Entre Nous: the European magazine for sexual and reproductive health: no. 28–29: from Cairo to Copenhagen

No. 28-29/May 1995 Danmarka Natur· og l.81gevtde""8pellge Blbllotek N•rre AIIII 48, DK 2200 ~n N. ta,IID {1 ~11 } '.$. :1 ~ ~~.---.... l!'A---1t---m, ht\ \~ -....a.~ I I ' ---- ....... 2 ENTRE Nous ENTRE NOUS is published by: The Sexuality and Family Planning Unit WHO Regional Office for Europe Scherfigsvej 8 DK-100 Copenhagen 0 Denmark Tel.: 39 17 14 51 or 39 17 14 26 Fax : 39 17 18 50 Coordinator Dr Assia Brandrup-Lukanow Editor AnverVersi Administrator & editorial assistant Dominique Le Buf Translators Keneva Kunz Yvon Prigent ISSN 1014-8485 ENTRE NOUS is funded by the United Nations Population Fund (UNFPA), New York, with the assistance of the World Health Organization's Regional Office for Europe, Copenhagen. It is produced and distributed three times a year in English and French by the Sexuality and Family Planning Unit of the WHO Regional Office for Europe. Present distribution figures stand at 4600 English,2100 French, 2000 Spanish, 2000 Portuguese, 1000 Russian, 500 Hungarian. ENTRE NOUS is produced in: Spanish by the Instituto de Ia Mujer, Ministerio de Asuntos Sociales, Almagro 36, 28010 Madrid, Spain Portuguese by the General Directorate for Health, Alameda Afonso Henriques 45, P-1056 Lisbon, Portugal Hungarian by the Department of Obstetrics and Gynaecology, University Medical School of Debrecen, P.O. Box 37, Debrecen, Hungary Russian by the WHO Information Centre for Health for the Central Asian Republics, Kierskaya 27, Bishlrek 729495, Kyrgyzstan. The Spanish and Portuguese issues are distributed through UNFPA repres- entatives and WHO Regional Offices to Portuguese-speaking countries in Africa and South America. Material from ENTRE NOUS may be freely translated into any national lang- uage and reprinted in journals, magazines and newspapers, provided due acknowl- edgment is made to ENTRE NOUS, UNFPA and the WHO Regional Office for Europe. Articles appearing in ENTRE NOUS do not necessarily reflect the views of UNFPA or WHO. Please address en- quiries to the authors of signed articles. For information on WHO-supported activities and WHO documents, contact the Sexuality and Family Planning Unit at the address given above. Please order WHO publications direct from the WHO sales agent in each coun- try or from Distribution and Sales, WHO, 1211 Geneva 27, Switzerland. MEMBERS OF THE EDITORIAL BOARD Professor Ayse Akin Dervisog)u Director-General Department of Maternal and Child Health and Family Planning Ministry of Health, Ankara, Turkey Dr Marla da Purifica~o Araujo Division of Maternal Health and Family Planning General Directorate for Health, Lisbon, Portugal Dr Istvan Batar Head, Family Planning Centre University Medical School of Debrecen Hungary Dr Chantal Blayo Director of Research lns~tut National d'Etudes Demographiques Pans, France Professor Henry P. David Director Transnational Family Research Institute Bethesda, USA Dr France Donnay Health Promotion Unit United Nations Children's Fund (UNICEF) New York, USA Dr Dominique Hausser Directeur, Section SIDA lnstitut universitaire de medecine sociale et preventive, Lausanne,Suisse Professor Jerzy Z. Holzer Institute of Statistics and Demography Warsaw, Poland Dr Ellen Karro Chief Medical Officer Maternal Health and Family Planning Tallinn,Estonia Contents EDITORIAL by Anver Versi .............................................. 3 FROM CAIRO TO COPENHAGEN by Nafis Sadik ............................................. .4 PUTTING THE ICPD PLAN OF ACTION TO WORK Turkey: Women's health tops the · agenda, by Ayse Akin and Arzu Koseli ........ 6 Moldova: Historic regional conference, by Vaeceslav Moshin ................ 7 Implementing the ICPD Plan of Action in Central Asian Republics and Kazakhstan Uzbekistan: Squaring up to a demographic crisis, by Shafkat Karimov ...................................... 8 Kazakhstan: Looming shadow of ecological disaster, by Aman Dujsekeev and Nina Kajupova ............................................ 10 Tajikistan: Succeeding against the odds, by Valentina Alexejevna Maltseva .................. 11 Kyrgyzstan: Breast-feeding is best, by Anisa Kushbakeeva ............................... 11 Turkmenistan: Abortion rate declines, by Khangeldi Mamedov ............................. 12 Front page illustration by Juan Galan Mr Thomas E. Kennedy Chief of International Affairs Danish Medical Association Copenhagen, Denmark Dr Evert Ketting Deputy Director of the Netherlands Institute of Social Sexologi~ Research (NISSO) Utrecht, Netherlands · . ~.,, Dr Susan F. Newcomer i Statistician Center for Population Research Bethesda, USA Ms Mary Porter Head of Education and Training Family Planning Association London, United Kingdom Dr Andntl A. Popov (t 23 April 1995) Director Transnational Family Research Institute Moscow, The Russian Federation Dr Hanne Ris¢r Chairman Danish Family Planning Association Hellerup, Denmark Mr John Rowley Editor, People & the Planet International Planned Parenthood Federation London, United Kingdom Dr Eltan Sabatello Director Division for Demography, Population Health and Immigrants Absorption The Central Bureau of Statistics Jerusalem, Israel Azerbaijan: Urgent need for Family Planning, by Valida Jafarova ...................... 12 City profile: Almaty, by Tamara Djusubalieva and G. Umurzina ............................................... 13 WHO FILE SFP intercoutry activities:Promoting the health of women ................................... 15 AIDS: UN to pool resources in battle ~against AIDS by Johannes Hallauer and Alex Gromyko ..................................... 17 FROM OUR READERS Infertility treatment, a women's perspective .................................................. 18 TECHNOLOGY IMAP Statement on emergency contraception .............................................. 19 TRAINING Training in Europe ...................................... 20 RESOURCES Books .......................................................... 22 Documents .....•............................................ 23 Magazines/Newsletters ............................... 23 Wall charts ................................................. 24 Databases .................................................... 24 ENTRE NOUS 28-29, May 1995 © World Health Organization 1995 Some journalists attending the Social Summit rounded on UN Secretary-General Boutros Boutros-Ghali and asked him if Copenhagen, following on from Rio (Earth), Vienna (Human Rights) and Cairo (Population) would serve any real purpose other than to increase "summit fatigue" . Boutros- Ghali reflected for a moment and then replied: "The duty of the UN is to cope with fatigue. Fatigue means indiffer- ence and our role, our raison d'etre, is to say we are all in the same boat". During the Summit itself however, it became patently clear that not all nations accept that "we are all in the same boat". There was thinly veiled resistance from countries of the developed world to commit themselves, financially and politically to eradicating global poverty. For example, despite valiant champ- ioning by UNICEF, the 20-20 Formula was so watered down and hedged with so many get-out clauses that it is virtu- ally meaningless. Attempts to persuade Western nations to write off the debts of the developing world, a debt burden that continues to condemn so many nations to eternal poverty, were stiffly resisted. Proposals to institute the Tobin Tax (James Tobin, winner of the 1981 Nobel Prize for Economics argued that a 0.5% tax on international currency transactions, which can exceed US$ l,000,000,000,000 a day would raise US$150 billion a year to fight poverty) met with stony stru:es. Yet the summit, in my view, was a success and worth the US$30m spent, largely by the Danish government, to make it happen. The issue was not really poverty, but the global consequences of poverty. Delegates however, were not spared the full, painful scale of poverty in our times: 1.3 billion poor, 13 million children under five die annuall~ •as a consequence of poverty, US$1.4 trillion owed by the poor nations to the rich. No degree of indifference can wish away these staggering statistics and no degree of wishful thinking can convince itself that the consequence of such abject poverty can forever be confined to the developing world. Indeed the aim of the Summit was to drive home the inter-connectedness of everything. In a shrunken world operat- ing in a globalised market, a sneeze in Singapore can result in a bout of fatal pneumonia in London - witness the shocking collapse of Barings Bank one of the oldest and most venerated institu- tions in Britain. Civil conflict goes hand in hand with underdevelopment. Conflict, in Africa, Asia, Latin America and Eastern Europe has led to massive movements of people and unsustainable pools of refugees. This leads to more conflict and an ever widening circle of poverty. Poverty on ENTRE NOUS 28-29, May 1995 this scale impacts negatively on the environment and leads to deforestation, degradation and desertification. This leads to even more conflict, more pover- ty. The result is a shrunken world mar- ket, which manifests itself, eventually, in recession and unemployment in industrialised countries. Such an economic environment, as history so clearly shows, is ideal breeding ground for extremist politics, terrorism and the rise of fascism. The message from the Summit was that the problem of poverty is not exclusively that of the poor world but very really that of everybody. We are, whether we like it or not, "all in the same boat" and if it takes a major international confer- UN Secretary-General, Boutros Boutros Ghali at the World Summit for Social Development, Copenhagen ©. UN, Office of Public Information ence to hammer this message home, then , let's have more of such conferences. From the point of inter-connectedness, the Social Summit was a logical contin- uation of Cairo and a validation of the holistic approach taken by the UN. Population policies have little real rele- vance unless they lead and are seen to lead to an alleviation of poverty. Cairo pointed out that population policies, in their full ramification, can be made to work; Copenhagen showed that unless the other causes of poverty are also tackled, a better, more equitable and therefore a more peaceful and pro- sperous world is an impossible dream. Perhaps it was significant that the 85th World Women's Day, which in fact was initially launched in Copenhagen, was celebrated during the summit. "The problems faced by women everywhere lie at the heart of the global agenda," said Boutros Boutros-Ghali. ''Unless the rights and full potential of women are achieved, enduring solutions to the world's most serious social, economic and political problems cannot be achieved." The majority of the world's poor are women, and therefore securing the rights of women t&.a decent life is another side of the co~ _of alleviating poverty. : . ~·" - In her address, Dr Nafis Sadik, Ex- ecutive Director of the United Nations Population Fund, underlined the linkage and re-connected with Cairo: "I would like to emphasize that the goal of em- powerment cannot be achieved without attention to the basic circumstances of women's lives. An essential component of empowerment is the right of all people, couples and individuals alike, to decide freely and responsibly the num- ber and spacing of their children and to have the information and the means to do so. The right to reproductive health is a principle of the first importance not only for women, but for all people and all nations." It is also perhaps significant that the United States, which is in the process of cutting aid generally to the poor nations, was sufficiently moved to pledge US$ 100 million towards better education for poor women in the poorest of develop- ing nations. "No single factor contri- butes to the long term health and pros- perity of a developing nation more than investing in education for girls and women," said US First Lady Hilary Clinton. However limited the concrete policies that emerged out of Copenhagen might have been, there is no doubt that the issue of global poverty, like that of the status of women and children, is now firmly on the international agenda. "There is no going back now," said Richard Jolly of UNICEF. "Human development, the emancipation of "women and the eradication of poverty have now become the benchmark of how we assess our civilization and ourselves as civilized human beings." Part of this resolution also forms the ICPD Programme of Action. In this issue we highlight how the Common- wealth of Independent States have already embarked on the Programme, with varying degrees of success. The point is that ICPD has, indeed, changed attitudes towards women, children and families; and revolutions only really begin when deep-held attitudes begin to alter. Is it just a coincidence that the next major global summit should be The Beijing Conference on Women and that it should be held in China, or have we finally arrived at a turning point for humanity? • Anver Versi Editor, Entre Nous 3 From Cairo to Copenhagen By Dr Nafis Sadik I n Cairo last September, the that inequalities between men and International Conference on women must be ended to meet the Population and Development goal of better r~roductive health. permanently changed the way fami- The Programm~· of Action ly planning is viewed by the world affirms "th~· righl-of men and wo- community. The Conference firmly men to be informed and to have placed family planning among the access to safe, effective, afford- totality of reproductive health able and acceptable methods of needs, and recognized that meeting family planning of their choice". those needs is a pressing global It further calls on countries to responsibility. ensure that adolescents have One hundred and eighty nations access to appropriate services and overwhelmingly adopted the 20- information to address such issues year Cairo Programme of Action. as teenage pregnancy, sexually The Programme of Action reflects a transmitted diseases and sexual new strategy emphasizing that abuse. population and development are Implementing this holistic inseparable, and focuses on indivi- ..__..r....::..ui...1111i:ll!l;;..-..