In f of the study and was widely disseminated among the media. The protocol on pregnanc organizations of the subje other staff from the Chilean Institute of Reproduc debates on EC conduc The Centro de Estudios de Estado y Sociedad (CEDES) in Buenos Aires coordinated the social science component of on caesarean section. the regional initiative The Institute for Experimental Buenos Aires continues to basic develop Biology sciences research and Medicine fertility. in the field of male in The Centre for Population Studies (CENEP) in Buenos Aires Buenos in (CENEP) Studies Population for Centre The is the coordinator and one of the study sites of the regional multicountry social science study on men’s perceptions and behaviour with respect to decision-making processes affect- health. reproductive and ing sexual Support has continued to the Centre for Perinatal Studies (CREP) in Rosario. CREP conducts research in the areas of maternal and infant health, adolescent health and repro- ductive health epidemiology, and serves as a training and countrythe the and for centre referral methodology research Region of the Americas. Argentina In 2001, the Department collaborated with in 20 10 countries institutions of Latin America: Argentina, Bolivia, Brazil, Chile, Colombia, Cuba, Guatemala, Mexico, Peru and Ven- coun- at developments main the of description brief A ezuela. follows. try level 178 Annual Technical Report 2001 agencies. In 2001, the Institute continued to receive a Basic a receive to continued Institute the agencies.2001, In funding international other and Department the of Groups Thematic various the with involved actively also is Institute programmes for the improvement of reproductive health. The including the Ministry of Health, which has extensive national rating centres receive major support from national authorities country.the in grammesupport collabo- its and Institute The National the in Institute of Nutrition, Mexico City is the main recipient of Pro- Biology Reproductive of Department The Mexico natal careinGuatemala. neo- and maternal planning, family of quality and to access improve would that interventions priority identify to 2001 in sarean section study. A strategic assessment was conducted cae- regional the of components sciences social and clinical the both in participated also centre Guatemalan orities. The pri- research country’s health the on focused programme reproductiveresearch a develop to mainly City support Guatemala received Hospital, Dios de Juan San the at based Health Reproductive in Group Research Guatemalan The Guatemala section study. caesarean regional the of components sciences social and clinical the both in participated Hospital Arias America The reproductive adolescent of health. field the in research global in active also is and health” reproductive and sexual affecting tions and behaviour in respect of decision-making processes percep- “Men’s on initiative research regional four-country nology. the Institute’simplemented The Unit Sciences Social immu- reproductive of area the in research sciences basic continuesThe National Institute of to Endocrinology conduct ESEX). (CEN- Education Sex for Centre National the and Hospital Coro Gonzalez Ramon the Arias, America ogy,Hospital the the duction, which comprises the National through Institute of Endocrinol- channelled is Cuba National Coordinating Network in for Research in activities Human Repro- to Support Cuba pre-eclampsia. of treatment the forsulfate magnesium of use evaluatesthe that Kingdom, United University,Oxford, Oxford by dinated coor- trial “Magpie” the in part take receiving to is support Cali Programme in Valle del University the at Centre The Colombia Section 7- Section Technical cooperation withcountries tive health”. reproduc- and sexual affecting processes decision-making of respect in behaviour and perceptions “Men’s on research initiative science social regional four-country, the of sites the of one was Lima in Studies Population for Institute The reproduction athighaltitudeandreproductive immunology. adolescents, of health reproductive of areas the in studies presently receiving a Resource Maintenance Grant, includes health. reproductive in Research carried out by centre the Institute of Research on trainingAltitude, and serves resource which a Lima as the in to Heredia Cayetano affiliated University centres Peru two supported Programme The Peru new initiatives. launching of process the initiate to Region the to and tries the regional networks will identify topics of relevance to coun- resulting from regional research initiatives. At the same time, those particularly findings, research of utilization and nation dissemi- the on placed be to continue will emphasis Special course inoperations research. training regional a for curriculum a develop to Council tion in collaboration with the FRONTIERS initiative of the Popula- identified.be will tres done been has work preliminary Some cen- regional from fellowsfor opportunities training and ties operations of research: area regional centres that will the be involved in in these activi- capacity strengthen to need the was priority top of as identified was that strategy new One fate for thetreatmentofpre-eclampsia. sul- magnesium of use the evaluates that Kingdom, United in the “Magpie” cios in Caracas. FUNDAMATIN received to take support part Pala- Concepción Maternity the at based organization profit non- private, (FUNDAMATIN),a Child and the Mother of for Study Foundation the with collaborates Programme The Venezuela temala, Mexico, Panama, Peru and Venezuela. Gua- Cuba, Chile, Argentina, in centres gramme-supported students graduated has Cuernavaca.in centre its Publicat of Health tute course The in reproductive epidemiology organized by the National Insti- programme degree M.Sc. two-year the to is grant Another inresearchtraining. sive participation Resources for Training for support Grant,its exten-as partial trial trial coordinated by Oxford University, Oxford, PLANNED STRATEGIESPLANNED vr h ps tn er fo Pro- from years ten past the over Annual Technical Report 2001 179

1 8 9 4 Totals

11 33 44 11 % of total The WHO Region of the Americas Region of WHO The

1 3 4 1 Number Developed countries Developed

% of total

Countries in transition Number

56 56 33 % of total

5 5 3 Number Developing countries Developing WPRO EURO SEARO AMRO EMRO Members Women from: AFRO

Luis Bahamondes, PLACIRH, Mexico City, Mexico City, Mexico PLACIRH, Luis Bahamondes, USA NC, Park, Triangle Health International, Research Roberto Family Rivera, Mexico City, Council, Mexico The Population Schiavon, Raffaela Collaborating agency scientists Collaborating

Carlos Cáceres, REDESS Jovenes, Lima, Peru Jovenes, Carlos REDESS Cáceres, Argentina Buenos Aires, Hospital de Niños, Stella Campo, Barcelona, Spain Díez, Hospital del Mar, Adolfo Canada Quebec, University, Laval William Fraser, de Bogotá, Colombia Ana Cristina González, Santafé ) USA (Chairwoman CA, of California, Health, University Guendelman, School of Public Sylvia R. Rica Costa de Costa Rica, San Jose, Universidad Luis Rosero Bixby, Bolivia La Paz, Silvia Salinas, USA Hartford, CT, College, Trinity Trostle, Jim Members Annex 1 Annex THE AMERICAS FOR PANEL ADVISORY THE REGIONAL OF MEMBERS 180 Annual Technical Report 2001 WPRO SEARO EURO EMRO AMRO AFRO from: Women All Serrón-Ferré,María Pontifical CatholicUniversity, Santiago, Chile Romero,Carmen HospitalJ.J. Aguirre, Santiago, Chile Oscar Rojas, University of Valle, Cali,Colombia Silvina Ramos, Centrefor theStudyofStateandSociety(CEDES),BuenosAires, Argentina Edith Pantelides, Centrefor Population Studies(CENEP),BuenosAires, Argentina Nagle,Carlos Centrefor MedicalEducation andClinicalInvestigation (CEMIC),BuenosAires, Argentina Gladys Muñoz,SimónBolivar University, Caracas, Venezuela Moreno,Carlos Centrefor ResearchinHumanReproduction,Panama City, Panama MexicoFernando Larrea,NationalInstituteofNutrition, City, Mexico Edgar Kestler, EpidemiologicResearchCentre, GuatemalaCity, Guatemala NationalInstituteofPublic Health,Cuernavaca, Hernández, MexicoBernardo Ellen Hardy, Centrefor andInfant ResearchandControlofMaternal Disease(CEMICAMP),Campinas, Brazil Gustavo Gonzales, Peru University Cayetano Heredia,Lima,Peru Franklin García,Centrefor SocialResearch,Appropriate Technology and Training (CISTAC), LaPaz, Bolivia Freddy Febres, Foundation for theStudyofMotherandChild(FUNDAMATIN), Caracas, Venezuela Graciela Etchegoyen, Centrefor (CENEXA),LaPlata, Argentina Endocrinology AppliedandExperimental Oscar Diaz,NationalInstituteofEndocrinology, Havana, Cuba Luigi Devoto, Institutefor andChildHealthResearch(IDIMI),Santiago, Maternal Chile (LARLAC),Ricardo Deis, ReproductionandLactationLaboratory Mendoza,Argentina Patricia Cuasnicú,Institutefor Medicine(IBYME),BuenosAires, BiologyandExperimental Argentina Horacio Croxatto, ChileanInstituteofReproductive Medicine(ICMER),Santiago, Chile Carroli,CentreforGuillermo Perinatal Studies(CREP),Rosario, Argentina Stella Campo, ResearchCentre(CEDIE),BuenosAires, Endocrinology Argentina Susana Bassol,University ofCoahuila, Torreon, Mexico Andrade, CentreforAmaury Reproductive Biology(CBR),Juiz deFora, Brazil Alvarado,Gloria Institutefor ScientificInvestigation, Durango, Mexico Principal investigators SCIENTISTS IN2001 Annex 2 Section 7- Section Technical cooperation withcountries Number Developing countries 26 11 26

% oftotal 100 100 42

Number Countries intransition Countries

% oftotal

Developed countries Number

% oftotal

Totals 26 11 26

Annual Technical Report 2001 181 51 24 427

AWARDED IN 2001 AWARDED Department scientific meetings articles and abstracts. OUTPUTS GENERATED BY THE CENTRES IN 2001 BY GENERATED OUTPUTS RESEARCH CAPACITY-STRENGTHENING GRANTS GRANTS CAPACITY-STRENGTHENING RESEARCH The WHO Regions of South-East Asia and the Western Pacific Western the and of South-East Regions WHO Asia The Table Table 7.5 shows the have list received of Long-term countries Institutional and Development Grants and (LID) centres Resource Maintenance that Grants (RMGs) during 2000–2001. Grants In addition, during 2000–2001, Training 14 Research countries in to scientists from developing given were (RTGs) Regions. the within trained were them of Twelve Regions. the Singapore Malaysia, India, China, in centres years, recent In Thailand and have hosted an increasing number of trainees under- significant requiring disciplines research of variety a in standing of local public health issues and epidemiologi- using studies community-based include These cultural values. which there is a pressing need cal or social science skills for setting. in a similar cultural training to provide As in collaboration years, previous between the Department and the grant recipient institutions in the Regions has been by: and successful in 2001, as evidenced productive —ongoing research projects supported the by courses/ —symposia/workshops/training review including original papers, —publications A notable example is the 11th Annual Indian Conference Society of for the the Study of Reproduction and Fertility, Wang Yi Fei , P.J. Rowe, A. Ntabona A. Rowe, P.J. , Fei Yi Wang the Western Pacific Western the INTRODUCTION The WHO Regions of South-East Asia and Regions of South-EastWHO Asia The Second, translating the reproductive health approach into concrete action is a daunting others, task raising and public includes, awareness among and harnessing commitment and political community involvement; expanding inte- grated services and ensuring their accessibility to hithertoof young (men, users range neglected wide a to and women people, marginalized strengthening populations); the capac- ity for programme monitoring and and evaluation; establish- system research health reproductive national enabling an ing and culture. Although significant progress has been made instrengthen- ing research capabilities brought which about have changes in reproductive health care policies faced currently and is Department the servicesRegions, these of countries in many with two major challenges. First, the human, technical and financial resources currentlyavailable to these Regions are grossly inadequate responding for to the enormous diversity of reproductive health status of the huge population, espe- cially in Asia. The WHO Regions of South-East Asia Pacific comprise and 46 countries the distributed Western over a very wide territory, representing a huge and diverse population (about 60% total) of and the a world’s variety of health reproductive Department the of this in objectives broad three The profiles. complex geographical area are: (i) to ensure that the needs of activities all in reflected are therein countries developing of the Department technical and financial receive and that they support to strengthen their capacity to undertake research (ii) to decision- apply in health; evidence-based reproductive making in programme development; and (iii) to care health implement reproductive improve to interventions appropriate and services. 182 Annual Technical Report 2001 reproductive healthprogrammes. institutional and levels and in national determining the goals and objectives of national at research health for reproductive priorities setting in role leading Thailand). a and play networks Lanka These Sri (China, countries three in tions institu- research between established been have Networks and Health of Family Ministry Welfare. Indian the and Research Medical for Council Indian the Delhi, New Reproduction), Human in Medical Sciences (a WHO Collaborating Centre for Research of Institute India All the by organized jointly was ticipants.It par- 100 than more by attended was which 2001, January in India Delhi, New in Contraception Emergency Con- for sensus National on Consortium the with conjunction in held National research institutionsnetworks Section 7- Section Technical cooperation withcountries PROGRESS ONREGIONALRESEARCH INITIATIVES G Deve Grant (RMG Resource Maintenance ran t lopment (LID) )