~L1 approach, based on the principle dual needs and human rights rather Photo: Klaus Holsting/2. maj @ of free, informed choice, will than on demographic targets. have the effect of promoting The key to this new approach is em- that none of them can be considered in smaller, healthier families. Lower birth powering women and providing them isolation. " rates will lead to a better balance be- with more choices through expanded The context of the Cairo Programme of tween population growth and resources. access to health care, education,training Action is a world of nearly 5.7 billion At the same time, nothing in the Cairo and employment opportunities. The Pro- people, growing at between 85 and 88 consensus weakens the power of nations gramme of Action calls on countries to million a year. More than one billion live to make their own decisions regarding make family planning services univer- in absolute poverty, and many more are population and development. The Pro- sally available through their primary only marginally better off. Infant, child gramme of Action emphasizes that health care systems by 2015 or sooner, and maternal mortality rates are still implementation is "the sovereign right as part of a broader reproductive health tragically high in many countries despite of each country, consistent with national package which also encompasses servi- the substantial progress achieved in laws and development priorities, with ces for pre- and post-natal care, safe recent decades. Throughout the world, full respect for the various religious and delivery, prevention of sexually trans- women and girls face tremendous dis- ethical values and cultural backgrounds mitted diseases including HIV/AIDS, advantages in regard to health care, of its people, and in conformity with infertility, and management of the education, training, and employment universally recognized international complications of abortion. prospects. human rights." The Programme of Action also Around the world, basic resources on A large and diverse group of non- includes goals in regard to education, which future generations will depend are governmental organizations (NGOs) especially for girls, and for the further being depleted. There is a vicious circle were involved to an unprecedented reduction of infant, child and maternal of poverty, social and economic ine- degree in the ICPD process and in sha- mortality levels. quality, rapid population growth, envi- ping the Programme of Action. The Pro- The Conference's adoption of this Pro- ronmental degradation, and unsustain- gramme of Action stresses the need for gramme on 13 September was..lU), elec- able production and consumption broad and effective partnership between trifying moment, the start of a new era , · patterns. Uncontrolled urban growth and Governments and NGOs in formulating, in dealing with population and develop- a steady increase in international migra- implementing and monitoring popula- ment concerns. It was the culmination of tion are among the consequences. tion and development programmes. a remarkable process of consensus The international community now building which took shape over the Strongest statement on women faces the challenge of translating the course of several years, in regional con- The ICPD approach recognizes that ICPD approach and commitments into ferences, Preparatory Committee these problems must be confronted action. This will require both significant sessions, and expert group meetings on simultaneously. To improve people's policy changes and a sizeable increase various related issues. quality of life and health, developing in national and international resources The ICPD strategy grew out of more countries must have sustained economic committed to reproductive health than 20 years experience with popul- growth within a framework of sustain- programmes. ation programmes, and the global com- able development; they must invest in In developing countries and those with munity's growing appreciation of the health and education, especially for economies in transition, the Programme importance of human development, girls; and women must be empowered so of Action estimates that comprehensive environmental protection and the that their social, political, economic and reproductive health and family planning empowerment of women. health status matches that of men. services would cost US$17 billion per As the Preamble to the Programme of In one of the strongest statements on year in the year 2000, about three times Action notes, "The 1994 Conference women ever to be included in a UN what is being spent today, and US$21.7 was explicitly given a broader mandate document, the ICPD Programme of billion in 2015. It is anticipated that on development issues than previous Action stresses that women must be full developing countries will be able to population conferences [in 1974 and and equal participants in all aspects of provide two thirds of the necessary 1984}, reflecting the growing awareness development planning and program- funds; about one third, or around US$5.7 that population, poverty, patterns of pro- ming; this is both a matter of basic billion in 2000 and US$7 .2 billion in duction and consumption and the envi- human rights and a prerequisite of 2015, will have to come from donors. ronment are so closely interconnected sustainable development. It also stresses Since the Conference, various national 4 ENTRE NOUS 28-29, May 1995 activities have got under way to dissemi- nate the Programme of Action and to develop implementation plans. More than a dozen countries have already begun to review their population pro- grammes to ensure consistency with the Programme of Action, including its approach to reproductive health. Mexico, for example, has decided to merge its family planning and maternal and child health programmes under a Directorate of Reproductive Health. Brazil is estab- lishing a Council on Population and Development which will facilitate participation by NGOs and community groups. At the United Nations Population Fund (UNFPA), a top priority is to ensure that policies and practice fully reflect and promote the ICPD Programme of Action. As part of a post-Cairo review of its policy guidelines, UNFPA in December hosted an expert consultation to seek guidance in developing new guidelines on reproductive health. Participants included international reproductive health experts, programme managers, representatives of women's health advocacy groups, and representatives of WHO and other international and bilateral agencies. New guidelines on reproductive health These new guidelines will focus on oper- ational aspects of reproductive health and specifically on the following compo- nents: family planning information and services; maternal care; prevention of abortion; reproductive tract infections; infertility; women's reproductive health conditions; and harmful practices in- cluding female genital mutilation. Among the many useful recommendati- ons were calls for increased emphasis on sexual health and rights, male responsibi- lity, and adolescent reproductive health. UNFPA's financial assistance will focus on the reproductive health package outlined in the Programme of Action. The greatest emphasis will be-@D those countries that have the farthest to go to meet the !CPD goals for the year 2015. The Fund intends to increase support for activities to prevent sexually transmitted diseases and infertility and reduce morta- lity and morbidity, and for advocacy work to eliminate female genital muti- lation. Greater attention will be also given to information, education and communi- cation with regard to reproductive health (including that of adolescents), gender concerns and education of girls. Additionally, the Fund plans to assist women's groups to better participate in monitoring implementation of the ICPD Programme, and to provide technical support for other organizations' and agencies' programmes to empower women and improve their status. In recent weeks, the Fund has conduct- ed four regional consultations, involving government officials, parliamentarians, NGO representatives and health experts ENTRE NOUS 28-29, May 1995 At Cairo the nations threw down a historic challenge in the field of social development. I hope this Summit will take up the gauntlet, not merely in the words of the Programme of Action, but in the hearts of everyone attending this meeting, and in your deeds in the future. from the public and private sectors in discussions on how to speed implemen- tation of the Programme of Action. A similar workshop for the Europe region will take place from 3-5 May in Bucha- rest. A Task Force on !CPD Implementa- tion has been set up to plan and support follow-up activities, in cooperation with UNFPA's geographic, technical and information/external relations divisions. UNFPA is also working to ensure that the programmes of the World Summit for Social Development and the Fourth World Conference on Women build on the agreement reached in Cairo. Our task now, both collectively and individually, is to ensure that the optim- ism which has emerged from the ICPD process and which the Programme of Action reflects is turned into tangible benefits for people everywhere. Sufficiently funded and properly carried out, the actions defined in the ICPD Programme will: • bring women into the mainstream of development; protect their health, promote their education, and encourage and reward their economic contribution; • ensure that every pregnancy is inten- ded, and every child is a wanted child; • protect women from the results of un- safe abortion; * protect the health of adolescents, and encourage responsible behaviour; • combat HN/AIDS; • promote education for all and close the gender gap in education; and • protect and promote the integrity of the family. pnergetic implementation of the , Programme adopted in Cairo will as a result contribute to slower and more balanced population growth; to the ending of poverty; and to economic development compatible with the demands of sustainability. The following is excerpted from the address delivered by Dr Najis Sadik, before the plenary of the World Summit for Social Development. Copenhagen: One of the major successes of the ICPD was consen- sus on a Programme of Action with a very strong emphasis on gender and equality. I am delighted to see that in Commitment 5 and in the draft Program- me of Action generally, this Summit has incorporated many of the goals and elements from the ICPD Programme of Action. It is important that this progress be maintained. Investing in people, in broadening their opportunities and en- abling them to realize their potential as human beings - that is the key to sust- ained economic growth and sustainable development, as well as to balanced, sustainable population growth. Both the ICPD Programme of Action and the draft Programme of Action for this Summit recognize the absolute necessity and urgency of empowering women as an important end in itself, as well as a key to improving the qualiu, of life for every- one. Without the full ano -equal participa- tion of women in all ij8 "'aspects, there can be no sustainable human development. I would like to emphasize however that the goal of empowerment cannot be achieved without attention to the basic circumstances of women's lives. An essential component of empowerment is the right of all people, couples and indi- viduals alike, to decide freely and responsibly the number and spacing of their children and to have the informa- tion and the means to do so. The right to reproductive health is a principle of the first importance, not only for women, but for all people and all nations. I urge the nations present at this Summit to endorse in this area the language you agreed to in Cairo, as an essential contribution to social development. At Cairo, the international community reached agreement on significant new investments in the areas of reproductive health care and family planning services. Many countries have already indicated that they will increase their support for population and development program- mes in the near future. • These resources will b~ complemented by funding a wide variety of measures aimed at meeting the educational and health goals set at earlier conferences. It would be heartening to see progress at this Summit towards the 20/20 vision for commitment of resources to meet social development goals. Together with com- mitment to implementing Agenda 21, this would make a coherent statement of the.international community's willing- neJ,s and determination to end poverty, 'build social justice, and work towards a sustainable future. At Cairo the nations threw down a historic challenge in the field of social development. I hope this Summit will take up the gauntlet, not merely in the words of the Programme of Action, but in the hearts of everyone attending this meeting, and in your deeds in the future. Then we may all be proud to say that we were here on this International Women's Day. Dr. Nafis Sadik, Executive Director of the United Nations Population Fund, was Secretary-General of the International Conference on Population and Development. 5 PUTTING THE ICPD PLAN OF ACTION TO WORK Turkey Women's health tops the agen~ by Prof Ay§e Akin and Dr Arzu Koseli Tie International Conference on Population and Development (ICPD) was explicitly given a broader mandate on development issues than previous population conferences, reflecting the growing awareness that population, poverty, patterns of produc- tion and consumption and the environ- ment are so closely interconnected that none of them can be considered in iso- lation. Turkey participated both during the preparatory phase of ICPD and also sent a 15 strong delegation, led by State Minister Mrs Onay Alpago, to Cairo. The delegation was made up of representatives from the technical departments of the Ministry of Health General Directorate (GD) MCH/FP, the State Statist- ical Institute, the Hacettepe University Insti- tute of Population Studies, the GD Women's Affairs and policy makers from the State Planning Organization, the Ministry of Foreign Affairs and national NGOs. We took the opportunity presented by a two-day conference, organized by the Ministry of Health to declare the results of the 1993 Turkish Demographic Health Survey, to brief the scientific community about the Conference and the ICPD Plan of Action. Members of the Cairo Dele- gation were thus able to discuss issues and recommendations raised by ICPD with both scientists and policy makers. As a result, a number of verbal commit- ments were made. The message was propagated further when, Professor Ay§e Akin, General Although the entire ICPD Plan of Action is relevant, our Ministry of Health is giving priority to: Repro- ductive Health, the Status of Women in our country and to Mortality and Morbidity. Photo: Jr;rgen Schytte/Billedhuset © Our strategy to implement the ICPD Plan of Action will involve: (1) Publicizing the goals of ICPD, (2) Sharing responsibilities and coordinating our activities with other sectors and (3) Following-up and monitoring both achievements and failures. After the preparatory phase, which was carried out in collaboration with UNFPA-Turkey, we organized a wide- ranging panel discussion for a large number of participants from various sectors. Delegates who had attended ICPD provided valuable information about the Conference and the Plan of Action to representatives of technical departments. We also discussed our targets and strategies to implement the Conference recommendations. 