R D Lao P China V M Indi Sri Lank Mongolia epubli iet Na emocratic y anmar a eople's m c a

Nor Centre(W Y Depart State Research Centre on Mother and Child Health and HumanReproduc Health M Jaffna and disciplina Hung R National All IndiaInstituteofMedicalSciences(AIIMS), N Institute National Univ Reproductiv a eproductiv ew Delh ew aternal and Child Health Centre, Mi ngon th Sumatra, e rsity, Surabaya V (NTC), Shanghai. Drugs Regulation Fertility of Toxicology the for Centre Evaluation National (8) Chengdu; (FPRIS), Sichuan of Institute Research ning Hanghzou;Family (FPRIZ), Plan- (7) Zhejiang of Institute Research Planning Family (6) Tianjin; (TMRIFP), Planning Familyfor Institute Research Municipal Tianjin (5) Beijing; Research, (IPRPU), University Peking Population of Institute (4) Beijing; (PUMCH), College Hospital Medical Union Peking Parenthood (3) Shanghai; Planned (SIPPR), of Research Institute Planning Shanghai Family (2) for Beijing; Institute (NRIFP), Research National (1) are: These reproductive health services in western China. inwestern reproductive healthservices integrated (iv) and promotion; baby healthy (iii) infections; tract reproductive for intervention (ii) care; contraceptive of quality the improving (i) on: components community-based gramme for the next decade comprising four comprehensive, Pro- Health Reproductive National Chinese the formulate to Board, Coordinating National which brings together the eight research institutions,1 has example, helped for China, In , ment ofMedicalResearch, Vi u ong Hospital, for Research in Reproduc forin Research C C entian r i IRHDC), o y T o P ordination ordinating Boardwitheightinstitutes eradeniya e Health e HealthResearch ask Medan e F

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Annual Technical Report 2001 183 were conducted in: were is almost completed in: MATIC ISSUES MATIC Action research ability and utilization of essential obstetric care at the emphasis on intrauterine devices, and emphasis on intrauterine devices, ities supported by the International Consortium for Emergency Contraception. —Lao PDR: where it focuses on strengthening the avail- the strengthening on focuses it where PDR: —Lao —China: on introduction of contraceptives with an of the introductory activ- on the evaluation —Indonesia: ippines, ippines, Sri Lanka, Thailand and Viet This Nam). study determin- of objectives the with mid-2000 in initiated was ing the complication rates with vaginal deliveries com- sections. caesarean emergency to and elective to pared the for patients the by incurred costs average addition, In predictors the will as estimated, be will procedures three for elective and emergency caesarean sections among the social variables of the patient, the obstetrician and the hospital. Stage II: . Strategic assessments Strategic Stage I. “Regional research initiative on adolescent migrants and migrants adolescent on initiative research “Regional reproductive health in the Greater Mekong region” is a five-country joint researchPeo- (China, programme Lao ple’s Democratic Thailand Republic, Myanmar, and Viet identify will 2000, early in started which study, This Nam). adolescent migrant populations, and interview selected knowledge their migration, for motivation their on groups access their and health, reproductive of perceptions and health services. to reproductive

The WHO Regions of South-East Asia and the Western Pacific Western the and of South-East Regions WHO Asia The • HIGHLIGHTS OF JOINT ACTIVITIES ON PROGRAM-ON ACTIVITIES JOINT OF HIGHLIGHTS health the quality of reproductive Improving care The Department has “The developed Strategic Approach to services”health reproductive of care of quality the improving which three involves stages, as described in the chapter on issues”. and programme “Policy During 2000–2001, the main as were Approach Strategic activities the of context the within Regions carried out in the follows: • • Finally, Finally, a joint plan of action, including country-specific both activities,was prepared regional during theregional and technical/training workshop on of prevention cervical cancer held in Kuala Lumpur, Malaysia on 26–31 March The 2001. workshop was jointly organized by the WHO Collaborating Centre for Research in Human Reproduction at the Depart- ment of Obstetrics and Gynaecology, Cantonal University Hospital of Geneva, the WHO Regional Officefor West- the and the Department.ern Pacific “Collaborative “Collaborative reproductive epidemiology research: pat- terns and predictors of caesarean section a in ten-country Asia” is joint research programme (Bangladesh, China, Indonesia, Mongolia, Myanmar, Nepal, the Phil-

• The implementation stages of the following two regional joint regional two following the of stages implementation The are the most advanced: research programmes Scientists in advanced research countries in the Regions two servethese as institutes coordinators for of developing regional joint research projects, and scientists countriesdeveloped participate from in these projects in order less- to learn how to develop well-designed research projects and data of local value. generate Several Several regional joint research programmes were initiated during the biennium in order to stimulate regional network- ing and thus render research capacity-strengthening efforts more cost-effective. Regional joint research networks research Regional joint Both South-to-South and North-to-South networks have been have networks North-to-South and South-to-South Both One strengthened. example of the latter is the twinning pro- gramme between the Prince of Institute Shanghai Henry’s the and Australia Melbourne, Institute Research, of Medical Research, Shanghai, China. Planned Parenthood Each network includes one or two “advanced” developing countries countries, and “less-developed” as several well as advanced institutes from countriesdeveloped with a view to resources within the Regions. optimizing the existing Intraregional cooperation networks cooperation Intraregional This mechanism is being set Department in up order with to utilize support the from the respective more mature institutions strengths in the the two The of Regions. objec- tive is to them involve in creative ways to assist in strength- reproductive national and research health reproductive ening health programmes in their neighbouring developing coun- identities. and cultural tries with similar demographic Research in reproductive health in Sri Lanka has been under- been has Lanka Sri in health reproductive in Research taken by four multidisciplinary groups and these are coordi- Reproductive on Research for Committee National a by nated Health based in Colombo. The Thai network comprises three university departments of obstetrics and gynaecology and regional seven hospitals. Support completed in 1999. to this network was An international conference was jointly organized by the Chi- the by organized jointly was internationalconference An nese Government and the WHO Country Office in Beijing on 5–9 June 2001 with the dual objective of presenting the national these of outcomes expected the and workplan goals, and seeking programmes national and international partner- their implementation. ships for 184 Annual Technical Report 2001 • Section 7- Section Technical cooperation withcountries

Stage III: Scaling-up —Myanmar: where it aims at developing a district-leveldeveloping a at aims it where —Myanmar: Ve Nm t fcltt a ie itouto o the of introduction wider a facilitate to Nam: —Viet oe fr mrvn te ult o fml planning family services. of quality the improving for model andcommunity levels;district and provision ofallcontraceptive methods. acetate (DMPA), while improving the quality of care in depot-medroxyprogesterone contraceptive injectable is currentlyongoingin: chapter on “Implementing bestpractices”. from ten provinces. The IBP process has been detailed in the managers planning family senior 45 of participation the with China Beijing, in wereheld workshops process,twonational this documents. Topromote guidance technical of process) to port the dissemination, adaptation and utilization (the DAU on a strategy to implement best practices (IBP) through sup- worked partners, its with collaboration in Department, The Adaptation andapplication ofnorms andtools Annual Technical Report 2001 185

5 5 8 Totals

13 13 % of total

1 1 Number Developed countries Developed

% of total The WHO Regions of South-East Asia and the Western Pacific Western the and of South-East Regions WHO Asia The

Countries in transition Number

63 63 88 % of total

5 5 7 Number Developing countries Developing Science, Peking University, Beijing, China University, Peking Science, Victor H.H. Goh, Department of Obstetrics and Gynaecology, National University of Singapore, Singapore (ChairmanSingapore, of ) National University Goh, Department Obstetrics of Gynaecology, and Victor H.H. Jakarta, of Indonesia, Indonesia University of Economics, Faculty Institute, Sri Hatmadji, Demographic Australia Canberra, National University, John Hearn, Australian of Biological Sciences, Research School Dhaka, Bangladesh Nasreen Huq, Naripokkho, Chennai, India Vellore, Mathai, Christian and Hospital, Medical College Matthews Myanmar Yangon, of Medicine (1), Hospital, Institute Women’s Tin, Central Than Than Thailand Nakorn Prathom, Social Research, Mahidol University, and Population Institute for Yoddymnern-Attig, Bencha Health and Population Reproductive Centre for WHO Collaborating Research, Zheng, Institute of Population Ying Xiao Members Annex 1 Annex IN 2001 THE PACIFIC ASIA AND FOR PANEL ADVISORY REGIONAL SEARO EURO EMRO AMRO from: AFRO Women Women Members

Diana L.C. Galwaduge, Office of the Provincial Director of Health Services, Sangaraja Mawatha, Kandy, Sri Lanka Kandy, Director of Health Services, Mawatha, Sangaraja Office of the Provincial Galwaduge, Diana L.C. Malaysia Lumpur, Kuala Ministry Bangsar, Health Institute, of Health, Jalan Hamid, Public Bte A. Maimunah Harun-Ar-Rashid, Bangladesh Medical Research Council, Mohakhali, Dhaka, Bangladesh of Korea Seoul, Republic Yeongdeungpo, of Korea, Federation Planned Parenthood Lee, Sea-Baick Temporary advisers Temporary 186 Annual Technical Report 2001 All Zheng Xiaoying, InstituteofPopulation Research,Peking University, Beijing,China Yang Hua,Family PlanningResearch InstituteofZhejiang,Hangzhou,China Nguyen Thi Thuy, Hung Vuong Hospital,HoChiMinhCity, Viet Nam ofHealth, Soe ofMedicalResearch,Ministry Thein, Department Yangon, Myanmar Harshalal Seneviratne, andGynaecology, ofObstetrics Department Faculty ofMedicine, University ofColombo, Colombo, Bouavanh ofPublic andChildHealthInstitute, Health, Ministry Senesathith,Maternal Vientiane, LaoPeople’s Democratic Janchiv Radnaabazar, StateResearchCentreonMotherandChildHealthHumanReproduction,Ulaanbaatar, Mongolia InstituteforChander Puri, ResearchinReproduction,Mumbai,India Piya Netrawichien, ChiangMaiUniversity, ChiangMai, Thailand Suneeta Mittal,AllIndiaInstituteofMedicalSciences, New Delhi,India Sumatra, Medan,Indonesia Delfi Lutan,University ofNorth Liu Xiaozhang,Family PlanningResearchInstituteofSichuan,Chengdu,China Hou Qingchang, Tianjin MunicipalResearchInstitutefor Family Planning, Tianjin, China Gu Zhongwei, NationalResearchInstitutefor Family Planning,Beijing,China Ge Qin-Sheng,Peking UnionMedicalCollege, Beijing,China Gao Ersheng,ShanghaiInstituteofPlannedParenthood Research,Shanghai,China Nguyen Duc Vy, Institutefor Hanoi, theProtectionofMother andNewborn, Viet Nam Virasakdi Chongsuvivatwong, ofSongklaUniversity, Prince Hat Yai, Thailand Chen Hailin,NationalEvaluation Centrefor the Toxicology RegulatingDrugs, Shanghai,China ofFertility ofCentresHeads in2001 REGIONAL SCIENTISTS Annex 2 Women AFRO from: AMRO EMRO EURO SEARO WPRO Section 7- Section Technical cooperation withcountries Sri Lanka Sri Republic Number Developing countries 19 12 8 7

% oftotal 100 42 37 63

Number Countries intransition Countries

% oftotal

Developed countries Number

% oftotal

Totals 19 12 8 7

Annual Technical Report 2001 187 The WHO Region of Europe Region of WHO The PROGRESS The Regional Advisory Panel (RAP) met to the review over- WHO Headquar- in both health programmes all reproductive ters and EURO to provide This regional strategies. and programmes health reproductive input overall towards WHO’s was emphasis Europe, for RAP the of meeting first the being placed on brainstorming priorities the future. for atten- draw to made be efforts that recommended Panel The tion to the immense reproductive health In Region, and that donor of agencies them. be made aware problems in the addition, reproductive health policies should reflect the prin- ciples elaborated at the International Conference on Popu- lation and Development in The 1994. Panel highlighted the need to include gender and cultural perspectives into repro- health policies in the Region. ductive and endorsed WHO/EURO The strategy reviewed the Panel paper on Health Reproductive the for Region, as well as the adolescent Safer; Pregnancy Making on: programmes overall sexual and reproductive health; gender mainstreaming; and the ongoing research projects within the Department. The Panel also the reviewed proposal to hold a symposium that principle, in agreed, and research health reproductive on it should focus on improving the “quality” of research. Panel Regional initiatives and activities Regional initiatives for Advisory meeting of the Regional Panel First Copenhagen, 20–21 September 2001, Europe, Denmark R. Guidotti, A. Ntabona A. Guidotti, R. The WHO Region of Europe WHO The INTRODUCTION The main of objectives the Department(i) to are: strengthen national capacity in reproductive health research coun- the for and health reproductive pro- in opportunities training vide Central and Easterncomprise which Europe, Eastern of tries European countries, the Newly Independent States and the Regional WHO the assist to (ii) and Republics; Asian Central Officefor Europe (EURO) in providing technical support to countries to implement their programmes health. in reproductive Objectives It is estimated that the population in the Eastern Fertil- European 2025. to 1994 from million ten by decrease will Region ity has declined from 2.1 children per woman in 1980–1985 to 1.6 children per woman have 12 Region, European Eastern during the in analysed countries 1990–1995. Of the 25 contraceptive prevalence rates (effective methods) of 50%. and 20% between less rates have 12 another and 20% than Nine abortion-to-birthcountries have ratios greater than 125 per 100 births and 15 countries have a maternal mortality ratio greater Thus, than the 30. major Region’s reproductive health concerns remain: (i) high levels of maternal mortality and morbidity; (ii) reliance on ineffective traditional methods of (iii) contraception; a large number of repeat abortions per (iv) woman; a growing number of sexually transmitted infec- tions (STIs), including and HIV; (v) poor availability of infor- health care. mation and services reproductive for 188 Annual Technical Report 2001 the effects ofradiation exposure onreproductive health. This will be one of the largest studies conducted to determine radiation dose, ageatexposure andtimeofexposure. individual to according and settlements control exposedand the between made comparisons and characteristics graphic Reproductive outcomes will be described according to demo- usa Fdrto ad kan.Te an betv was objective main The Ukraine. and Federation Romania, Russian Moldova, of Republic Lithuania, Latvia, khstan, Kaza- Republic, Czech countries: eight from participants 17 Reproductiveof Health, Targu-Mures,Romania. wereThere Institute European East byorganizedthe and project TIERS FRON- the and Department the by supported jointly 2001, October 1–12 on Romania Targu-Mures, in held was gies methodolo- research operations reproductive on course A Regional self-reliance inresearch training • • • The studywillexamine thefollowing outcomevariables: and digitized inanelectronicdatabase. records original the from extracted be will Data outcomes. exposureon region, the in authorities radiationto health and health publicby collected previously data use will study The United Kingdomandtheprojectwillbelaunchedin2002. Sutton, Research, Cancer of Institute the developedbywas study follow-up a for proposal research A (UNFPA). Fund Population Nations United the Semipalat- by funded Kazakhstan” in insk, site test nuclear the around exposure ation radi- to relation in health reproductive of “Assessment the on project pilot the in participated Department the 2001, In Regional research initiatives than focus onscreeningtechniquesperse. rather screening seeking not were women why to given be should attention more Region, the relevanceto of was topic the although that, concluded which Panel was the cancers by reviewed gynaecological on training for proposal The ductive healthresearch. repro- of to newsletter) Office European issue WHO (the nous Entre an devoting of proposal the supported Members Section 7- Section Technical cooperation withcountries

tial preconceptionalexposures thetesting. during cancer, in offspring born after 1957 to women with and poten- malformations congenital from including mortality, individuals; and cancer, in persons exposed and malformations congenital from including mortality, before thereproductive orduring age; outcomes fertility and in birth women who were exposed in utero, and fertility in these in 2003. Federation Russian the in held be will research operations research on course second months. A 14–16 these at estimated is projects of duration maximum The course. Mures the developedTargu-at projects research operational the of to It severalis planned to fund and provide technical support students eachyear, mainlyfromdeveloping countries. 30–40 by attended been has course fewthe years,past the University the of Geneva, of as well as Medicine from other universities. of Faculty Over the from teachers and gramme Pro- the of members staff by annually taught is It gramme. Pro- the and Geneva,Switzerland of Hospital University the at Reproduction Human in Research for Centre laborating Col- the byWHO organized jointly is course two-month This aspectofreproductive health. particular a of study in-depth an in participate to required Genevaare in training research their continue to choose who students diploma plan. The “re-entry” a in participating or Geneva in training research their continuing of option the have dents the of stu- examination, certificate the passing and course training part compulsory the completing successfully countries. After home their in concerns health reproductive the toinitiate to appropriate work research in the trainees participate and/or research to allow knowledge sufficient vide pro- to aims course training The contraception. modern of methods different of knowledge in-depth an provides also It health problems in both developed and developing countries. reproductive of dimensions demographic and social the ing general, knowledgestructured in reproductive health, includ- 1991. This course enables scientists and clinicians to acquire in Geneva of University the at created was Biology ductive A Postgraduate Course in Reproductive Medicine and Repro- the firstdraft oftheprojectproposal. completed successfully had participants course, the of end (Ukraine). care the By obstetric in partogram of introduction (Romania); physicians care health primary to use traceptive of introduction (Romania); physicians care health primary of education breastfeeding Federation); (Russian practices best perinatal and obstetric sexual health counselling using peers (Lithuania); introducing health services (Latvia and Republic of Moldova); adolescent reproductive adolescent improving (Kazakhstan); education of reduction Republic);(Czech covered:rate sexualsection adolescent caesarean was topics of range Independent wide Newly A States. the and Republics Europe, Asian Central Central and the Eastern in networking and building capacity of part in as funding possible research for health operationsreproductive on proposal detailed a prepare to developed at the Targu-Mures course to operations researchSupport projects PLANNED ACTIVITIESPLANNED Medical eligibility criteria for con- for criteria eligibility Medical Annual Technical Report 2001 189 The WHO Region of Europe Region of WHO The Following Following the successful completion of the the first project phase and the of development of the research protocol, the Department, serving as the executing responsi- be will project, research three-year agency UNFPA-funded for this ble for providing technical support to the project as well as its progress. overseeing Assessment of reproductive health in relation to to health in relation of reproductive Assessment in site nuclear test a around exposure radiation Kazakhstan Semipalatinsk, 190 Annual Technical Report 2001 Petr Velebil, ResearchInstitutefor Health,Prague, Maternal Czech Republic Saule Nukusheva, SchoolofPublic Health,Almaty, Kazakhstan Alfred Merkle,DeutscheGesellschaftfür Technische Germany Zusammenarbeit(GTZ),Eschborn, Gunta Lazdane, Family PlanningAssociation,Riga,Latvia Ketting,Evert SchoolofPublic Netherlands Health,Utrecht,Netherlands Helle Karro, University of Tartu, Tartu, Estonia(Chairwoman) ofHealth,Bucharest,Romania Mihai Horga,Ministry RussianAcademyElena Baibariana, ofMedicalScience, Moscow, RussianFederation Ayse Akin,HacettepeUniversity, Ankara, Turkey Members REGIONAL ADVISORY PANEL FOR THE EUROPEAN REGIONIN2001 Annex 1 WPRO SEARO EURO EMRO AMRO AFRO from: Women Members Section 7- Section Technical cooperation withcountries Number Developing countries 1 1 1

% oftotal 11 11 11

Number Countries intransition Countries 6 4 6

% oftotal 67 44 67

Developed countries Number 2 2

% oftotal 22 22

Totals 9 9 5

Annual Technical Report 2001 191 Section 8 Implementing best practices Implementing 192 Annual Technical Report 2001 ihqaiy nomto i aes hr i i ms needed most (Box 8.1). thisgap.RHL isbridging is it where areas in information high-quality and peer-reviewed evidence-based, of dissemination the in access gap considerable a to remains There information. technologies care health electronic from other benefited and yet Internet the not have countries years, developing recent many in advances technological large been have major resource a care.there health Although reproductiveevidence-basedfor isbecoming publication, in of now year fifth (RHL), its Library Health Reproductive WHO The 2. in makers tomake thebestuseofthisevidence. decision- capacity enable build to countries to in medicine (iv) evidence-based and evidence; research good- up-to-date, quality disseminate to (iii) reviews; systematic evidencethrough this summarize to research; (ii) conducted rigorously through evidence generate to (i) aims: Practices Health Reproductive Best Map to Programme WHO The I. on two majorprojects: partners and agencies other with working is Department the their of implementing health and populations. reproductive To policies the address the issue improveof knowledge setting management, to in programmes countries help processes to dissemination current of effectiveness the and practices ofbest mapping the specifically knowledge, this of management the about emerged have concerns years, recent However, services. in to access and quality promote way in which policies and the broader social environment can health-related behaviour, and an increasing awareness of the people’s of understanding improved an services, provide to best how about knowledge of body considerable a is There Section 8-Implementing practices best Section INTRODUCTION Implementing practices best M. Gülmezoglu, M. Islam, M. Usher-Patel, J. Villar, A. Shah hospitals in Mexico and 18 in Thailand have been allocated been have Thailand in 18 and Mexico in hospitals 22 design, trial randomized unit) the as (hospital cluster a Using settings. local in established already group) (control sharing information of form standard the to months, six of semination strategy through three workshops within a period dis- active an comparing is trial This 2001. in initiated was RHL WHO the on based medicine evidence-based moting pro- programme a evaluate to trial controlled randomized A Progress strategy actuallychangesclinicalpractice. care interventions presented through an active dissemination practices. improve provided, to up-to-date information electronically on whether the effectiveness strategies todetermine of is health future aim the Specifically, guide will that evidence generate to is activity this of objectiveoverall The ae bs patcs n erdcie elh n re to order in health reproductive improve thequalityofcare. in practices best based Best “The called evidence- implement countries consortium help to Consortium” Practice a form to agencies partner practicesbest (IBP). with working been has Department The identify to required interventions that effectively is address barriers to approach implementing systematic and strategic materials ineffective.A written largely are sessions of educational didactic and distribution that concluded (EPOG) Group Organization and Practice Effective Cochrane The Specific objectivesSpecific Research activities THE WHO PROGRAMME TO MAPBESTREPRO- DUCTIVE HEALTH PRACTICES Annual Technical Report 2001 193 WHO y ar The The Implementing best practices Implementing The WHO Reproductive WHO Reproductive The isseminated through through isseminated (RHL) Library Health Reproductive WHO The D Reproductive Health Libr Reproductive Health Research in progress