6 Director of MCH/FP gave a compre- hensive presentation on ICPD during a meeting to honour the late Professor Nusret Fi§ek. Professor Fi§ek, the founder of the Primary Health Care system in Turkey, also managed to change what was then a national pronatalist population policy into an antinatalist one some 30 years ago. Professor Akin's clear exposition of ICPD drew considerable interest during the commemorative meeting organized by the Turkish Medical Association. Members of the audience requested that the Plan of Action be published in Tur- kish. As a result, the GD MCHJFP has translated, printed and distributed chapters relating to reproductive health, status of women and mortality and morbidity. Efforts are also being made to translate the entire document. An important step was taken when a plethora of Government Ministries and NGOs attended the Population Planning Advisory Committee's (PPAC) annual meeting on January 24. Participants included the Ministries of Health, Na- tional Education, National Defense, The Interior, Foreign Affairs, and Transport- ation. Other organizations that attended this important meeting included The Women Health Advisory Board ( estab- lished in 1993 under the PPAC), the State Planning Organiza- tion, the State Statisti- cal Institute, Hacettepe University Institute of Population Studies, the Higher Education Coun- cil, and national and international NGOs. The Plan of Action was discussed in detail, the roles of each sector were identified and every department made a commitment to take responsibility for implementing the Plan. Follow up mechanisms were also established at the meeting. Recommendations and guidelines from ICPD documents have also been incorporated into the Seventh National 5- Year Development Plan. In January this year, the State Planning Organization reviewed national Reproductive Health, Popula- tion and Family Planning policies. In addition, the Prime Minister, Professor Tansu Ciller has initiated a special study aimed at developing an accelerate programme on population and family planning issues. Using ICPD recommendations as guidelines, the current situation on population, reproductive health and family planning in Turkey can be summarized as follows: * Population is a priority area. Detailed goals and targets have been laid down in the Seventh National 5-Year Develop- ment Plan. * Improvement in the Status of Women is considered to be of special signifi- ENTRE NOUS 28-29, May 1995 cance. Since 1990, the General Direc- torate, Status of Women was established under the State Ministry, to help women overcome psycho-social and cultural barriers and also to participate in various international activities related to the issue. * Reproductive Health, Family Plan- ning and SID services have been inte- grated within Primary Health Care since 1961. * As a result of special programmes initiated by the Ministry of Health, such as giving priority to disadvantaged groups and targeting high-risk groups, the general level of community health, especially maternal and child health, has improved as it is shown by the 1993 Turkish DHS. The informed free and voluntary choice of FP methods is one of the principles of the national FP pro- gram. * International assistance in health has been better directed according to national needs. More work needed However, considerable work still needs to be done in some areas such as promo- ting the decentralization of health servi- ces and, although there is no legislative barrier to FP, medical barriers are con- siderable. The question of abortion was one of the most contentious issues during the ICPD. In Turkey however, the issue of unsafe abortions is not a major public health concern and there are no legis- lative or social barriers. The current approach is to reduce recourse to abortion through expanded and im- proved FP services. Certified nurse-mid- wives are authorized to give FP services. Moldova The ICPD was an excellent international forum in which to draw attention to some of the most neglected areas in health and development. It also effectively emphasized the relationship between population and sustainable development. More signifi- cantly perhaps, the Confe- rence has enabled countries to re-evaluate their priorities and has stimulated the desire to implement the Plan of Action. In addition, improved services both in quality and method (surgical contracep- tion, Norplant, injectable) is provided. Pregnancy termination is legal up to the 10th week of pregnancy and certified general practitioners have been author- ized to terminate pregnancy by MR procedure since 1983. As a result of these approaches, the mortality due to induced abortions is almost nil at present and termination services are available in all public health institutions. The use of modem FP methods is higher than the use of traditional methods. The unmet need is decreasing, while the abortion rate has levelled off and is beginning to decline. Additional support services include the distribution of the National Family Plan- ning Guideline to all health institutions, and an improvement in IEC material for both health personnel as well as the pub- lic. A sourcebook, Population-Health- Environment-Development which illus- trates the relationship between these topics, was prepared, printed and distri- buted to decision makers and com- munity leaders at all levels in the country. The recommendations of the ICPD have been taken into account in preparing the National Women's Health Strategic Plan, which is scheduled to be completed this year. There is now a sufficient data-base to prepare the natio- nal plans of action. ... - Follow up mechaniims vital However, while th~re ·is-political support of FP activities, the :financial commit- ment is not yet sufficient to meet the need. In conclusion, the !CPD was an excel- lent international forum in which to draw attention to some of the most neglected areas in health and develop- ment. It also effectively emphasized the relationship between population and sustainable development. More signifi- cantly perhaps, the Conference has enabled countries to re-evaluate their priorities and has stimulated the desire to implement the Plan of Action. However, it is vital to establish follow up mechanisms at both national and international levels so that countries can monitor their progresses, or lack of it, and also share in each other's experiences. Professor Dr Ay§e Akin is General Director of Maternal and Child Health and Family Planning (GD MCH/FP), Ministry of Health, Turkey. Dr Arzu Koseli is a staff member of the GD MCH/FP, Ministry of Health,Turkey. Historic regio~al conference by Dr Veaceslav Mo~hin Soon after the !CPD, a historic re-gional conference organized by the Directorate of Maternal and Child Health and the Family Planning Asso- ciation of Moldova, was held Kishinev, Moldova on 18-19 October, 1994. The conference, entitled Problems of Family Planning in Eastern Europe, was attend- ed by about 400 Moldovan delegates representing different governmental and non-governmental organizations, and 25 delegates from Romania, Russia, Belar- us, the Ukraine and Georgia. The confe- rence, which received the approval of the President of Moldova and the Mini- stry of Public Health of Moldova, became a reality because of the support of UNFPA, WHO and IPPF. The main objectives of the conference were to inform the public about the recommendations of ICPD, analyse the status of women's reproductive health ENTRE NOUS 28-29, May 1995 and family planning in Eastern Europe and find ways to implement the ICPD Plan of Action. During discussions, the major popula- tion related problems in Eastern Europe were identified as follows: (1) social and economic problems facing most families (2) the high rate of morbidity and morta- lity of the population; (3) a slump in the birth rate;( 4) increasing recourse to abortions, (5) rising incidence of vene- real diseases; and (6) the absence of an effective family planning system. There was general agreement that in order to resolve this crisis, it was essen- tial for both Governments and NGO to cooperate closely in fashioning out national population programmes in each country. In order to improve women's reproductive health in this region, parti- cipants felt,that the following steps have to be taken urgently: (1) To provide populations with sufficient contracep- tives; (2) Actively promote family plan- ning concepts through the mass media, (3) Train specialists and open FP offices and centres; (4) Introduce sex education in the curricula of Pedagogical Insti- tutes; (5) Create national and regional statistical and sociological data-bases on population issues. The conference in Kishinev was one of the most significant ever held on the subject because it brought together people of different ages, creeds, political affiliations and from different profes- sions together to discuss vital issues concerning family planning. Dr Veaceslav Mosbin is the President of the Family Planning Association of Moldova. 7 Implementing the ICPD Plan of Action in Central Asian Republics and Kazakhstan (CARAK) Over the next few pages, we concentrate on the efforts of Central Asian Republics to implement wide ranging reforms in MCH care systems. Most of the articles are edited excerpts from presentations made during an International meeting on MCH and Family Planning in the Central Asian Republics which was held in Tashkent, Uzbekistan from November 30 to December 2, 1994. ..... Uzbekistan Squaring up to a demographic ·crisis Presentation by Dr Shafkat Karimov, Minister of Health, Uzbekistan Tie ancient land of Uzbekistan, which has given birth to some of the world's greatest thinkers, scientists, and military leaders, people such as Alhoresni, Abouhairom Berouni, Alifaghani, Ali Farobi, Ulukbeck, Nackjbandt, Navoi and many others, is also the soil that produced the brilliant physician of old times, Abou Ali lben Sina and visionary architects whose works adorn cities like Samarkand, Bukara and Hivee. Uzbekistan is rich in natural resources and endowed with fer- tile land -and massive rivers, but today, this republic of20 million people is in the throes of a demographic crisis. Addressing the international meeting on Strengthening Maternal and <_:;hild Health and Family Planning in the Central Asian Republics, Dr Shafkat Karimov, Uzbekistan's Healfu Minister, warned of the demographic problems the country will have to face in the near future. "Over the past ten years," said the Minister, "the birth rate has been stable at around 30 per 1000 of population, and this has led to an annual population increase of 2.5%. If this growth r~te stays the same, the population of Uzbekistan will have increased by 50% by the year 2015 to some 35 million people," a huge leap for any nation. Scientific population policy Given the significance of these figures - the serious influence rapid demograpliic change can have on the social, econpmic and political fabric of nations, he said that the both he and the Goveriunent "have become aware of the importance of a balanced, scientifically-based popu- lation policy, which will include measures to regulate the population growth." · Uzbekistan is already showing the signs of a demographic crisis today, characterized by a rising level of infant and maternal mortality, a wprsening of the general health status of the popula- tion and a shorter life expectancy. The crisis is being played out against an already difficult social and ecological 8 background. The drying up of the Aral sea is but one factor in the steady decline of both the quality and standard of living in the country. Indeed in his book, Uzbekistan, Indivi- dual model of the transition to market economy, the President of the Republic, I.A. Karimov highlights the demo- graphic problem when he writes : "The economic problems in the context of the demographic situation bring to light the need for clear solutions to social prob- lems. In Uzbekistan, we have today one of the lowest standards of living. In 1990, 70% of the population of Uz- bekistan lived below the poverty line, whereas in Russia and Ukraine, only 30% of the population found themselves in the same predicament". The Health Minister Dr Karimov war- ned: "If we do not take measures to con- trol negative factors,'we will have an increase in maternal and infant mortality of between 50 and 100%." But proving just how serious the Government is in tackling the problem, Dr Karimov was able to give a detailed analysis of the issues at stake, and how Uzbekistan's medical service had been able to respond • to them. Dr Karimov blamed the low health We must develop the desire among our young . people to achieve certain social and economic· goals before getting marri d. . e have to increase the value of independence; autono y, education, positi.on in· society, and career develo ment in their eyes, especially among girls, and we, the Government, have to invest in education. index of women of reproductive age and the spread of various extra-genital disea- ses as the main causes of the crisis. He said that frequent births by women suf- fering from extra-genital diseases, short child spacing, and giving birth at either too early or too advanced an age had all led to high infant morbidity and mortali- ty. Not only does it endanger the health of the women, he said, but "the material and moral state of the family and the economy of the society as a whole." "We know that birth by women under 20 and above 35 is accompanied by a higher risk of perinatal mortality and can lead to