fertility regulation (1 review, 1 review update); 1 review fertility regulation (1 review, update); 1 review abortionunsafe (3 reviews, HIV/AIDS and sexually transmitted infections (STIs) (2 and 1 protocol); update, 1 review reviews, health systems (1 review). maternal health (4 reviews, 7 review updates, 2 protocols); 2 updates, review 7 maternalreviews, (4 health

is to provide health care workers in developing countries with countries developing in workers care health provide to is Dissemination of evidence-based reproductive reproductive of evidence-based Dissemination information: health care Health Library Objectives of objective The • • • • • Progress In 2001, systematic reviews were issues in: conducted on specific Systematic reviews were also initiated Systematic on reviews other health ques- tions such as screening/diagnostic tests incidence and of The morbidities. first of prevalence/ these studies is a sys- tematic review of the screening tests for pre-eclampsia. A draft protocol was prepared and the full review will be com- pleted in the second half of 2002. In addition to these review activities, the Department vided pro- seed support to the Group Editorial Cochrane Base in Fertility Leiden, the Regulation Netherlands. This col- China from further was laboration reviewers when enhanced and India went to Leiden to work on the reviews they been conducting. had tices Evidence-based clinical Evidence-based prac Evidence-based implementa- Evidence-based )

tices potheses eness of prac tiv protocol including an explicit and comprehensive c (inappropriate hy (inappropriate Effe (benefit/harm) Programme implementation implementation Programme a priori strategy to search, identify, critically appraise and then select then and appraise critically identify, search, to strategy studies The for inclusion. systematic reviews are conducted through the Collaborative Review Groups of the Cochrane Collaboration. Objectives evidence synthesize and appraise locate, reviews Systematic from scientific studies in order to provide informative empiri- cal answers to scientific research questions. In addition,by identifying the known and the unknown, they are an inval- uable first stepbefore carrying out new primary research. The main characteristic of a systematic review is the use of an Summarizing evidence Summarizing to intervention and control groups. Baseline data collection included information on clinical practices intervention The used survey. Profile” for Provider “Care a and 40 women 000 phase started in October 2001 in both countries. Outcome data collection on another 40 000 women is scheduled start 2002. in August to 194 Annual Technical Report 2001 the RHL project. The strategy incorporates incorporates strategy The project. RHL the of initiation the since followed been has egy Dissemination: (iv) (iii) (ii) (i) Contents: RHL contentsareorganized intofour sections: Progress Collaboration. Cochrane the and countries developing in centres research RHL is the product of collaboration between the Department, of theconditionspractice inthosecountries. knowledge extensive with individuals by or countries, oping cations of these reviews prepared by researchers from devel- impli- practice and commentaries reviews,by supplemented countries. Systematic reviews included in RHL are Cochrane on reproductive health problems of high priority for developing is an electronic review updated yearly, journal which focuses reviewssystematic up-to-date of reproductivein health. RHL source user-friendly affordable, and an efficiently-distributed Section 8-Implementing practices best Section cies). agen- funding links, web presentation, initiative Births (Better information useful (69 63 practical aspects); database Cochrane reviews, 63 commentaries and health reproductive making (6documents); decision- for summaries effectiveness (3documents); countries developingin reproductivehealth vantto rele- articles educational and editorials Figure 8.2. A concrete dissemination strat- published in2001 RHLNo .

4 inEnglishandSpanish w ere Figure 8.3.

these efforts have successful. efforts been these not Cana- with Contacts efforts for a French version have continued in 2001 but so far Fundraising 2002. September by have available RHL to Chinese a is aim The China. Shanghai, (SIPPR), Research laboration with the Shanghai Institute of Planned Parenthood Translations:col- versionin Chinese wasinitiated a Workon inLatinAmerica. major roleinincreasingsubscription playedProgramme,havea all the with collaborating centres of and (AMRO) Americas the for of Office Regional WHO participation the active the and Spanish, in RHL of lication subscriptions pub- 8.3. in The Figure in shown are increase 2001 and 2000 between the and Region WHO by tions subscrip- RHL of distribution 9500. The reach subscriptions RHL global facilitatedCurrent countries. developing in RHL substantially to access has system subscription free The • • • the following elements: b Subscriptionle

y WHO Region [EURO]), India, Nepal, the Philippines, South Africa, Africa, South United Republic of Tanzania and Philippines, Turkey. the Europe Nepal, for India, Office [EURO]), Regional (WHO Argentina, Denmark in Bolivia, place took presentations RHL 2001, In meeting. the of nature the developed,on are depending presentations four-day and two-day one-day, pres- entation, conceptual two-hour the as such RHL presentations of models Several editors. regional RHL by and Department the by conducted are workshops and tions Active dissemination with demonstration. RHL presenta- icine. raising awareness about RHL and evidence-based med- of purpose the serve meetings WHO and presentations Active dissemination without demonstration. to ensurecontinued access. selective a in lists manner, encouraging all mailing who receive a copy to subscribe newsletter Library WHO the and Department the of Utilization distribution. Mail , October 2001 October v els of

T he WHO Reproducti . v e HealthLibr Conference ar y Annual Technical Report 2001 195

1 Medical eligibility Implementing best practices Implementing IMPLEMENTING BEST PRACTICES Ensure that the Department’s recommendations for prac- for recommendations Department’s the that Ensure tices and implementation are based on best available reviews. from systematic evidence Expand the content of RHL to systematic cover reviews of observational studies, including systematic reviews of morbidities mapping the burden of reproductive health. ill- Maintain and improve the quality of RHL. The number and type of documents included in RHL increase every revision needing them of third a approximately with year, in translations the as well as increase This updating. and chal- significant created already have languages several lenges in the management of RHL. By the end of 2002–2003 the biennium, RHL will need to include to 90 close Cochrane reviews, accompanying commentaries and practical aspects, all of which will need to be annu- The ally Spanish updated. and Chinese versions will be on the same lines. developed Contribute to creating a critical mass developing countries who are of knowledgeable and com- scientists in petent in preparing systematic reviews in AFRO with reproductive developed jointly initiative training The health. and the South African Cochrane Centre could be instru- this objective. mental in achieving

Partners: EngenderHealth, Family Health International, International International, Health Family EngenderHealth, Partners: Development of the IBP process Development have have worked together to develop a practical and structured The DAU approach to capturing and applying best practices. process was developed as a result of discussions on how best to support the dissemination, adaptation and utilization of the products associated with best practices. The DAU approach is based on lessons learned from past experiences. One such experience has been with the very successful technical guidance document, criteria for contraceptive use, now in This its second edition. document, which introduces best practices for using family languages seven into translated been has methods, planning and has been used to update national policies, guidelines in more than 50 countries. and practices In addition, a Cochrane systematic review was undertaken to examine the technical and managerial processes associ- 1 Since mid-1999, WHO, the United States Agency for Inter- national Development (USAID) and other partner agencies • • • • Planned Parenthood Federation, INTRAH, JHPIEGO, Johns Hop- kins University Center for Communication Programs, Management UNFPA. Health Institute, Public Health, Pathfinder, Sciences for Ensure that systematic become reviews an integral first step of all research activities undertaken by gramme. Ideally, the all Pro- clinical research protocols should be accompanied by a systematic review supporting the and maternal in case the already is This protocol. project incorporate importantto be will it and research, perinatal this into other research areas of the Programme.

• The future challenges for the “WHO Programme To Map Best Map To Programme “WHO the for challenges future The are the following: Health Practices” Reproductive RHL has become a recognized comprehensive source of evi- of source comprehensive recognized a become has RHL dence-based, up-to-date information in reproductive health. RHL is now incorporated into the medical curriculum of sev- eral universities and is a major Furthermore, resource examinations. membership college for and training postgraduate the RHL impact evaluation trial will provide useful insights into in changing behaviour underresourced professional set- tings. New challenges emerge as RHL, systematic reviews and capacity building in reproductive evidence-based health care decision-making activities expand and become more widely known. The future future The Spotlight countries of the Making Pregnancy Safer initiative are given priority in all these capacity-building For activities. example, in Africa, initial Africa workshops South to addition in will Uganda, and Nigeria be Mozambique, conducted in in Latin America, initial activities have Similarly, and Zambia. place in Bolivia. taken In Asia, preparatory activities have been establishment of initiated an evidence-based resource for centre in the the Department of Obstetrics and Gynaecology of to centre this to Khon provided be Supportwill Kaen Thailand. University, and disseminate to network subregional a create to it enable to RHL. contribute In Latin America, support has been provided to collaborating collaborating to America,supportprovided Latin been In has a initiate to Colombia Cali, and Argentina Rosario, in centres and dissemination programme. systematic training In Africa, an “Evidence-based Reproductive Health Training Care: of Trainers” project was initiated WHO jointly Regional Officefor Africa The with (AFRO). South African the Cochrane Centre in Cape Town, South Africa is developing currently a five-daytraining package. This package be will pilot-tested in early project The 2002, 2003. for and and 2002 of half second the for countryplanned workshops are component. evaluation includes an in-built Capacity building in evidence-based building in evidence-based Capacity health care reproductive dian French-speaking groups and local French institutions are continuing. 196 Annual Technical Report 2001 through mentorship and supportive follow-up.through mentorshipandsupportive tional change. organiza- Finally, support it encourages continuous and improvement lead to require they tools the offers and leaders, these among skills technical and managerial duction and use of best practices. The IBP process develops intro- the developto to approaches order in experience their ership and creative thinking among key players, who build on encourages it that is change from within the system. It does this process by fostering lead- IBP the of feature key The individuals’ needs, andagreater programmatic impact. and communities’ to response improved an is result changes.The positive to lead will that steps through systematically work to and health, reproductive in practices best evidence-based with familiarity their increase to them enables policy-makers.It and managers programme viders, pro- service among players key identifies process IBP The systems, projectsandprogrammes. services. tivecare health health benefit will process IBP health The the reproduc- of of quality and levelto access improve any to system at care used be can It process. (IBP) Practice Best Implementing the renamed was process The h patcl plcto o te B iiitv hs been has initiative IBP the of application practical The Formation oftheIBPConsortium • • Subsequently, theDAU process was revised inorderto: of bestpractices. implementation the sustain and absorb to programmes and ated with developing the capacity of health systems, projects Section 8-Implementing practices best Section

Figure 8.4. The logooftheImplementingBestPractices low-up programme. fol- supportive and mentorship a of implementation the through programmes country of follow-up the improve tries; and coun- the of needs programmatic and technical mation, develop an approach that is more responsive to the infor- and ApplyBest "Helping Deve "Helping Health P r P ac r of t Initiative ices in Reproduc e ssionals Captur loping C ountr tiv e y e Health" • • • meeting: Egypt the during field-tested be will initiative, IBP the of tion introduc- the support to developed materials, following The 2002. ary take to place scheduled in Egypt in October 2001, but was was postponed to Febru- meeting This milestones. of ment achieve-the monitor and process IBP the of implementation the support to order follow-upin and mentorship of gramme pro- a to resources a committed have and on basis cost-sharing activities all undertake to agreed have Region. partners The the in countries nine from managers programme ners and Country Teams. The meeting will involve 120 senior Office (EMRO) to prepare an Inter-Country Meeting with Part- in collaboration worked with the WHO haveMediterraneanEastern Regional initiative IBP the in involved partners The IBP achievements during 2001 tinuous improvement through mentorship and supportive supportive follow-up. and mentorship through improvement con- tinuous encourage and system the within from change mote the technical materials and tools developed by pro- partners, use efficiently resources, donor of use the maximize effort, of duplication minimize will effort This organizations. major among cooperation international of model dynamic demon- a strate will and levels country the and at regional work international, will Consortium The systems. health country developinginto reach organizational and strengths partners’ the leverage can Consortium up. The scaled and sustained nurtured, be to needs buteffort together this come has tions organiza- health-focused and donors of Consortium unique countries. This developed and developing both in grammes pro- country from stakeholders of variety wide a include to expand to expected is membership time, Over countries. in process worldwide and to IBP coordinate support to the IBP activities of use the promote to be will role Its mid-2001). in Consortium IBP (the Practice Best Implementing on sortium Con- a formed agencies Toinitiative,the IBP the strengthen refineit. to further used been feedbackhas and Nepal) and India (Bangla- China, desh, meetings country and regional through explored

versity” sessions). Uni- (“Mini guidelines specific on sessions information two-page summary with power point presentations of the a and capacity search a with CD-ROM a as developed was This documents. resource key to linked agencies partner the by produced sites web and tools guidelines, managerial and technical of bibliography annotated an facilitator’s a guide; and and exercises management of series a heads explaining theIBPinitiative; brochure, poster, technology café brochure and two advocacy over-paper, IBP the containing pack advocacy an Annual Technical Report 2001 197 Implementing best practices Implementing The IBP team will start preparing a guide to train regional and regional train to guide a preparing start will team IBP The it 2002, During process. IBP the of use the in countryleaders and development the particularto attention pay to planned is implementation of the mentorship and supportive follow-up been has initiative IBP the which countriesin in programmes determined be will initiative IBP the of impact The introduced. by a system that will evolve through the monitoring of achievement the of milestones identified by countries planning process. in their Future plans Future and functional Consortium become IBP will the During2002, open to new members from both and developing developed countries. Although the Consortium will identify additional funding sources to support its activities, it will expect continue to all partners to previously assume agreed roles upon and and to responsibilities undertake on these a activities cost-sharing basis. The tools under development will be field-tested during the intercountry meetings due to be held in China, Egypt and India. The IBP Department will respond Team to within the feedback received, continue the to refine the IBP process under development. and finalize the tools currently 198 Annual Technical Report 2001 Manorama Purwar, ClinicalEpidemiologyUnit,Nagpur, India Haroldo Capurro, Centerfor LatinAmerican Perinatology (CLAP)/PAHO, Montevideo, Uruguay Juan Carlos Vazquez, Hospital,Havana, Arias America Cuba Festin,Mario University ofthePhilippines, Manila,thePhilippines representativesCountry Kenneth Schulz,Family Research HealthInternational, Triangle Park, NC, USA Suneeta Mittal,AllIndiaInstituteofMedicalSciences, New Delhi,India Pisake Lumbiganon,KhonKaen University, KhonKaen, Thailand Justus Hofmeyr, University of Witwatersrand, Johannesburg, SouthAfrica Ana Langer, The Population Council,Mexico City, Mexico PeaceLinan Cheng,International andChildHealthInstitute, Shanghai,China Maternal deEstudiosPerinatales Carroli,CentroRosarino (CREP),Rosario,Guillermo Argentina Regional editors Editorial group WHO PROGRAMME TO MAPBESTREPRODUCTIVE HEALTH PRACTICES IN2001 Annex 1 All Women AFRO from: AMRO EMRO EURO SEARO WPRO Section 8-Implementing practices best Section Number Developing countries 10 4 1 4 3 2

% oftotal 91 36 36 27 18 9

Number Countries intransition Countries

% oftotal

Developed countries Number 1 1

% oftotal 9 9

Totals 11 4 1 5 3 2 Annual Technical Report 2001 199

1 1 1 1 3 Totals

33 33 % of total Implementing best practices Implementing

1 1 Number Developed countries Developed

% of total

Countries in transition Number

33 33 33 66 % of total

1 1 1 2 Number Developing countries Developing WPRO SEARO EURO EMRO AMRO from: AFRO Women Women All Mario Festin, University of the Philippines, Manila, the Philippines of the Philippines, University Mario Festin, Argentina Rosario, Rosario University, Figueroa-Casas, Pedro USA NY, York, Council, New The Population Fikree, Fariyal of Liverpool, Liverpool, United Kingdom University Garner, Paul Mexico City, Health, Mexico National Institute of Public Gonzàlez-Cossio, Teresa Edgardo Abalos, Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina (CREP), Rosario, Centro Rosarino Perinatales Edgardo Abalos, de Estudios Assiut, Egypt University, Abdel-Aleem, Assiut Hany Nigeria Sagamu, Ogun State University, Lekan Adetoro, Ibadan, Nigeria Ibadan University, Isaac Adewole, of Liverpool, Liverpool, United Kingdom University Alfirevic, Zarko Uruguay (CLAP), Montevideo, Perinatology Latin American Center for Althabe, Fernando Brazil Sao Paulo, of Sao Paulo, University Preto, of Medicine Ribeirao Faculty Andrade, Jurandyr Brazil Sao Paulo, of Sao Paolo, Atallah, University Alvaro Thailand Bangkok, CountryTeam, Support UNFPA Katherine Ba-Thike, Pakistan Karachi, Zulfiqar Bhutta, Aga Khan University, Switzerland Geneva, of Geneva, University Michel Boulvain, South Africa Johannesburg, Witwatersrand, of Eckhart Buchmann, University Uruguay (CLAP), Montevideo, Perinatology Latin American Center for Haroldo Capurro, Brazil Sao Paulo, of Campinas, Guillerme Cecatti, State University Cali, Colombia Valle, of University Edgard Cobo, of Cali, Colombia University Agustin Conde-Agudelo, Africa South Johannesburg, Witwatersrand, of University Cooper, Peter Mexico City, National Institute of Nutrition, Mexico Maria del Carmen Cravioto, Bogotá, Colombia of Javariana, University Luis Gabriel Cuervo, Switzerland Health Research, Geneva, for Global Forum Andres de Francisco, Mexico City, Mexico Council, CharlotteThe Population Ellertson, Brazil Sao Paulo, of Campinas, State University Anibal Faundes, Switzerland Geneva, of Geneva, University Anis Fekih, Brazil Sao Paulo, of Sao Paulo, University Preto, of Medicine Ribeirao Faculty Rui Ferriani, Other scientists

Ana Langer, The Population Council, Mexico City, Mexico City, Council, Mexico The Population Ana Langer, Leiden, Netherlands University, Leiden Regulation Group, Ferility Helmerhorst, Cochrane Frans Thailand Khon Kaen, University, Lumbiganon, Khon Kaen Pisake Principal investigators Principal Annex 2 Annex IN 2001 SCIENTISTS 200 Annual Technical Report 2001 Ray Yip, UnitedNationsChildren’s Fund(UNICEF),Beijing,China Chris Williams, Oxford University, Oxford, UnitedKingdom David Wilkinson, AdelaideUniversity, Whyalla, Australia Gijs Walraven, MedicalResearchCouncilLaboratories, Farafenni FieldStation,the Gambia Juan Carlos Vazquez, Hospital,Havana, Arias America Cuba Vanchai Vatanasapt, KhonKaenUniversity, KhonKaen, Thailand Cyril Van Gelderen, Thomas Jefferson University, Philadelphia, PA, USA Jorge Tolosa, Thomas Jefferson University, Philadelphia,PA, USA Jadsada Thinkhamrop, Khon KaenUniversity, KhonKaen, Thailand Yawana Tanapat, Pramungkutlao Hospital,Bangkok, Thailand Cochrane Centre(SACC), SouthAfrican Louise Spruyt, Cape Town, SouthAfrica Cochrane Centre(SACC), SouthAfrican Nandi Sigfried, Cape Town, SouthAfrica Lale Say, Istanbul University, Istanbul, Turkey Haroon Salooje, University of Witwatersrand, Johannesburg, SouthAfrica H.P. Sachdev, MaulanaAzadMedicalCollege, New Delhi,India Ramji,MaulanaAzadMedicalCollege, New Delhi,India Siddarth Manorama Purwar, ClinicalEpidemiologyUnit,Nagpur, India Pattinson, University,Robert Pretoria SouthAfrica Pretoria, Fathima ResearchUnit,University Paruk, ofNatal,Durban,SouthAfrica MRCPregnancyHypertension Nguyen thiNhuNgoc, HungvuongHospital,HoChiMinhCity, Viet Nam Nikodem, UniversityCheryl of Witwatersrand, Johannesburg, SouthAfrica James Neilson,University UnitedKingdom Liverpool, ofLiverpool, Dina Neeloufer-Khan, University ofGeneva, Geneva, Switzerland Stephen Munjanja,University ofZimbabwe, Harare, Zimbabwe Jack Moodley, University ofNatal,Durban,SouthAfrica Joy Melnikow, University California, Davis, ofSouthern CA,USA James McIntyre, University of Witwatersrand, Johannesburg, SouthAfrica Matthews Medical CollegeandHospital, Mathai,Christian Vellore, India Nandita Maitra, BarodaMedicalCollege, Vadodra, India Kassam Mahomed,University ofAdelaide, Port Pirie,Australia Pisake Lumbiganon,KhonKaenUniversity, KhonKaen, Thailand UniversityGunilla Lindmark, ofUppsala,Sweden Gerhardt Lindeque, SouthAfrica University Pretoria, ofPretoria, Jerker Liljestrand, World Bank, Washington, DC, USA Lede,deEstudiosPerinatales CentroRosarino (CREP),Rosario,Roberto Argentina UnitedKingdom Khalid Khan,University Birmingham, ofBirmingham, Edgar Kestler, EpidemiologicalResearchCenterinSexual andReproductive Health(CIESAR),GuatemalaCity, Guatemala Richard Johanson,University ofKeele, Stoke-on-Trent, UnitedKingdom Ingram,Charlotte University of Witwatersrand, Johannesburg, SouthAfrica SouthAfrica Graham University Howarth, Pretoria, ofPretoria, Honest Honest,Birmingham Women’s UnitedKingdom Hospital,Birmingham, Babar Hasan,AgaKhanUniversity, Karachi, Pakistan

All Women AFRO from: AMRO EMRO EURO SEARO WPRO Section 8-Implementing practices best Section Developing countries Number 51 15 17 18 3 1 9 3 % oftotal 73 21 24 25 12 4 1 4 Countries intransition Countries Number