chromosomal and other abnorm- alities in the offspring" he said. From this, "it becomes clear that children should be born during the optimal period for a woman, i.e. between the ages of 20 and 29. Today, we have many women who give birth under the age of 20 and who only stop reproducing after the age of35." Discouraging early marriage In Uzbekistan, according to sociological research, 45.1 % of women marry below the.age of 20 and the first child is usual-1, born in the first ye3:T of marriage, The interval between marriage and the first child is therefore often very short. Some 37.4% of married women under 20 have children, 20.3% have one child, 15.7% have two and 1.4% have three children before they are 20 years old. Dr Karimov argued that marriage age not only influences population growth but also the nation's economy "since a woman between the ages of 18 and 25 who is· not preoccupied by her family and children, has a higher productivity for society.'' The Minister pointed out that measures to discourage early marriages could only be successful if they were designed with social, economic, psychological and medical characteristics in mind. "We must develop the desire among our young people to achieve certain social and economic goals before getting mar- ried. We have to increase the value of independence, autonomy, education, ENTRE NOUS 28-29, May 1995 position in society, and career develop- ment in their eyes, especially among girls, and we, the Government, have to invest in education. The establishment of a healthy family has to be one, but not the only priority, in the eyes of our citi- zens. We have to raise the conscience of young people and alert them to their responsibility towards the State, because the health of the Nation is of utmost value." Dr Karimov then introduced the central pillars of what he hoped would produce a viable demographic policy. These are: (1) A reorientation of all social institu- tions so that large families are no longer perceived as necessary for social securi- ty; (2) Strengthening of the nuclear, two- generation rather than three-generation family (3) Reducing and ultimately removing economic motives of giving birth; ( 4) Encouraging families to have no more than an average of three to four children and (5) using the mass media to change the attitudes of the people. Significantly, one of the first medals to be instituted in the new Uzbekistan, called Soglom Avlod Utshun, is presen- ted to citizens who have given out- standing service to maternal and child care, ecological improvement, physical education, or for active participation in the development of charity organizations for children. In addition, a special international non- governmental fund has been set up to improve the health of future generations. Programme reinforced Reviewing his Ministry's achievements in promoting mother and child health in Uzbekistan, Dr Karimov said that the current national programme continues a policy first established in February 1991, when the Government began a regional scheme called ''Urgent measures to improve the health of women of fertile age 1991-1992 programme." The following year, 1993, the Ministry of Health began working with seven other Ministries as well as NQQs to implement the programme. · The aims of the programme are: to improve the health of women of repro- ductive age, to prevent unwanted preg- nancies, to decrease the number of abor- tions and to promote early diagnosis and prevention of congenital malformations. Public centers for dealing with child and adolescent gynecology, as well as the prevention of obstetric hemorrhage and extra-genital diseases have been established to support these aims. But just as important, regular public opinion surveys on attitudes towards different aspects of maternal and child health protection, and towards family and marriage, are being conducted in order to provide a basis for policy. "Sociological research," the Minister said, "allows us to constantly have our finger on the pulse of the most important demographic processes occurring in our society. It is the precise knowledge of ENTRE NOUS 28-29, May 1995 Food is now given to pregnant women, to women with many children and to poor families free of charge. All pregnant women are given vitamin tablets and the free treatment of anaemia in pregnant women, and women suffering from extra- genital diseases has been established. public opinion which allows us to estab- lish priorities in the Governmental pro- gramme of Mother and Child Health." Part of this programme, he said, inclu- ded the training of general practitioners and medical students. Contraceptive ser- vices are now available in all obstetrics and gynecology centres as well as in women's polyclinics. As far as results go, according to the last sociological survey, 53% of women and 48% of men positively responded to the use of con- traceptives. Of all social-demographic groups, women aged between 30 and 39 are the highest users of contraceptives. And since these women are close to or already in an age group with a higher risk of pregnancy, the high use of contra- ceptives can only be a positive develop- ment. But the fact that every fifth woman under 20 has hardly any information at all on contraceptives or other means of preventing unwanted pregnancies, he said, presents "an open field for a great deal of activity." . The most frequently used contraceptive in Uzbekistan is the IUD - which is employed by 30% of women using contraception. Hormonal contraceptives have proved less acceptable. Many women and men still rely on traditional, but not very effective methods. "In this context,"said Dr Karimov, ''we think that the introduction of a longacting contraceptive would be positive, because it does not require constant attention." The quality of maternal and child care available in polyclinics and in obstetric services has also improved. By merging women's consultations with polyclinical functions - which has significantly improved their diagnostic potential - the opportunity to use preventive measures has increased considerably. Thanks to financial support from the Government, food is now given to preg- nant women, to women with many chil- dren and to poor families free of charge. All pregnant women are given vitamin tablets, and the free treatment of anae- mia in pregnant women, and women suf- fering from extra-genital diseases has been established. ''Through the integration of our internal medicine, obstetrics, gynecology and pe~atric services into a single center," said Dr Karimov,"we have managed to improve antenatal care. We have also introduced a rooming-in policy in the obstetric wards, as wc;I) as early breast- feeding, instead of ariilicial milk." Dr Karimov said tqathis ministry was now using a computer system to carry out maternal mortality audits. "This system can give us daily information on the maternal mortality situation, and thus allows us to take appropriate measures. The system of monitoring of women of reproductive age, especially of the high- risk groups has been functioning better and better, said Dr Karimov. "As a result, we have managed to decrease maternal mortality from 73.2 per 100,000 live births in 1990 to 42.4 in 1993. This means the lives of 19'.? women were saved." "Apart from this, we have observed a decrease in the number of births, younger age at first contraceptive use, and a decrease in abortions by 2.5% compared to 1988." Dr Karimov says that the bulk of pre- paratory work has now been done to enable an enlargement of the family planning programme, and the popula- tion, he believes, has been sensitized to the importance of family planning. His Ministry will continue and even reinforce its work in educating and informing all groups of the population, especially young people, on how to adequately prepare for family life, the optimal age of marriage, and the impor- tance of judiciously spacing births. In order to raise the public conscious- ness towards health, said Dr Karimov, ''we are using television and radio pro- grammes as well as producing booklets, po~ters, and brochures, popular scientific boeks and other literature." & • Since it is essential to inform every adolescent of risks which can influence the health, especially of future mothers, Dr Karimov said it was necessary to carry out medical and gynaecological examinations of all schoolgirls at least twice a year. He stated that his Government was constantly working on contraceptive methods in cooperation with WHO as well as pharmaceutical companies like Schering, Upjohn, and Organon. Uzbekistan is even on the verge of producing its own oral hormonal contraceptives. Concluding his address, Dr Karimov invited other delegates to try and find ways and means of involving Central Asian men more actively in family plan- ning. "How can we induce the so-called stronger half of humanity to carry the burden of family planning equally with women?" he asked. • 9 Kazakhstan Looming shadow of ecological disaster by Dr Aman Dujsekeev and Prof Nina Kajupova Tie Republic of Kazakhstan is a ast area stretching from the shores of the Caspian Sea to China. The population of some 16 800 000 is widely scattered although the majority live in urban areas. Like many of the Central Asian repub- lics, Kazakhstan is an ecological disaster area. The Aral sea, once the source of massive irrigation projects, has con- tracted to such an extent that it could disappear in the not too distant future. The coastal zone, which once provided a good living from the sea has been severely degraded and denuded. The country has also been a nuclear test site and radiation activity in some areas, combined with chemically harmful ferti- lisers have been a major health hazard. In addition to all this, is the poor state of the economy and a general running down of social services. Since the health of the nation depends so heavily on the health of the most vulnerable groups, women and children, the new Republic of Kazakhstan has extended a protective umbrella over them. By legislation, "Family, maternity, paternity and childhood are under the protection of society and the state." Legal status of women _ The legal status of women is considered from three positions: The role of women in society as a whole, in working collec- tives, and as part of a family. In the national economy, women form a very important segment: they constitute 62% of specialists with higher and secondary specialized education. Since their contri- bution to the national economy ls.so critical, policies to protect their social, economic and health status are vital. However, women's social and econo- mic positions are inseparably linked to the quality of their reproductive health. This in turn, often influences their health during their entire life span. Although the rate of maternal mortality is relatively high, there has been an overall decline over the past four years. The most prevalent causes of maternal mortality in Kazakhstan are complica- tions arising out of pregnancy and labour and during the postpartum period. Over the last few years however, the propor- tion of deaths from these causes has declined from 40% in 1991 to 31.1 % in 1993. A similar reduction has occurred in deaths arising from abortion compli- cations (which is the second highest cause of maternal deaths) from 23% in 1991 to 21.4% in 1993; deaths from obstetric hemorrhage (the third highest cause of death) has declined from 13.5% 10 in 1991 to 16.3% in 1993. From our research, we have come to the conclusion that interdependent fact- ors which influence the maternal morta- lity rate include the general state of women's health, reproductive function and the quality of health service. The age of the mother and the number of times she undergoes labour are the main determinants of maternal mortality. Among the women, who have died from these causes, multipara make up 60.0%, including 28.0% of grand multipara. The probability of obstetric complications is higher in primapara over the age of 30 and in women reaching the age limit of fertility. Multiple labours pose universal risks. Studies show that at birth intervals of up to two years, pregnancy complications occur in 46.7% of women but when the interval is 3-5 years, the risk of compli- cations is reduced by 25%. Unwanted pregnancy remains one of the prime causes of maternal death. Although the number of abortions as a cause of maternal death is declining, the problem of unwanted pregnancies re- mains a difficult one. It is clear that reducing the number of abortions would reduce maternal mortality rates. As early as 1978, the Alma-Ata Decla- ration stressed that primary health care involved: ''Women and children's health, including family planning". We consider family planning as a system aimed at preventing and reducing "The problems faced by women everywhere lie at the heart of the global agenda. Until the rights and full potential of women are achieved, enduring solutions to the world's most serious social, economic and political problems can- not be achieved." UN Secretary-General Boutros Boutros Ghali at the world Summit for Social Develop- ment, Copenhagen. abortions so that women would only very seldom have to resorfto this muti- lating operation and 11-ever have to die in full bloom. - In order to reduce the number of abor- tions, we have to give families the opportunity to make deliberate choices and use a wide range of effective methods. But concepts of family plan- ning and the reproductive system are still shrouded by ignorance. We there- fore use the mass media, including radio and television broadcasts, newspapers and magazines to disseminate informa- tion on reproductive health. We realize that such a sensitive issue as family planning has to be handled by competent specialists with due regard for traditions, religion and customs. Educating and training students, physicians and mid- wifes, is a priority as a result. Following the joint WHO and UNI- CEF Declaration on Protection, Encou- ragement and Support of Breast-feeding a special programme has been develop- ed jointly by the Research Centre for Regional Nutrition Problems, the Re- publican Research Centre for Maternity and Child Health Care, the Centre of Pediatrics and Children's Surgery, and Almaty Institute of Advance Medical Studies. Although breast-feeding has been a long-held tradition in Kazakhstan, previous health systems built hospitals with separate wards for mothers and newborns. To rebuild the maternity homes to accommodate both mothers and newborns will take many years. But, in the meantime, we have set out to popularize breast-feeding everywhere. ';.