% oftotal

Developed countries Number 19 12 4 5 2

% oftotal 27 17 6 7 3

Totals 70 19 17 23 13 10 3 5 Annual Technical Report 2001 201 Implementing best practices Implementing Abdel-Aleem H, Vogelsong K, d’Arcangues C, Gülmezoglu AM. Treatments for irregular bleeding associated with the use of associated with the use irregular bleeding for Treatments AM. Gülmezoglu K, d’Arcangues C, Vogelsong Abdel-Aleem H, Protocols Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gülmezoglu AM. Patterns of routine antenatal care for low-risk pregnancy. low-risk of routine antenatal care for Patterns AM. Piaggio G, Gülmezoglu Carroli G, Khan-Neelofur D, Villar J, May W, Ba-Thike K, Gülmezoglu AM. Antibiotics for incomplete abortion.Antibiotics for AM. K, Gülmezoglu Ba-Thike W, May Hofmeyr GJ, Gülmezoglu AM. Vaginal misoprostol for cervical ripening misoprostol for and induction of labour. Vaginal AM. Gülmezoglu GJ, Hofmeyr Gülmezoglu AM, Hofmeyr GJ. Maternal nutrient supplementation for suspected impaired fetal growth. impaired fetal Maternal suspected nutrient supplementation for GJ. AM, Hofmeyr Gülmezoglu Gülmezoglu AM, Hofmeyr GJ. Hormones for suspected impaired fetal growth. suspected impaired fetal Hormones for GJ. AM, Hofmeyr Gülmezoglu Gülmezoglu AM, Hofmeyr GJ. Betamimetics for suspected impaired fetal growth. growth. impaired fetal suspected Betamimetics for GJ. AM, Hofmeyr Gülmezoglu Gülmezoglu AM, Forna F, Villar J, Hofmeyr GJ. Prostaglandins for prevention of postpartum haemorrhage. prevention Prostaglandins for GJ. Hofmeyr Villar J, F, AM, Forna Gülmezoglu Cheng L, Gülmezoglu AM, Ezcurra E, Van Look PFA. Interventions for emergency contraception. Interventions for Look PFA. Van E, AM, Ezcurra Cheng L, Gülmezoglu Carroli G, Bergel E. Umbilical vein injection for management of retained placenta. injection for vein Umbilical Carroli G, Bergel E. Brocklehurst P, Volmink J, Rutherford G. Antiretroviral therapy for reducing the risk of HIV transmission of mother-to-child for therapy Antiretroviral G. Rutherford J, Volmink P, Brocklehurst infection. updated Reviews Wilkinson D. Nonoxynol-9 for prevention of sexually transmitted infections (awaiting publication of primary of publication studies). (awaiting infections transmitted of sexually prevention for Nonoxynol-9 Wilkinson D. Wilkinson D. Nonoxynol-9 for preventing sexually acquired HIV infection (awaiting publication of primary publication studies). (awaiting acquired HIV infection sexually preventing for Nonoxynol-9 Wilkinson D. Say L, Kulier R, Gülmezoglu M, Campana A. Medical versus surgical methods for first trimester termination surgical methods for of pregnancy Medical versus M, Campana A. R, Gülmezoglu L, Kulier Say (in press). Kulier R, Nardin JM, Boulvain M, Peterson HB, Campana A. Techniques for the interruption of tubal patency for female female the interruption patency for of tubal for Techniques Campana A. HB, M, Peterson JM, Boulvain R, Nardin Kulier sterilization (in press). first trimester terminationSurgical methods for of pregnancy. Campana A. GJ, A, Hofmeyr R, Fekih Kulier Forna F, Gülmezoglu AM. Surgical procedures to evacuate incomplete abortion. procedures to evacuate Surgical AM. Gülmezoglu F, Forna Duley L, Gülmezoglu AM. Magnesium sulfate versus lytic cocktail for eclampsia. for lytic cocktail versus Magnesium sulfate AM. L, Gülmezoglu Duley Cuervo LG, Mahomed K. Treatments for iron deficiency anaemia in pregnancy. iron deficiency anaemia for Treatments Cuervo K. LG, Mahomed Briggs CJ, Capdegelle P, Garner P. Strategies for integrating primary integrating health services for countries:Strategies in middle- and low-income Garner P. Capdegelle P, Briggs CJ, costs and patient outcomes. on performance, effects Abalos E, Duley L, Steyn DW, Henderson-Smart DJ. Antihypertensive drug therapy for mild to moderate hypertension during mild to moderate for drug Antihypertensive therapy Henderson-Smart DJ. DW, L, Steyn Abalos E, Duley pregnancy. , Issue 5, 2001. Oxford: Update Software) Oxford: Library(cited as The Cochrane , Issue 5, 2001. Cochrane reviews Cochrane Annex 3 Annex IN 2001 PUBLICATIONS 202 Annual Technical Report 2001 of heterosexual transmission ofHIVinmen. N, Muller M, Siegfried Volmink J, Egger M, Low N, Weiss H, Walker S, Deeks J, Williamson P. Male circumcision for prevention of pregnancy. Kulier R,Hofmeyr GJ, Gülmezoglu AM,Bianchi-Movarekhi PG,CampanaA. termination Medical methodsoffirsttrimester Kulier R,Gülmezoglu M,deOnis Villar J. Vitamin Asupplementationinpregnancy. Adetoro O, Hofmeyr GJ. Prophylactic antibioticadministration inpregnancytoprevent infectious morbidityandmortality. PUBLICATIONS IN2001 Annex 3 Section 8-Implementing practices best Section ( c o n t i n u e d ) Annual Technical Report 2001 203 Section 9 Monitoring and evaluation Monitoring 204 Annual Technical Report 2001 (e.g. adolescents) and minority groups. there Furthermore, is groups age different populations, those urban as and rural such between countries, within status health in ferences dif- obscure general, in indicators, Global purposes. toring formoni- useful global are that relevantthose and indicators status health locally between discrepancy a levels. as is Unfortunately,there well as goals development international monitoring for important are indicators health Reproductive • • • ductive ill-healthbasedonthefollowing principles: and summarize epidemiological data on the burden of repro- generate to is objective main developed.The also are tors provide access to, and training in, reproductive health indica- towards progress the achievement development of international goals. monitor Tools to to “indicators” on work the and miological studies to map the burden of reproductive ill-health epide- includes work of evaluationarea and monitoring The Section 9-Monitoring andevaluationSection

well. burdenthe of reproductivemagnitude of the as ill-health assessing to apply practices care health of effects the evaluatingto apply that review principles systematic the made available; tions, as in any scientific endeavour. Protocols should be comprehensive, systematic, is transparent, and with an acknowledgement of the limita- that process should a ill-health follow reproductive of burden the mapping ties; priori- research of identification the to and resources of tribute to better identification of the needs and allocation mapping the burden of reproductive ill-health should con- INTRODUCTION Monitoring andevaluation M. Gülmezoglu, A. Betran, W. Doedens Objectives as useful. regarded be could indicators these of some before needed are efforts capacity-strengthening and research more that seems upon. it Therefore,agreed been have that indicators reproductivethe health of some experiencewith limited very tors of the incidence, prevalence,incidence, relativerates,case-fatalitythe of tors indica- be level.will project country the the of outcomes The at and regionally globally, mortality and morbidity measure maternal to aims review The committee. Pro- the forms gramme’s by reviewed form extraction data the and pleted com- been has review this for protocol causes. The its and mortality review systematic the maternal include of will ment docu- completed. working been This has studies tion-based and data from WHO datasets and recently published popula- drafta 2001, In monograph methods principles, the outlining systematic review andsevere morbidities: Maternal mortality a Progress lished studiesanddatasets. unpub- or published of reviews systematic from morbidities reproductive and pregnancy of fractions attributable and lae prevalence/incidence,calculate to case-fatality rates, seque- programmes,country and advocacy. The specific objective is evidence-based of implementation morbidities, reproductive prevent to practices on research future for: support provide will mapping fashion. in This systematic and comprehensive morbidities a reproductive the map to is goal overall The EPIDEMIOLOGY OFREPRODUCTIVE ILL-HEALTH Annual Technical Report 2001 205 Monitoring and evaluation Monitoring FUTURE CHALLENGES REPRODUCTIVE HEALTH INDICATORS HEALTH REPRODUCTIVE The challenges in the area of monitoringcan and evaluation be summarized as follows: Ectopic pregnancyEctopic A short review of the prevalence, associated morbidity and mortality from ectopic pregnancy between 1990 and 2001 conducted in 2001. also was Reproductive health indicators are used at global, regional and national to levels monitor the reproductive health status There of are populations. 17 global reproductive health indi- cators that have been agreed upon by international agen- The cies. Department’s work on mapping the epidemiology of knowledge available enhance will ill-health reproductive of the status of these indicators while globally, the tools devel- in help will indicators these of use and collection the for oped in countries. capacity building Progress The report of the Second Inter-Agency Meeting on Repro- ductive Health Indicators for Global Monitoring, which was convened by the Department in July 2000 of at the the request WHO/UNICEF/UNFPA Coordinating Committee on Health (CCH), was published in July 2001 and was widely distributed. As a follow-up to the meeting, the Department gave tech- nical advice and feedback for two workshops in Africa and These were Europe. organized with a view to decide appro- health indicators. priate regional reproductive Since the July 2000 meeting, the Department has compiled the available data and developed a composite report of the indica- 17 the for organizations various the of datasets global tors. An interactive CD-ROM of country profiles and awall- chart mapping the global collection of these indicators will be finalized in early 2002. “WHOThe toolkit” for collecting and using the indicators has been by experts reviewed from The finalagencies documentand several willinstitutions. be in 2002. published In 2001, the Department project with initiated a collaborative the University of Aberdeen, Aberdeen, United Kingdom, to develop a computer-assisted training package on selected reproductive health indicators (Computer-assisted learning package on maternal health The [CALMAT]). first phase of this project will be reviewed in will be planned accordingly. developments January 2002 and future Objectives WHO Reproductive A review was A conducted review to document the status of maternal Europe. in populations displaced and immigrant among health Despite the large numbers of women in this a scarcity situation, of revealed Nevertheless, data in this review area. the studies from the Netherlands and the United Kingdom indi- cate that the immigrant and migrant populations in Europe reduced have access to maternal health services compared to resident populations, and their health status too is favourable. less Maternal health of immigrant populations in Europe health of immigrant Maternal Global, regional and country estimates on the incidence of low birth weight, perinatal and neonatal period 1995–1999 mortality are for being the developed. Estimates of burden of the disease, deaths and disability-adjusted life years related to low birth weight and perinatal causes are (DALYs) under revision. Perinatal mortalityPerinatal The database on the prevalence of anaemia among preg- nant women has been updated with new studies, up to end- 2001. The data are currently available electronically in the database on and Department’s the will Depart-be published site in 2002. web ment’s Anaemia pregnancy during Skilled birth attendant percentage the of estimates subregional and regional Global, been completed of births skilled personnel have attended by in 2001, and the data will be published on the Department’s site in 2002. web In 2001, the global, regional and national maternal mortality estimates for 1995 were published Nations by Children’s Fund (UNICEF) WHO, and the the United Nations United Population Fund A (UNFPA). paper describing the limi- method and strengths its and estimates, these producing in used published. also was tations, Maternal mortalityMaternal estimates There is currently limited across experience incidence/prevalence of data observational of with reviews the systematic pool- of techniques the to regard with especially populations, issues, these address to order In studies. such from data ing a methodological working group has been constituted which in March 2002. will convene (RHL) No. 6 and will be periodically updated. Health Library (RHL) No. Data extraction, Data from extraction, 1995–2001, will be completed by end- This will review be 2002. included in the risks and sequelae of morbid of the risk as measures as well factors. conditions nancy, related to preg- 206 Annual Technical Report 2001 • • Section 9-Monitoring andevaluationSection

conditions have to be conducted. This process was ini- was process conducted. This be to have conditions health reproductive of prognosis and sequelae bidities, health, systematic reviews to evaluate the ill- extent of mor- reproductive of extent true the understand to in order ill-health: reproductive of epidemiology of Mapping provide usefulinsightsintothisprocess. will 2002 convenedMarch be in will that Group Working tional studies and producing estimates. The Methodology observa- from data pooling of methodology the and ies to data searching, the critical appraisal of identified stud- challenges. newrelate pose These morbidities and ities Methodological challenges: systematic reviews of mortal- •

ational indicators poses a challenge for international international for agencies. challenge a oper- poses and indicators relevant ational locally and goals global gap between The demonstrated. be to remains status populations health of reproductive the reflecting in indicators chosen of success the indicators: health Reproductive incontinence and uterine prolapsewillbeconducted. incontinence anduterine urinary of reviews systematic 2002, Kingdom. In United and rics Gynaecology, University of Liverpool, Liverpool, Obstet- of Department The with collaboration in tiated Annual Technical Report 2001 207 Section 10 of information Communication and dissemination and Communication 208 Annual Technical Report 2001 • • • • ing mainobjectives: tion, advocacy and information group has set itself the follow- and communica- the Scientific (STAG)2001, Group in Technical Advisory Department’s the to presented munication com- and dissemination information for strategy the per As global reproductive health. improving in objectives and mandate the WHO of support in Department, the outside and within knowledge, health tive reproduc- to access facilitate to seeks group dissemination improving of elements global keyhealth. The communication, advocacy and information the of one is Communication Section 10-CommunicationSection anddissemination ofinformation