\ctive work by WHO specialists in this field is helping us to successfully carry out the campaign. At present, according to our data, 51.1 % of mothers breast-feed for up to six months. Our current annual target, employing the programmes mentioned above, is: (1) To reduce maternal mortality by 18.0% (2) To reduce the number of abortions by 14.0% and (3) to reduce mortality from acute respiratory infections by 0.9%. Prof Nina Kajupova is Chief Obstetrician-Gynecologist of the Ministry of Health and Director of the Republican Research Centre for Maternity and Child Health Care. Dr Aman Dujsekeev is the First Deputy Minister of Health of the Republic of Kazakhstan. ENTRE NOUS 28-29, May 1995 Tajikistan Succeeding against the odds by Dr Valentina Alexejevna Maltseva T ajikistan lies in the Central Asian region and is bordered by Af-ghanistan, Chin!',, Uzbekistan and Kyrgyzstan. This republic is the smallest in the region, with a population of 5.7 million living on some 143 000 sq.km. Tajikistan differs from other Central Asian republics in that the majority of its population is rural. In fact the rural population has grown from 67% in 1989 to 71.3% in 1993.Tajikistan has an astonishing number of nationalities (80), although the most numerous are Tajiks, 65.8%,) followed by Uzbeks (24.4%) and Russians (22.5%). Traditionally all families are large. Some 60% of women give birth to five or more children; 25% of them with birth intervals interval of 1.5-2 years. The high mortality rates for pregnant women, in childbirth, in parturient pe- riods and for infants are the result not only of a severe socio-economic situa- tion, but also the consequence of the civil war, which broke out in 1992. Damage caused to health care alone as a result of the war is estimated to be around USD 20 million. Currently, the quality and quantity of Mother and Child Health services have declined substantially. The main reasons are the exodus of trained personnel, the severe shortage of medical_ drugs, the lack of facilities and poor management and monitoring. The main causes of death for pregnant women, women in childbirth and puer- perium remain, as before, bleeding, tox- aemia and extra-genital diseases. The main causes of death for infants are still infectious diseases (incl. diarrhoea), respiratory diseases and pathological perinatal conditions. Following the International Year of The Child in 1979, the Government of Tajikistan instituted a number of pro- grammes, including those of a medical nature, aimed at improving Maternal and Child Health. In some illstances, the difference has been spectacular: Infant mortality, for example has been reduced from 93.6 per thousand in 1979 to 40.8 per thousand in 1990. Priority on survival In 1991, the Ministry of Health, in con- junction with 27 other Ministries and departments, produced a State Program- me on Maternal and Child Health.The draft programme was submitted for consideration to the government, but because of a large deficit in the country's budget, it could not be adopted. The Civil War of 1992 not only ruined the economy, it also retarded the country's development by 10 years. The political instability dominated people's thoughts and their sole priority was on how to survive. At present however, field programmes on immunization, and against the spread of diarrheal and acute respiratory infec- tions have been worked out and ap- Kyrgyzstan Breast-feeding is best by Dr Anisa Kushbakeeva One among the many unpleasant consequences of the socio-econo-mic problems, which began in 1990, has been the dire impact on the general health of the people of Kyrgyz- stan. A major decline in income, poor- living standards, and social insecurity are all reflected in many negative demo- graphic indicators, such as low fertility rate, high maternal and infant mortality rate, and shorter life expectancy. These indicators, which highlight the poor state of mother and child health care, also point to the dangers posed to society as a whole. Many social diseases, such as tuberculosis, viral hepatitis, anaemia, hypertrophy, and rachitis have become very common among young children. ENTRE NOUS 28-29, May 1995 In an effort to arrest the situation, breast-feeding has been promoted so vigorously that it has gained the impor- tance of a National Programme. Breast- feeding is in fact, the lynch-pin in the Government's campaign to safeguard and improve the nation's health. There are many unresolved issues which have to be tackled if any improve- ment to Mother and Child Health is to be brought about. Among these is the high neonatal mortality rate. . It is not really possible to develop peri- natal services, without first taking care of the health of pregnant women. The maternal mortality rate has been increa- sing fairly steeply; it was 76.4 per 100 000 live births in 1991, and now it is 84.2 per 100 000. proved. Assistance towards breast- feeding and family planning program- mes is also being provided. The programmes, based on recommen- dations by WHO, UNICEF and other international organizations also take into account the country's demographic situ- ation, Woman and Child Health indi- cators and the current state of health care services. Within the framework of these programmes, trainins.courses have been carried out, and mat~al for health care personnel as well .asiror public educa- tional work has beeil prepared. However, although the full range of action on Women's Health in the Euro- pean Region, as stipulated in the Vienna Conference of October 1994, cannot be carried out at present, the MOH is making efforts to improve health care in the country by reforming the sector. The main thrust of the reforms will be direct- ed towards increasing accessibility, and improving the quality and effectiveness of medical care. At this juncture, it is vitally important to revise the approach towards the structure of medical care for women and children. Greater emphasis has to be placed on care before labour, and modem methods of delivery have to be introduced. Changes hav~ to be made in the training of obstetricians in order to develop practical skills and abilities; and specialists in various fields have to be produced. It is equally important to enlist and train volunteers to work with women and children. In addition, there is an urgent need to produce publications and other educational material on training and methodology. Dr Valentina Alexejevna Mattseva is Chief, Department of Mother and Child Health, Ministry of Health of the Republic of Tajikistan. Since 1989, there has been a func- tioning family planning service and a system of "social patronage" in ~ Kyrgysztan. The "social patronage" system involves a social worker taking charge of families which are considered to be "at risk". At present, one worker on average, looked after 30 such family groups. Over the past year, international or- ganizations have been a big help. The financial problem has been partially solved by The International Planned Parenthood Federation(IPPF) which has financed 689 social patronage workers for one year. International organizations have also supported the supply of con- traceptives mainly through humanitarian assistance. As a result of this, the num- ber of women accepting family planning is rising and a trend towards decreasing fertility rate (from 28.2 per 1000 in 1991 to 26.9 in 1993) can be detected. Dr Anisa Kushbakeeva is Senior Pediatrician of the Kyrgyzstan Republic 11 Turkmenistan Abortion rate declines by Dr Khangeldi Mamedov Tikmenistan, situated in the estern part of Central Asia, xtends over 1100 km from east to west and over 650 km from north to south. On the north, it borders with Kazakhstan, on the east and north-east with Uzbekistan, on the south with Iran and on the south-east with Afghanistan. On the east, the country is washed by the Caspian Sea. The northern and central parts of the country consist of the sandy deserts of the Toranian Plain and the Kara-Kum, which make up some 80% of the total area of Turkmenistan. To the south the sandy deserts give way to the foothills of the Koppeg Dagh, and to the south-east to those of the Paropamiz. The rivers Amu Darya, Murgab, Tedzhen, Atrek and others flow through the country. The main water artery is the Karakumskim: a man-made canal. Turkmenistan has a population of Azerbaijan 4 361300. Torkmens make up 72% of the population, Russians 9.5%, Uzbeks 9%, Kazakhs 2.5% and others 7%. The majority of the population is Muslim. The national language is Turkmen, while Russian is the language of international communication. The annual rate of increase of the population is 3% with a high birth rate (33.1 per 1000) and a natural growth rate of 25.2 per 1000. The maternal mortality rate in Turk- menistan is high, 105.3 per 100000 live births. The main cause of maternal mor- tality, obstetrical hemorrhage, accounts for one third of deaths. The perinatal mortality rate is 23.8 per 1000 live births (stillbirths: 14.5, neo- natal iportality: 9.3). Preterm infants accounted for 42.2% of perinatal mortality. A family planning service has existed in the country since 1989. Of the family_ planning methods used by the popula- tion, intrauterine contraception has proved to be the most popular with some 41,666 intrauterine coils inserted in 1993. Hormonal contraception was received by 0.2% or 1610 women. In the past five years, the rate of abor- tions per 1000 women of childbearing age has declined by 27.2%. The most promising approach to fami- ly planning in Turkmeni$ta.n, appears to be the widespread reyi\YaI of the tradi- tional practice of exclusive breast-feed- ing. A level of up to 98% natural contra- ceptive protection can be achieved as a result of lactation amnerrohea until the infant is 6 months old, with a corres- ponding level of 90-92% up to the age of 12 months. Year by year, Turkmenistan is expan- ding its network of establishments delivering outpatient, polyclinic and inpatient care to women and children in particular. Dr K.haogeldi Mamedov is Deputy Minister of Health of urkmenistan. rgent need for family Planning by Dr Valida Jafarova men the serious health-problems our country, especially those affecting women and children, it is very important for newly independent states like Azerbaijan to participate in international conferences like the ICPD. As a result of war, the situation has become dire. More than one million people have fled the country, and puge numbers have been wounded. There has been a dramatic increase in the nWilber of patients, especially children with infectious diseases. Because of the economic and ecological crisis, cases of genetic diseases have multiplied as has the number of patients with congenital anomalies. Over the last year, the mater- nal mortality rate increased substantially. In 1990, as reflected in government statistics, there were only 9.3 gynaecolo- gists for 100 000 women. Baku City had the highest maternal mortality rate while the lowest is in the rural areas. Death was common among women who delivered many children, had unwanted pregnancies or abortions. Analysis of maternal mortality showed that death due to late toxicosis (15.4% in 1992, 27.2% in 1993) was the highest cause of maternal mortality. Other causes include postpartum hemorrhage, DIC syndrome (23.6% ), peritonitis after Cesarean sec- tion (5.1 % in 1992 and 8.4% in 1993), 12 and sepsis 8.6%. Over the three year period, 1990-1993, the national maternal mortality rate rose by 23.0 to 28.20%; in some regions the rate even increased by 80%. Mortality rate due to respiratory tract diseases was 57.2%, perinatal pathology 13.3%, diarrheal diseases 10.2%, congenital an6maly 5.8%, sepsis 2.5%, still births 0.9%, perinatal death 14.3%, early neo- natal death 5.2%; some 48% of women suffered preterm labour. A recently formed committee to promote breast-feeding, encourages exclusive breast-feeding for at least four months after birth. Our long-term goal is to persuade women to breast-feed infants for two years. Until now Azerbaijan had no family planning policy. In 1992, there was an attempt to set up family planning pro- grammes but the good intentions came to nothing. Instead, there has been a serious increase in the number of abor- tions and abortion-related complications. In 1993, there were 2 259 per 100 000 induced abortions; and the proportion of abortions among first-time pregnant women went up to 4.2% of the total. The statistics do not reveal the true picture because the majority of abortions are not registered at health institutions. Particu- larly worrying is the increase in the number of abortions among teenagers. In the same way, the decrease in time interval between births by multigravida women and women suffering from severe anaemia also present a serious problem. A well orchestrated Family Planning programme would obviously solve many of Qiese problems, but at the moment, tile ·supply of contraceptive devices in ' Azerbaijan is hopelessly inadequate. Only 1.4% of women of childbearing age use IUDs; 0.6% use oral contracep- tives and condoms are generally unpopu- lar. FP devices that are not designed for mass use can be found in some pharma- cies but they are extremely expensive in a country where the average monthly salary is US$2. At present, in Azerbaijan, there is one centre which deals with all aspects of reproductive health such as genetics, sex education and family planning. In order to solve the multitude of prob- lems we have in Azerbaijan,we hope to receive cooperation and help from all friendly countries and also from the UN and WHO. Dr Valida Jafarova is Director of the Center for Reproductive Health, Azerbaijan ENTRE NOUS 28-29, May 1995 Almaty, Kazakhstan by Dr Tamara Djusubalieva and Dr G. B. Umurzina D uring the last five years, figures coming from the ~edical services of Almaty, the capital of Kazakh- stan, have revealed a very serious state of social distress in the city and its environs. The female population has become increasingly unhealthy, and at the same time has come to rely on abor- tion to resolve the problems of unwanted pregnancies rather than use preventative contraceptive measures. The abortion rate is staggering - an average of five abortions per women - and has meant a widespread increase in the number of women with gynaecologi- cal problems. Infertility is increasing, as is the figure for women who are healthy de- creases every year. Today, it stands at only 30%. Indeed 70% of all registered pregnant women have one kind of disea- se or another, the most frequent being anaemia, which has increased four-fold during the last four years. Diseases of the urinogenital system have doubled over the same time period, and the number of premature deliveries is growing annually - currently at 8% of all deliveries. Realizing the severity of the situation, the City Health Care Department de- clared a state of emergency for gyneco- logical and obstetrical services. Monumental task On 12 February 1994, Order 33 approv- ed the Family Planning Programme. The order required all medical institu- tions both to provide, and to massively expand family planning services for the monumental task of decreasing th~'num- ber of abortions by half, and decreasing maternal and perinatal mortality. The Programme covered the integra- tion of obstetrical and gynecological services with medical services in order to boost cohesion and access to both patients and services. It also defined the duties of obstetricians, gynaecologists, general practitioners, pediatricians, and other medical experts. 