to initiateadvocacy andpublic relations interventions. ing ofdissemination/communication strategies; and the of communication evaluationstrengthen- as well as activities dissemination of impact of a support manage in programme and research develop initiate, to communication; participatory on focusing media, and strategies appropriate through to facilitate the transfer of reproductive health knowledge stakeholders; and audiences target to of knowledge health reproductive communication and dissemination the for gramme cost–effectivepro- and proactive strategic, developa to INTRODUCTION Communication anddissemination of information J. Khanna, C. Hamill, S. Kolev Production ofdocumentsProduction andpublications also produced in print format. also producedinprint the of copies of number policy-makers. international and small national A to and tists scien- to primarily distributed, were CD-ROM the of copies 2500 2000. than to More 1998 from Department report the the of work on information of package biennial full a provide reports beginning, these new a 1998–1999; WHO: at research health Reproductive 1998–1999; report biennial Cairo, ing implement- development: programme health Reproductive the to addition CD-ROM. In on format electronic in distributed and the time, first the For technicalAnnual 2000+ report Department’s web site. the on published also are Chinese. They into translated be covered research on adolescent sexuality. Issues continue to tal care and maternal mortality and morbidity, and the second were published in 2001. The first was on research on antena- newsletter the public.of Twogeneral issues the and entists sci- managers, programme policy-makers, to information dissemination for instrument main the as serve to continued The newsletter Progress inreproductive healthresearch distributed in2001: and produced were publications/documents following The , the CD-ROM included CD-ROM the 2000, report technical Annual Annual technical report 1999. report Together,technical Annual the and Progress in reproductive health research has was published was report technical Annual PROGRESS Annual technical report 2000 report technical Annual was Annual Technical Report 2001 209 Annual Annual technical report 1995. HRP Online and a new look was What’s What’s new on the web? has been designed Communication and dissemination of information dissemination and Communication An up-to-date to help focus users on new additions to the web site. Sub- stantial progress has been made on overhauling the gramme’s Pro- old web site created for the Department’s home page. The navigational structure and user-friendliness of the web been further imporved. site have also These workshops focus on the skills involved in writing a sci- writinga in involved skills the on focus workshops These the in scientists encourage to aim and paper research entific Scientific writing workshops Scientific writing A description of the Programme’s scientificshops can writing be work- found in the Strengthening the capacity for communication the capacity communication for Strengthening of the dissemination and information Centres Collaborating Programme’s The Programme’s collaborating centres worldwide are partners its in the conduct of research. The Programme con- tinues to conduct various activities to enhance partnership in communication and dissemination of reproductive health a that believes Programme The well. as information research effec- more be will communication to approach decentralized tive in reaching diverse audiences who speak different lan- channels. communication guages and use different The Programme’s strategy involves convincing the collabo- rating centres about the value the of strengthening policy-makers, communicating and public research the to knowledge communication capabilities of individual researchers in the effective and writing scientific on workshops (through centres communication with the mass media), and helping the cen- management information for capacity their strengthen to tres technical assistance providing in the and (by communication units). setting-up or strengthening of communication The WHO Reproductive Health Reproductive WHO of The Dissemination 5 4 and production of RHL No. Library (RHL) No. The fourth issue of RHL was published in February 2001. Later in the year, its Spanish version was also A published. total of 15 000 copies copies of of By the December Spanish were version produced. the English version and 500 2001, more than 13 000 copies of the English strategy version dissemination the had of element key A distributed. been subscrip- a on distribution free the been has RHL for adopted tion Subscriptionsbasis. to RHL continue to By rise rapidly. December 2001, there were close to 7800 addresses in the mailing list for the English an version; additional 900 people Individual edition. Spanish the for subscription requested had physicians and health workers in developing countries and medical libraries make up almost 80% asso- of scientists and institutions the include recipients recipients Other of RHL. ciated with the Department. During 2001, work was started on RHL No. 5, including the digital editing videos to be included in that issue. of two training Safe Safe motherhood: a in 1989. In 2001, one issue of the of issue one 2001, In 1989. in Making Pregnancy Safer health and reproductive Adolescent sexual motherhood costing spreadsheet. Safe The Strategic Approach to reproductive health Approach to reproductive The Strategic Reproductive tract infections/sexually transmitted infec- tions including HIV/AIDS

• • • • • Notable additions to the web site this year include web pages web include year this site web the to additions Notable on: Reproductive health web site health web Reproductive The site web Department’s (http://www.who.int/reproductive- approx- houses now and grow to continues health/index.htm) imately 1600 files. Almost all documents producedDepartment by the are now available online in a format compatible which for is basic hardware even with poor connectivity and this, furthermore, allows for texts to be downloaded for are documents new Increasingly, countryat adaptation level. on the available web in site they are printedbefore available format. Any modificationsmade to documents after printing will be reflected in the documents site. All containeddocuments are available in English and onsome have the web and/or Spanish versions. French The manner in which documents are produced is also being CD in available made being information more with expanded, format and all printed technical documents posted on site. web Department’s the The greatly increased number and variety of materials pro- merg- in success Department’s the reflect 2001 during duced to addition In supportactivities. technical and research its ing general programme management activities, the documents address a broad range of health issues such as antenatal care, adolescent sexual health, HIV/AIDS and female gen- ital mutilation (FGM) and such deal as gender; information, education and with communication cross-cutting issues (IEC) monitoringactivities; and and rights-basedevaluation; approaches. A number of the documents jointly were with other produced departments, notably the Departments of Health. Women’s HIV/AIDS and Gender and newsletter of global activity activity global of newsletter skilled of topic the on focused which prepared was newsletter attendance. Other documents Safe motherhood: a newsletter global activity of Safe motherhood: The Safe Motherhood Initiative is a global effort to reduce maternal mortality and As morbidity. part of its contribution to the WHO Initiative, began publishing 210 Annual Technical Report 2001 Section 10-CommunicationSection anddissemination ofinformation Clinic

Clinic normativ Nuev leursimplic Clinic Essential D Nouv relationsSexual among young people countries: in developing evidence from PaperOccasional series Clinic healthprog M cont C P A T M P Manual fortheimplementationofnew mutilation(FGM)intonursingandmidwifer ofHI Exploring T Integ E HRP P Annual technic Breastfeeding andreplac Guidelines forthemanagementofsexuallytr 17–19July2000 Integ Language Integ mutilation(FGM)intonursingandmidwifer Reproductive healthindi mutilation(FGM)intonursingandmidwifer planningandSTI/HIVprev Management ofpregnan New dataontheprev maternit r he r rev lec rit dvancing safe motherho rint do ocuments underocuments field-testing ansforming healthsystems: aternit aternal mortalit omoting reproductiv è WHO Reproductiv ention ofmother-to-childtr tronic documentsonCD Progra r os datossobrelaprev r r r elles donné r al guidesforHIVinmaternit al guidesforHIVinmaternit al guidesforHIVinmaternit al guidesforHIVinmaternit es de recevabili V a a a a : ting theprev ting theprev ting theprev anassessmenttoolforresearchandprog ceptiv é sansrisques cuments c y setting c as are practice guide for pregnancy, ommon ground: mme budget2002–200 v ations politiques r e a es rsions mme managers a :

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Annual Technical Report 2001 211 PLANNED ACTIVITIES Communication and dissemination of information dissemination and Communication at present, the focus will be on In response to requests from managers programme in skills. imparting communication these workshops, the training in advocacy skills has been expanded. At the end of the firstworkshop, all participants specificwill projectsbe ingiven line withwork, their in which the In skills. communication newly-acquired their use will they second workshop, the same participants will return after a period of 3–6 months to discuss their experiences of use of and to furtherthe skills in real life hone their skills. In 2002, the Department will continue to produce its usual serial and nonserial publications, disseminate appropriate public relations material and conduct its scientific communication writing, and information management workshops. Special emphasis will continue to be placed on the develop- ment of the Internet site. web China, in workshops writing scientific conduct to planned is It India and the Islamic Republic of Iran. cen- capacity of collaborating strengthen the communication Other activities to tres will also continue. Evaluation of information products information of Evaluation Safe motherhood newsletter the among survey Departmenta the conducted 2000, had In readers of Safe motherhood: a newsletter of global activity. The response rate was Data very analysis satisfactory. was under way in 2001 and results are expected to be available in 2002. Collaboration The Department variety a in Programme the with of collaborates USA NY, Ithaca, Communication, Cornell University, of activities including the conduct of communication work- scientists. shops for A scene from the communication workshop for scientists and policy workshop for A scene from the communication 2001. June Egypt, in in Cairo, held makers In order to enhance the effectiveness of the communication workshops, plans were developed to conduct these work- shops in two stages. In the first workshop, as is the case In June 2001, a communication workshop was conducted at the Egyptian Fertility Care Society in Cairo, managers, programme Egypt. researchers, participantsThe included 15 policy-makers and communication experts from the Ministry of Health. The mass media play a vital about role new in scientific informing developments, building the public public opinion on health issues and facilitating the conversion of new find- it ings Therefore, is into importantpolicy actions. to promote networking between local journalists, scientists, programme managers The and Programme that believes policy-makers. researchers have a responsibility not only to publish findings their in peer-reviewed journals, but alsofindingsto known make their to generalthe public who are investors in, and beneficiaries of, research.For these reasons, the Pro- gramme supports the improvement of communication skills and policy-makers. managers programme among scientists, Workshops to improve communication skills and communication improve to Workshops networking with the mass media A scientifictrainers’ writingworkshop was conducted at the Faculty of Medicine, University of Malaya, Kuala The Malaysia. Lumpur, 12 participants in the workshop were senior of Medicine. teachers in the Faculty During 2001, three scientific writing workshops were con- ducted: two were held for a total of The third was 30 Malaysia. Lumpur, Kuala researchers of Malaya, University at the conducted at the Shanghai Institute of Planned Parenthood Research in Shanghai, China for 22 junior- and middle-level scientists. Programme’s Programme’s collaborating centres to publish more papers, journals. in internationalespecially peer-reviewed 212 Annual Technical Report 2001 23 Khanna J. Science communication indeveloping countries: experience from WHO workshops. PUBLICATIONS IN2001 Annex 1 Section 10-CommunicationSection anddissemination ofinformation :50–56. Science communication, 2001, Annual Technical Report 2001 213 Section 11 Clinical trials and informatics support and informatics trials Clinical 214 Annual Technical Report 2001 national multicentre studies. ity of individual centres to handle their own single-centre and tre studies from Geneva while continuing to enhance the abil- multicen- international coordinate to is strategygroup’s The to theadministrative managementoftheDepartment. support informatics providelocal also group the of members developingcountries. Staff in health reproductive in projects research multicentre of analysis and management conduct, the for techniques appropriate of development the to tribute con- trials. also Theysingle-centre own their out carrying or studies multicentre some in participating centres of staff to training in research data management and statistical analysis on-the-project provide group Support Informatics Trialsand Clinical the of institutions.Staff collaborating from scientists conduct of workshops and training courses in these areas for and organization the in and processing, data and statistics in policies institution-strengthening of review and execution to countries, the cal groupsupport assists in the formulation, Programme’sthe of activities.research techni- of area the In all in guidelines (GCP) Practice Clinical Good of mentation imple- the coordinates also group The Programme. the by out carried studies multicentre all nearly and single-centre forresponsibility and some of analysis and management the projects, research of development and review the in advice statistical includes activities research to support Technical of theDepartment. in technical statistics support and data processing to the rest provides group Support Informatics and Trials Clinical The Section 11-Clinical trials andinformatics support Section Clinical trials andinformatics support INTRODUCTION O. Ayeni, G. Piaggio, A. Peregoudov, S. Landoulsi the endof2001isshown in Table 11.1. at byprojects these distributionsupport of The of stage their bygroup. the weresupported projects research 63 of total A • • • • • • of support in 2001 in research projectsincluded: group the by out carried Activities to research projects Support Progress logical rigour, includingadherencetoGCPguidelines. methodo- and statistical ensure to and Programme, the by conducted research all to support data-processing and tical The objectives are to provide high-quality and efficient statis- Specific objectivesSpecific

from theprojects. resulting papers scientific of writing the in participation data analysisandpreparation ofstatisticalreports; and andmanagement; data processing,monitoring assistance withprojectorganization; statistical design; technical adviceintheirdevelopment andreview; SUPPORT TO RESEARCH ACTIVITIES Annual Technical Report 2001 215 9 13 Clinical trials and informatics support and informatics trials Clinical

revisions revisions

trolled trials at the 11th Postgraduate Course in for Reproductive Training Medicine and Reproductive Biology at the Centre WHO of Collaborating the Cantonal Hospital, Univer- sity of Geneva, Geneva, Switzerland. It was attended by 28 participants. Site-visits Staff of the group visited Reproduction Humaine the et Centre Démographie (CERRHUD) de and WHO Institut Recherche Régional the de Santé (IRSP) Publique both in en train- establishing of possibility the discuss to Benin Cotonou, ing courses in biostatistics and data processing for French- speaking African countries. Staff of the Department visited (NRIFP), Planning Family for Institute Research National the Beijing, China, to help assess its capabilities to coordinate three research projects of the Foundation Rockefeller Initia- assist- Shanghai, and Beijing to visit another In China. in tive ance was provided in the preparation on Quality Care in of the Chinese family planning programme. the Conference Issues related to data of management the in col- the context laboration between the State Family Planning Commission (SFPC) and the Department also discussed. were preparation of final analysis final of preparation , manuscript in preparation, ed, t draf final data cleaning ACTIVITIES nd/or additions to final analysis final to additions nd/or a monitoring, interim analysis interim monitoring, analysis: Final Statistical report Statistical SUPPORT TO INSTITUTION-STRENGTHENING TO SUPPORT Objective A staff member of the group gave lectures on strategies for data analysis of observational studies and randomized con- The following are the highlights of activities during are the highlights of activities 2001: The following and workshops seminars courses, Training Activities The objective of these activities is to strengthen the statisti- cal and data-processing capabilities of selected developing country institutions to support research work. their own During 2001, efforts continued to formally implement WHO GCP research guidelines research activities. throughout Scientific staff the of the DepartmentPro- Operating Standard were 69 the edit to groups Programme’s into organized editing The year. previous the during drafted (SOPs) cedures the during completed be will and progress in still is procedure first half of 2002. Implementation of GCP guidelines in research Implementation of GCP guidelines in In addition to the technical support given to these specific projects, all of which are being coordinated in sup- Geneva, port was given to Programme staff with the technical review of projects submitted to them for funding and arrangements for logistic support to projects before launching. The tech- nical review focused mainly on the biostatistical and processing data aspects of the protocol arrangements included while site-visits to the proposed study and logistic support coordinating centres to review facilities and data collection mechanisms. 216 Annual Technical Report 2001 CONSULTANTS AND TEMPORARY ADVISERS DURING2001 Annex 1

Section 11-Clinical trials andinformatics support Section Name Virgile Capo-chichi Sihem Landoulsi David Machin Alain Pinol Nationality Benin Tunisia United Kingdom France Place ofassignment Geneva Geneva Geneva Geneva Annual Technical Report 2001 217 :3571–3587. Statistics Statistical Methods Statistics in Medicine, :401–416. Clinical trials and informatics support and informatics trials Clinical Statistics in Medicine, 2001, 20 (submitted). Trials Controlled Clinical :689–695. Statistics in Medicine, 2001, 20 British Medical Journal (submitted). The Lancet, 2001, 358 :325–328. :3487–3488. :3487–3648. von Hertzen H, Honkanen H, Piaggio G, Bartfai G, Erdenetungalag , Gemzell-Danielsson K, et al. for the WHO Research the for Hertzen K, et al. Bartfaivon H, Honkanen H, Piaggio G, G, Erdenetungalag , Gemzell-Danielsson study of three misoprostol regimens after WHO multinational Fertility Regulation. Methods for Group on Post-Ovulatory Efficacy. earlyI. medical abortion: for mifepristone Piaggio G, d’Arcangues C, Machin D, eds. Statistical methods in reproductive health. Special issue. issue. Special health. Statistical methods in reproductive eds. Machin D, Piaggio G, d’Arcangues C, 2001, 20 health. reproductive to the Special issue on statistical methods in Preface Machin D. Piaggio G, d’Arcangues C, in Medicine, 2001, 20 Piaggio G, Elbourne D, Villar J, Pinol A, Schulz KF and Gülmezoglu AM, for the WHO Collaborative Group To Evaluate Evaluate To Group Collaborative WHO the AM, for Pinol A, Schulz KF and Gülmezoglu Villar J, Piaggio G, Elbourne D, concealment and Reporting randomisation, for of methods of Labour. Third Stage of the Misoprostol in the Management third stage of labour trial.WHO misoprostol of the the example blinding: Donner A, Piaggio G, Villar J. Statistical methods for the meta-analyses of cluster randomization trials. of cluster randomization the meta-analyses for Statistical methods Villar J. Donner A, Piaggio G, Annex 2 Annex IN 2001 PUBLICATIONS , 2001, 10 in Medical Research to Evaluate Group WHO Collaborative the for G, Carroli G, Adetoro L, et al. Nhu Ngoc N, Piaggio Villar J, AM, Gülmezoglu trial of misoprostol in the randomized WHO multicentre of Labour. Third Stage of the Misoprostol in the Management third stage of labour. management of the health trials. approach in reproductive Use of the equivalence Piaggio G, Pinol A. on the design and Methodological considerations et al. L, Lumbiganon P, Pinol A, Bakketeig J, Villar Piaggio G, Carroli G, randomization trial. cluster stratified analysis of an equivalence 218 Annual Technical Report 2001 Section 11-Clinical trials andinformatics support Section Annual Technical Report 2001 219 1 1 1 1 1 1

2

2 2 1, 2 2 2 1 1, 2 1, 2 2 2 2 2

1, 2 2 1 1

2 1 1 2 1 1 1 Gloria Lamptey, Secretary Gloria Lamptey, Secretary Pasini, Lynda Rita Kabra, Medical Officer Rita Kabra, Catherine Legros, ClerkCatherine Legros, Archana Shah, Technical Officer Technical Archana Shah, Midwife Della Sherratt, Medical Officer Villar, Jose David Griffin, Scientist David Officer Technical Johnson, Sarah Medical Officer Herbert Peterson, Officer Technical Annie Portela, Secretary Sellaro, Lynn Officer Technical Vayena, Effy Scientist Vogelsong, Kirsten SecretaryShamilah Akram, Luc De Bernis, Medical Officer Project Manager Bocar Diallo, Secretary Maureen Dunphy, Secretary Ferguson, Janette Officer Technical Helga Fogstad, Medical Officer Ornella Lincetto, Mario Merialdi, Medical Officer Secretary Eirwen, Pizot Jane Secretary Anne Riccio-Fazli, Olusola Ayeni, Statistician Olusola Ayeni, Assistant (Statistics) Annie Chevrot, Assistant (Statistics) Catherine Hazelden, Clerk Jiguet, Evelyn Analyst Sihem Landoulsi, Programmer Clerk Natalie Maurer, Analyst Programmer Peregoudov, Alexandre Statistician Gilda Piaggio Soto, Assistant (Statistics) Schlagenhaft, Frederick Assistant (Statistics) Vucurevic, Milena Officer Technical Kathryn Church, Annex 1 - Staff of the Department, December 2001 December the Department, of 1 - Staff Annex Making Pregnancy Safer Clinical Trials and Informatics Supportand Informatics Clinical Trials Planning Family Promoting 1

Appendix 1 Appendix

1 1, 2 2 1 1, 2 1 1 1 1, 2 2 1 1 1 1 2 2 1 1, 2 1, 2 1 1 1 1 Staff of the Department, December December 2001 Staff of the Department, Maire Ni Mhearain, SecretaryMaire Ni Mhearain, Nalini Wijesundera, Clerk Svetlin Kolev, Information Officer Information Kolev, Svetlin Clerk Linda Kreutzer, Sue Lambert, Secretary Assistant Technical Christine Meynent, Annette Edwards de Lima, Clerk Annette Edwards Officer Technical Catherine Hamill, Harmand, Assistant (Supplies) Teresa Officer Technical Khanna, Jitendra Lucy Adokojok, SecretaryLucy Adokojok, Assistant Technical Åsa Cuzin, Medical Officer Metin Gulmezoglu, Monir Islam, Medical Officer Officer Technical Maggie Usher, Jane Cottingham, Technical Officer Technical Cottingham, Jane Officer Technical Adriane Martin Hilber, Secretary Karie Pellicer, Secretary Perrin, Jenny Claire Tierney, Secretary Tierney, Claire Ziaei, SecretaryHazel Officer Technical Colombini, Manuela Paulo dos Santos, Clerk dos Santos, Paulo Secretary Kayser, Barbara Officer Technical Lissner, Craig Scientist Michael Mbizvo, Bérengère Nail, Secretary Secretary Corinne Penhale, Anne Allemand, Secretary Reproduction Equipment Operator Luc Bernier, Catherine Medical Officer d’Arcangues, Paul Van Look, Director Look, Director Van Paul Staff of the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Training and Research of Research, Development Bank Special Programme Staff of the UNDP/UNFPA/WHO/World staff Temporary Communication, Advocacy and Information Communication, Advocacy Implementing Best Practices Best Implementing hts Rig Gender Issues and Reproductive Programme Management Programme Reproduction (see also the companion report entitled Reproductive health research at WHO: biennial report 2000-2001). WHO: Reproduction (see also the companion report health research at Reproductive entitled 1 2 220 Annual Technical Report 2001 Preventing Unsafe Abortion Transmitted Infections Addressing Reproductive Tract andSexually Monitoring andEvaluation 2 entitledReproductive healthresearch at Reproduction (see alsothecompanionreport WHO: 2000-2001). biennial report 1 Annex 1-Staff oftheDepartment, December 2001 Temporary staff StaffoftheUNDP/UNFPA/WHO/World BankSpecialProgramme ofResearch,Development andResearch Training inHuman Bidia Deperthes, Bidia Deperthes, Technical Officer Ina Warriner, Scientist Helena Von MedicalOfficer Hertzen, Iqbal Shah,Scientist Nicola Sabatini-Fox, Secretary Janette Marozzi,Secretary Maud Keizer, Secretary Isaac Malonza,MedicalOfficer Sophie Lacroix,Secretary Isabelle De Vincenzi, MedicalOfficer Nathalie Broutet,Scientist Secretary AgnesAnciano-Muriel, Maria Wilma Doedens, Technical Officer Ana-Pilar Betran, MedicalOfficer Justin Mandala, Technical Officer Sybil Taylor, Secretary Carol Peters, Secretary Timothy Farley, Scientist Harriet Kabagenyi,Harriet Secretary 1 1 1

1 1

1, 2 2 1 2 1 1,2 2 1,2

2 2

1 1,2

1, 2 Policy andProgrammatic Issues Technical Team Support Ruth Malaguti,Secretary Broderick, Mary Technical Officer Nini Zotomayor, Secretary Alexis Ntabona,MedicalOfficer Kaufmann,Secretary Margrit Amel Fahmy, Technical Officer Ezcurra, Scientist Enrique David Chikamata,MedicalOfficer Vanessa Campos, Clerk Blanc,Catherine Secretary Jennifer Bayley, Secretary Heli Bathija,Scientist Peter Fajans, Scientist 1 1 1, 2 1 1 1 1 1 1 1, 2

1, 2 1