1993 saw the institution of 25 family planning rooms to deal with the crisis. They are coordinated by the City Human Reproductive Center, which serves as the city's Family Planning Centre. The primary focus of activity is the District Family Planning Room, one in each of the eight health districts' women's consultation centres. Each district family planning rooms is responsible for the effectiveness of the programme in its district, and it is here that vacuum aspirations (mini-abortions) are carried out on an out-patient basis ENTRE NOUS 28-29, May 1995 Photo: Dr Marc Danzon © for women whose menstruation is de- layed for no more than 18 days. There are then family planning rooms in all the territorial women's consulta- tion centres, and family planning rooms have also been set up in every territorial polyclinic serving the adult population. Services are provided by nurses who have been trained at the City Family Planning Centre. While their role is primarily to provide advice to women in their reproductive years, one of the most effective ways of ensuring that the con- cept of family planning is put across to • the population at large has been to make it compulsory for any woman attending a clinic, whatever the cause of her visit, Almaty Factfile Almaty, the capital of Kazakhstan, has a population of 1182 400 people with a female population breakdown of 39 533 women aged between 10 and 15 years old, 52 770 women between 15 and 19, and 340 000 between 15 and 49. Deliveries are provided in seven maternal houses throughout the city. There are 7 .8 midwifery beds per 10 000 population and 5.2 gynecologi- cal beds per 10 000 population. The level of medical services as measured by medical beds and pro- viders per population is higher in the city than in the Republic as a whole. to discuss contraception at the family planning room. Following a consultation, which in- cludes a physical and gynecological examination, the nurse will recommend a contraceptive method. Oral contracep- tives are available at the facility. Pedia- tricians provide sex education to teen- agers, and advise breast-feeding women on appropriate means of contraception. Under the Programme, general practi- tioners identify women who have con- traindications to pregnancy and offer th~m,family planning advice or direct , them to the family planning rooms. Each family planning room submits the information it has acquired over the course of a month to the District family planning room, which in tum sends a special monthly report form to the City Family Planning Centre in order to monitor the effectiveness of their activi- ties, and provide an invaluable picture of the health and reproductive patterns of the city's women. Invaluable information These reports provide a wide variety of information, including such data as the number of abortions carried out in the district; the number of abortions among children, teenagers, and first pregnan- cies; the number of mini-abortions, the number of inserted IUDs, and the num- ber of women registered for IUDs or oral contraceptives; numbers of women using contraceptives, women with geni- tal complications, numbers of sexually 13 active teenagers, breast-feeding women, women with many deliveries, and frequent users of abortion services. This whole network of family planning rooms was modelled on British systems which we studied during a training tour to London organized by the Internation- al Planned Parenthood Federation. Family planning rooms have also been established in two special institutions, one serving woman with mental dis- orders, and one serving women with drug and alcohol problems. These rooms are charged with providing maximum contraceptive coverage to these women. But the programme does not stop there. Pharmacies which sell contrace- ptives have been established in all the medical institutions and industrial enter- prises. Indeed many large industrial enterprises provide free contraceptives to employees, and students are given free contraceptives as well. A further method of tackling the prob- lem has come from the gynaecological departments, all of whom have started to insert IUDs immediately after abortions. In 1993, 25% of women accepted IUDs immediately after abortion. Oral contraceptives popular Oral contraceptives are also becoming more popular at least in part as a result of their increasing promotion. In 1993 alone 14 500 women began taking oral contraceptives and 17 000 IUDs were inserted. Although oral pills were not used in previous years, the 1993 oral pill prevalence rate made a firm start at New SFP Adviser in Romania Dr Katy Shroff was assigned to the post of WHO Technical Adviser for Sexuality and Family Planning in Bucharest, Romania, in October 1994. Katy Shroff is a Bachelor of Science, a Medical Bachelor and a Bachelor of Surgery. She also has a thorough ·grounding in family planning (Certifi- cate of Competence, Instructing Doctor, and Regional Assessor+ MFFP, Royal College of OB/GYN, London). Her last assignment was as Associate Director of Services for Women, Parkside Health NHS Trust, London. In Romania, Dr Shroff is working closely with the Ministry of Health, Directorate of Maternal and Child Health on the National Family Planning Programme. We are happy that Katy has joined us. 14 4.2%. In 1993 IUD prevalence was 31 %, and total contraceptive coverage in 1993 increased from 27% in 1992 to 35%. Contraceptive coverage of high risk women has increased from 30% to 58%. Following the USAID-funded October 1993 Conference on surgical steriliza- tion conducted by the representatives of the Association on Voluntary Surgical Contraception, 32 surgical sterilizations were conducted using the mini- laparotomy method. And the whole gamut of medical Photo: Dr Marc Danzon © reform appears to be paying off. Abor- tions decreased from 20 000 in 1992 to 16 500 in 1993, representing a huge 16.3% decrease. This is particularly important considering that the number of abortions decreased while the birth rate also decreased. In comparison, during previous years the birth rate decreased as the number of abortions increased. Induced abortions dropped by 23%, and abortions per 1000 women of fertile age decreased from 60 to 50. A25% decrease in the number of abor- .tions occurred among women 19 to 34 years of age, those who were given access to consultation rooms, and those for whom IUDs were inserted immedi- ately after abortion. Abortions did how- ever increase among children under 15 Erratum years of age, from 0.7 to 0.9 per 1000. Abortions also increased among teen- agers between 15 and 18 years of age, from 28.8 to 35.3 per 1000. Among first pregnancies abortions increased from 7.9 to 8.2 per 1000. A review of quarterly indicators of abortions and contraceptive coverage indicates a decreasing abortion rate (in comparison with the first quarter by 30% ), increase in contr.a:,ceptive covera- ge by 23.2%, and coverl}ge with surgical contraceptives by means of laparotomy by 0.1%. . - But the final goal of our Programme is not limited simply to the reduction of abortion levels. Maternal and perinatal mortality are also targeted, and in 1993, the maternal mortality rate dropped by more than half, from 108.3 to 48.9. Perinatal mortality dropped from 18.8 to 15.0, testifying to the efficacy of our work in family planning. Dr Tamara Djusubalieva is the Chief Physician, City Human Reproductive Center Almaty Dr G.B. Urmurzina is the Chief Expert on Family Planning, City Health Care Department, Department Manager Reference is made to the article "Albania: Breaking the chains of the past", Entre Nous 26-27, p. 17. The Authors of the article and the Ministry of Health have the following comments on the graph on infant mortality: 1. The source was not the Ministry of Health, but the National Institute of Statistics. 2. There was a contradiction between the text and the graph on infant mortality. 3. Also, before 1991, infant mortality was underestimated, due to different defi- nition of infant mortality which did not include neonates from 500-lOOOgr born after 22nd week and omission of infant deaths in the first week at the civil register - due to this omission, the level of infant mortality was underestimated by one third. Also there was a repression of reporting on infant deaths. ENTRE NOUS 28-29, May 1995 WHO FILE WHO FILE SFP INTERCOUNTRY ACTIVITIES Promoting the health of wom~n -.. -. -o ... The "Women's Health Counts" initiative. -· ~-- I n 1993, the WHO Regional Office for Europe launched the Investing in Women's Health initiative. In its first phase, the Initiative focused on the status of women's health in the countries of Central and Eastern Europe (CCEE) and the Newly Inde- pendent States (NIS) of the former USSR. In its second phase, the Initia- tive is expanding its focus to include all of the Member States of the Europe Region. To increase the understanding of the issue pertaining to the health of women in the European Region, the Regional Office has embarked on collecting and analyzing information to assess the top health priorities and provide the basis for programmes to improve women's health in all the Member States of the European Region. The key components of the WHO Investing In Women's Health initiative consists of: (1) Establishing a European Women's Health Network; (2) Producing Women's Health Profiles for each of the Member States; (3) Gathering Women's Health Profiles from each country into a comparative analysis; (4) Conducting regular meetings of women and health counterparts; and meetings of the Women's Health Forum which will bring together leaders inpolitics, interna- tional affairs and policy analysis to serve as advisers to the WHO Regional Director for Europe. Nearly all European Member States have contributed national data on women's health. These will be com- piled and published as a series, Country Highlights on Women's Health and distributed at the Women's Conference in Beijing. Family planning and reproductive health in CCEE/NIS by Dr Assia Brandrup-Lukanow and Ms Dorte Jepsen I n November 1994 UNFPA requested the WHO-EURO SFP unit to produce a background document for policy makers, decision makers and bilateral donors to identify main needs in family planning in the CCEE and NIS. A draft document by Dorte Jepsen and Assia Brandrup-Lukanow, containing 22 short country reports on family planning and reproductive health in the CCEE and NIS was distributed in December. The draft also included data, an outline of the current situation, recommendation for action and international activities.. The project is now being extended to include. , all CEE and NIS countries (27 countries in all) and the full report (120 pages) will be published in June. Both the draft document and the report can be request- ed from the SFP unit. Excerpts from the document are reproduced below. Women's health Infant and child health indicators are used as yardsticks of reproductive health, because children's health is strongly tied to their mothers' health, reflecting among other factors, condi- tions during pregnancy and at birth. Healthy mothers have an increased chance of having healthy newborns and children; while a woman's ill health affects not only her own opportunities and potential, but those of her children as well. Women's health is therefore an issue that crosses borders, political systems and cultural differ- ences. It is an excellent investment as it ENTRE NOUS 28-29, May 1995 guarantees an improvement in the health of the next generation. Profound and rapid changes are under- way in the countries of Central and Eastern Europe (CCEE) and the Newly Independent States of the former USSR (NIS). These changes have led to social and economic hardship and, in some cases, to war. The result is a widening gap in health indicators between the Eastern and Western halves of the WHO European Region: a serious inequity. The leading causes of death in . CCEE/NIS are the same as in most other European countries: cardiovascular diseases, malignant neoplasms and external causes. A closer look at the CCEE and NIS reveals a particularly disadvantaged group in these countries, i.e. women. While women bear more of the burdens imposed by change, they also comprise an invaluable, largely untapped resource for the response to change. Studies by the UN and the World Bank have shown that invest- ments in women yield high returns in the form of faster growth, higher efficiency, greater savings, and reduced poverty. Comparison of the data between West and East shows great differences in women's health indicators. Though women generally live longer than men both in Western (5 to 7 years) and Eastern (7 to 13 years) Europe, the greater mortality rates of men often draw attention away from the problems that women face. Women have more years of unhealthy life in terms of higher rates of J=fom Abortion to contraception chronic illness and disability associated to some extent, with their longer survival. As a prerequisite for health, women's economic situation is generally less favourable than that of men. The most fundamental and universal difference between households headed by women and those headed by men is the relative poverty of female-headed households in all countries. Poverty is a general indi- cator for ill health. For old women living alone, poverty often reaches extreme levels that threaten survival. Food shortages and economic difficul- ties prevent many people from eating healthy diets. Malnutrition is a growing problem in many countries in the Region. Furthermore the prevalence of anaemia among young women is reaching levels of up to 40 to 50% in the Central Asian Republics, and 17% 15 WHO FILE among pregnant women in Europe in general. The issue of security and women's health and safety in the home, the work- place and the community, applies to women world-wide. Although violence against women often goes unnoticed and undocumented, there are indications that domestic violence and rape are increas- ing, and the health consequences of this can be seen both physically and psycho- logically. There is a need to increase services for women who·have become victims of violence. The growing health problems, and particularly the widening gap between women's health in Western and Eastern Europe, require the re-thinking of social and health policies, and also the in- creased participation of women in making policy decisions over their health and future. Family planning With limited resources available, family planning services are increasingly being viewed as an appropriate mechanism for improving women's reproductive health. Some key reasons for providing a broader array of reproductive health ser- vices through family planning include: (1) The incidence of induced abortions is integrally linked to access and avail- ability of safe and effective contracep- tion. Furthermore, women who visit family planning clinics seek abortion counselling, treatment of abortion complications and post-abortion family planning advice. (2) Family planning services that provide pregnancy testing, prenatal and delivery care are often integrally linked to provision of appropriate care for pregnant, postpartum and breast-feeding women. (3) Appropriate provision of contra- ception based on a woman's risk cate- gory and reproductive goals. Contraceptive prevalence rates range from about 60 to 70% in some countries of Western Europe, to less than,~ o/p in some countries of Eastern Europe. In many countries, the financial resources or the political will is lacking to make the necessary changes. Non-governmental organizations concerned with women's reproductive health are becoming increasingly successful in bringing about changes in their countries. The growing social respect for these organizations was reflected by the fact that many women belonging to family planning or other women's health organizations were members of national delegations attend- ing the recent International Conference on Population and Development in Cairo. Thus, they directly influenced the decision-making process on women's health globally. Although there is a growing interest in contraceptives in most countries of the CCEE and NIS, their limited availability and high costs do not make them a viable option for many people. In a situ- 16 Although there is a growing interest in contraceptives in most countries of the CCEE and NIS, their limited availability and high costs do not make them a viable option for many people. In a situation where abortion is very cheap or free while contracep- tives can cost as much as one third of one's salary, choice is effectively denied. ation where abortion is very cheap or free while contraceptives can cost as much as one third of one's salary, choice is effectively denied. In some countries, the lack of sex education in the presence of changing social and moral values has led to an increase in teenage pregnancies, which vary widely between countries, with the UK reporting one of the highest, and the Netherlands the lowest rates in Europe. Also, many countries report increasing rates of sexually transmitted diseases, including lilV infe~tion. The dire eco- nomic situation in many Eastern European countries has lead to an in- crease. in prostitution/sex work. Though the number of AIDS cases is still generally low, there is an increase in female cases, not only due to sexual transmission, but also to intravenous drug use. 1\vo major problems in integrating reproductive health care within family planning programmes are: 1) The difficulty of~roviding Sexually Transmitted Disease (STD) diagnosis and therapy. Many STDs can be asymp- tomatic in women and this complicates clinical management. Implementing limited STD screening and/or manage- ment services can require significant commitment of human, laboratory and drug resources. 2) The fear that the reputation and credibility of family planning program- mes may be damaged if STD/AIDS prevention and services are offered. Th~efore, the level of reproductive health services to be provided should be determined on a case-by-case basis, taking into account the client needs and programme capabilities. At the mini- · mum, family planning programmes should provide a broad range of contra- ceptive choices, STD prevention and linkages with safe birth and abortion care. In particular, family planning program- mes are one element of health services throughout the life-span of women. They will only be successful, therefore, if embedded into a comprehensive system of health care which also addresses the problems highlighted earlier. The abortion issue Due to the lack of appropriate contra- ceptives and counselling services, abortion was and still r$ffiainS the prin- cipal means of fertility J.'~gulation in the CCEE/NIS, sometipies,.equalling the number of livebirths; ancl sometimes even exceeding this by two or three times. As a possible result of the econo- mic difficulties that these countries are encountering in their transition period, some are facing rapid fertility declines to levels below replacement. Since most women who terminate an unwanted pregnancy intend to have a child later, it is extremely important to identify possible adverse effects of induced abortion on subsequent repro- ductive function. Cervical trauma, cervical and uterine adhesions, pelvic infections, to mention only a few, are complications which could adversely affect future pregnancy. A review of available information concerning the long-term impact of induced abortion and subsequent repro- ductive outcome shows no consensus because some studies were conducted in countries where abortion was illegal, while others did not adequately control for confounding factors. However, it is generally agreed that vacuum aspiration in the first trimester, performed by an experienced and skilled specialist, is a safe procedure with few, if any, long- term adverse effects, i.e. secondary infertility, ectopic pregnancy, preterm delivery etc. There are also several safety issues ( abortion in nulliparous women, multiple pregnancy terminations, second trimester abortion) which have not been addressed adequately and need special atteµtion, not to mention the psycho- secial effects of multiple abortions and • possible secondary infertility. When designing family planning and reproductive health programmes, all the above factors should be taken into account. Above all, these services must be embedded as one element of health services provided during a woman's life-span. lnteragency meeting In spring 1994, the SFP unit organized an inter-agency meeting to discuss technical and financial assistance to the Maternal and Child Health and Family Planning sector in Eastern Europe and the NIS. The meeting was attended by representatives from 28 multilateral, bilateral and non-governmental agencies working in the field. A further 25 agencies who could not participate sent background documents and information material. The purpose of the meeting was to exchange information on and coordinate program- mes, projects and activities, and to identify geographical or technical areas in which assistance was necessary, but had not yet been provided, as well as. areas in which activities were being duplicated. The background papers, contributions of participants, and the report on the meeting are available from SFP together with the report. ENTRE NOUS 28-29, May 1995 WHO FILE GLOBAL PROGRAMME ON AIDS REGIONAL OFFICE FOR EUROPE UN to pool resources in battle against AIDS by Johannes Hallauer and Alex G"romyko Anew initiative by the United Na-tions will pool the resources of its :various agencies in Europe in the fight against HIV/AIDS. The UN Joint and Co-sponsored Programme on AIDS (UNJCP), the new umbrella programme, will involve UNDP, UNICEF, UNESCO, UNFPA, WHO and the World Bank in the urgent fight to halt the march of the disease. The programme, which will replace the WHO's Global Programme on AIDS (GPA) is scheduled to begin in 1996. The vast (WHO) European Region, home of some 850 million people, stretches from Greenland in the north- west to the Mediterranean countries in the south; and then cuts a vast swath across the heart of Europe to the Pacific coast of the Russian Federation. Massive political and social changes that have swept through the European !legion from 1990 have seen the splintering of old empires and an upsurge of natio- nalism. One result is that the number of Member States has shot up from about 30 pre-1990 to 50 today. An estimated 500 000 people in the Region are infected with mv. As of September 1994, the cumulative number of AIDS cases reported for the ~on was 138 901. The highest concentration of cases is in Western Europe. By December 1994, the highest rates recorded were in Spain, Switzerland, France and in Italy. Although these countries represent only 19% of the population of the European Region, they accounted for 72% of all diagnosed AIDS cases. The countries of Central and Eastern Europe, on the other hand, accounted for less than 4% of all diagnosed cases, although they comprise 50% of the population of the WHO European Region. However these countries are undergoing traumatic political and social changes. The breaking up of once im- penetrable borders, for example, has led to a sharp growth inmobility and has thus increased contacts with areas with higher prevalence of mv. This, accom- panied by changes in lifestyles, may vastly increase the potential for a rapid rise in HIV transmission rates. The large ENTRE NOUS 28-29, May 1995 number of drug users infected in Poland, almost 2 800 paediatric AIDS in Ro- mania, increasing numbers of STDs 'Europe-wide' and a more pronounced trend towards using injectable drugs indicate a real risk that HIV will spread rapidly unless immediate and appropri- ate action is taken. The UNJCP is one response to this potential epidemic. The main aim of the new programme is to strengthen the efforts of each country in the prevention of HIV I AIDS by providing technical and financial assistance to the national programmes. When the programme is fully funct- ional, a UNJCP adviser will be assigned to each of the 28 countries of Central and Eastern Europe and the Newly Inde- pendent States, and will coordinate the efforts of UN agencies like WHO, UNICEF with those of NGOs and na- tional organizations, to plan out and im- plement a programme specially tailored to the needs of the country in question. Working in collaboration with co-spon- soring agencies, a UNJCP adviser in any country will assist the national AIDS Coordinator in planning, administration, implementation, monitoring and evalua- tion of the national AIDS prevention • programme, and hopefully bring the knowledge, expertise, experience and competence accumulated by the agen- cies constituting the joint programme to the country concerned. Thousands 25 20 · · · · j- AIDS cases I 15 Using WHO experience It seems umealistic however, to assume that sufficient funding for one UNJCP adviser per country will be available in the immediate future. In the interim then, the programme will have to rely on inter-country advisers covering a group of countries. The WHO/GPA/EURO programme, which ceases at the end of 1995, has been employing a similar structure and it would make sense to put the vast ex- perience of WHO EURO staff at the disposal of the UNJCP. WHO EURO has already established firm foundations in the health sector of the Region through a variety of programmes, such as Sexuality and Family Planning, Drug Abuse Prevention, Communicable Diseases, Health Promotion. It would be logical for other UN agencies to link up with the existing WHO structure and create a regional body. As it is, in 1994/95 WHO/GPA/EURO provided external assistance to all coun- tries of Central and Eastern Europe, the Newly Independent States and the Baltics for the first time. A network of five posts for Inter-country Advisers on AIDS was established by the Global P;ogi-amme on AIDS across the Region, each post is responsible for the follow- ing countries: Almaty: Kazahstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan Copenhagen: Albania, Bosnia and 10 __ .......... -. -···--·-·-···-·-·--·---··-·-·--·---···--·--·---·-.. -··--·-·--···-- 5 O Ja::;;:::z::z:::::;:::::;~2'...-2-L!::I <1982 1982 1983 1984 1985 1986 1987 1988 1989 1990 19911992 1993 1994 ANNUAL INCIDENCE OF AIDS CASES IN EUROPE 17 Herzegovina, the Czech Republic, Croatia, Slovenia, the Slovak Republic and the Former Yugoslav Republic of Macedonia Kiev: Belarus, Republic of Moldova and Ukraine Moscow: Armenia, Azerbaijan, Georgia and the Russian Federation Sofia: Bulgaria, Hungary, Romania and Turkey In order not to interrupt the work while the GPA is being phased out, it makes sense to set up a UNJCP regional group comprising of experienced WHO staff and additional staff from co-sponsoring UN agencies. The UNJCP regional group could assist countries in planning, implementing and monitoring national AIDS programmes through intercountry activities and provide direct country support according to the objectives of the other UN agencies constituting the joint programme. The regional group could set up a mechanism to ensure cooperation with the European Union and the Council of Europe in areas related to IDV/AIDS prevention in European Member States. Key areas for UNJCP Indeed other key areas in which the UNJCP regional group would be effective include: * Advocating political commitment to IDV/AIDS prevention and health promotion. *Supporting policy development and capacity building at national, regional and local levels to facilitate smooth programme implementation. *Providing technical cooperation for the development of effective national plans for IDV/AIDS with involvement of all relevant sectors, including non- governmental organizations. *Fostering multi-sectorial involvement in programme implementation. *Supporting the development of complementary programmes such as the control of sexually transmitted diseases and other infectious diseases. ' -, , * Assisting governments in fundraising, coordination and the allocation of ex- ternal resources for AIDS prevention. *Supporting a non-coercive national policy against discriminating or stig- matizing high-risk groups and those infected with IDV/AIDS. The countries of Central and Eastern Europe, the Newly Independent States and the Baltic have already embarked on their crucial battle against an AIDS epi- demic and one hopes that the UNJCP will prove to be a decisive weapon in their armory. 18 Dr. J. Hallauer, Regional Coordinator, Global Programme on AIDS, WHO Regional Office for Europe Scherfigsvej 8, 2100 Copenhagen 0 , Denmark. Dr A . Gromyko, Public Health Officer, Global Programme on AIDS Infertility treatment: a woman's perspective Much unfavourable press has been written about the 'hi-tech' infertility treatments: how costly they are, their discouraging success rates, etc. Marcel Vekeman's article Is the treatment of infertility a luxury in a world in the middle of a pop- ulation expansion? is no exception to this trend (Entre Nous, No 25, May 1994, page 5). Although Dr Vekemans raises valid points, there are some that I wish to contest as a woman who has benefitted from infertility treatment. He states that infertility is largely the result of inappropriate sexual behaviour ("up to 85% of the cases"). This needs correcting. One should always be wary of statistics for which no references are given, especially those construed to further an individual, often biased, point. Indeed, infertility is not as simple as Dr Vekemans would lead us to believe. Many' practicing infertility clinics en- counter a significant minority of cases for which there is no defined cause. Possible causes of infertility include: insufficient hormonal production, environment pollu- tion and other factors, the stress engen- dered by modem lifestyle, and nutritional deficiencies. Dr Vekemans writes that sterility "is not just an accident", but in some cases, it may well be an accident of nature or society. Dr Vekemans thinks that society believes that sterility is a social disgrace, that society considers the "sterile individual as a 'useless element' of society". This statement is made more than once in the article without any mention to what part of the world he refers to. I have met scores of women and couples - European, North and South Americans, Africans - with fertility problems. These people come from all social and economic classes and contribute to society in their own special ways using their unique talents, like anybody else. They are no different. Moreover, not one • person has ever mentioned that he or she feels any form of "social disgrace" for not being able to procreate. Along the same line, one very important point that Dr Vekemans missed entirely is that the desire to have a child comes from within, both men and women feel it; and it is not usually a society-driven force. Thus a "worldwide, educational campaign to eradicate the idea of sterility as a disgrace" would undoubtedly be a waste of precious public health budgets. Thirdly, the notion that treatment should be limited to women up to the age of 35 is pure discrimination. Is not Dr Vekemans aware that many couples are married several years before as certaining and investigating infertility problems? That they give "Mother Nature" a chance before resorting to medical intervention? Many women seeking assistance tend to be in stable marital relationships, many for 10 years and upwards, falling into the age bracket of 35 to 40. Some are even older. And, many of them succeed in making their dreams come true. I was one of them. On what basis then should a couple be denied the chance for parental happiness because the woman is over 35 year of age? Would a cardiologist consiQer withholding by-pass surgery because ~ patient is "too old"? One should recall that the World Health Organization's definition of health is one of a state of physical, mental and social well-being and not just the absence of disease or infirmity. Based on this definition, infertility treatment should not be denied automatically to a pre-menopau- sal, or even menopausal, woman. The issue of costs incurred during a pregnancy resulting from infertility treat- ment was not presented with all the facts. Again, I should like to draw upon my per- sonal experiences and my contacts with many infertile couples. Most of the women I have met who succeeded with treatment (i.e. simple hormonal stimulation to the more demanding IVF, GIFf, ET, etc.) went on to have very normal pregnancies, given their age category. They continue working, doing exercise, travelling, in short, leading very normal lives. However, because of the exceptional circumstances surrounding the conception of the baby, obstetricians seem to opt for a cesarean delivery as a precautionary measure and not necessarily because of a difficult pregnancy. I for one found pregnancy to be a wonderful ex- perience, suffered absolutely no incon- venience, was physically very active walking and biking up to the day the baby was born, and had a perfectly normal delivery. My daughter, a bouncy full-term 3.7 kilo baby, was born two months before my 36th birthday. In ending his article, Dr Vekemans writes that "Then, and only then,will dealing with sterility become more than a useless luxu- ry". I would agree that certain forms of treating infertility are costly, just as is the case for cardiovascular surgery, neuro sur- gery :.and other forms of "hi-tech" medical intervention. Are these other forms also ' considered "luxury", in particular "useless luxury"? One may try to argue that these other forms are deemed life-threatening inter- vention. Infertility treatment could also be deemed "life-threatening" from a mental (psychological) point of view and treat- ment is fully justified if it helps a woman, or a couple, come to terms with an infer- tility problem, and maybe, just maybe, have that very desired "bundle of joy". It would be socially and medically wrong to deny infertility treatment to those who need it. Dr Barbara Fontaine Special Programme in Human Reproduction* World Health Organization CH-1211 Geneva 27 Switzerland *[Note: the views expressed are those of the author and may not necessarily reflect those of the Special Programme and the World HeallhOrganization.] ENTRE NOUS 28-29, May 1995 i- TECH NOLOGY , IMAP on Emergency Contraception Statement developed by the International Medical Advisory Panel to IPPF (IMAP), 1994. ~ ~?··- D espite the availability of highly ~ffective methods o~ contracep-tion,many pregnancies are unplanned and/or unwanted. These preg- nancies carry a higher risk of morbidity and mortality, often due to unsafe abor- tion. The risk of pregnancy with one unprotected act of intercourse can be as high as one in four, depending on the cycle day of exposure in relation to ovulation. For the woman exposed to unprotected sexual intercourse, emer- gency contraception ( also known as postcoital contraception) can be used to avoid an unwanted pregnancy. Since the mid-1960s, the postcoital use of certain orally administered steroid hormones has been shown to be highly effective in preventing pregnancy. However, this should only be considered as an emergency procedure since data on efficacy and safety of long-term use is not available. Copper-releasing IUDs have also been used effectively for emergency contra- ception. The precise mode of action of emergency contraceptive methods is uncertain. It is thought that they inhibit ovum transport, ovulation ano implant- ation. Established methods Combined oral contraceptives Combined oral contraceptives con- taining ethinyl oestradiol and levonor- gestrel, or comparable formulations, can be taken in a regiment known ds·the 'Yuzpe method'. When the 50 µg ethinyl oestradioV 250 µg levonorgestrel Pill is available, two tablets should be taken as soon as possible and no later than 72 hours after unprotected intercourse, followed by two more tablets after 12 hours. When Pills containing 30 µg ethinyl oestradioV150 µg levonorgestrel are the only Pills available, these lower dose Pills can be used, taking four tablets followed by another four after 12 hours. The Yuzpe method has a failure rate of up to 2%. Indications for use This method is indicated in women exposed to unprotected sexual-inter- course, eg lack of contraceptive use, condom breakage, missed Pills, or in the case of rape. Contra-indications There are no known contra-indications to the use of hormonal emergency contraception. ENTRE NOUS 28-29, May 1995 Side-effects Approximately half of the women will experience nausea. If vomiting occurs within one hour, the dose should be repeated and the use of an anti-emetic is advisable. Irregular uterine bleeding and breast tenderness also commonly occur. Follow-up Ideally, all clients should be followed up as soon as possible for contraceptive counselling. Most women will have their menstrual period early. Clients should be advised to visit a clinic if they experience a delay of their period in order to exclude the possibility of failure of the method with consequent preg- nancy. In the event of a pregnancy, the woman should be counselled. She should be made aware of the available options and her decision should be respected and supported. If she chooses to continue with the pregnancy, she should be reassured that there is no evidence that this method of emergency contraception has any teratogenic effect, nor that it increases the risk of ectopic pregnancy. The use of hormonal emergency contraception has no impact on future fertility. The use of copper-releasing flJDs Emergency contraception can also be achieved by the insertion of a copper- releasing IUD within five days of un- expected and/or unprotected sexual intercourse. this method has been • reported to be highly effective with a failure rate below 1 %. · The copper-releasing IUD may be part- icularly useful when the client is considering its use for long-term con- traception and/or when the woman no longer qualifies for the Yuzpe regimen because more than 72 hours have elapsed. When using an IUD for emergency contraception, the same contra-indications should apply as for regular use. Counselling Whenever possible, the woman should be counselled at the time of obtaining emergency contraception. Counselling should include discussion of the correct use of the emergency contraceptive method; possible side-effects and their management; and her requirements for continuous contraception. If the environ- ment is not conducive to proper counsel- ling, the client should be advised to visit a family planning or health care facility where she can obtain contraceptive counselling and services. Methods under investigation Experience with the use of levonorgest- rel alone suggests that it is an effective method of emergency contraception. One controlled clinical trial showed levels of efficacy similar to that of the Yuzpe method, with fewer side-effects. The regimen used was two doses of 750 µg levonorgestrel administered 12 hours apart, the first starting within 48 hours of unprotected intercourse. Anti-progestagens have also been tested for use as emergency contracep- tives. Mifepristone (RU486) has been found to be highly effective at a single dose of 600 mg, also with fewer side- effects than the Yuzpe method. How- ever, its use is restricted because of its limited availability. The minimum effective dose and the time period in which it can be used effectively still have to be defined. Access to emergency contraception Family Planning Associations should advocate the availability of emergency contraception and, where this is avail- able, they should advertise it widely so that health care providers and the public will know in advance that it is an option for avoiding pregnancy. Easy access to emergency contraception should be P,rovided through the most practical d'elivery systems so that people in need of this method can obtain it without delay. The important issues of privacy and confidentiality should be taken into account when developing systems for making emergency contraception available. (This replaces the Statement on Post- coital Contraception which was adopted by Central Council in November 1981 and amended in November 1982 and November 1985.) This Statement is valid for the currently available methods for emergency con- traception. IMAP reserves the right to amend this Statement in the light of further developments in this field, when sufficient scientific information becomes available. Published in the IPPF Medical Bulletin, (28), 6, December 1994. 19 TRAINING IN EUROPE Course on Population and Development. An intensive two-week course (17-28 July 1995) in Cambridge for professionals working in the field/s of health, development/family planning. This course is designed to give an over- view of the relationships between population, development and sexual and reproductive health; and to explore the elements needed to develop appropriate programme strategies. The course is organized jointly by The International Planned Parenthood Federation (IPPF) and the German Agency for Technical Cooperation (GTZ). For further details, please contact: Programme Department, International Planned Parenthood Federation, Regents College Inner Circle, Regents Park, London NWl 4NS, United Kingdom. Tel .: (44)-171- 4860741 , Fax: (44)-171-4877950. Sth post-graduate course for training in Reproductive Medicine and Biology. This course is organized by the Clinic of Infertility and Gynaecological Endocrinology, Faculty of Medicine, University of Geneva to provide post- graduate training in reproductive health, to educate graduates in current research on Family Planning and Infertility and to acquaint trainees with the most recent advances in the technology of these areas of research. The course programme provides a broad international orientation including neuro-endocrinology, andrology, various clinical aspects of contraceptiQn and infertility, psycho-social factors and epidemiology of reproduction. The course will be given by the teaching taff of the Departments of the Faculty of Medicine of Geneva and by advisors and staff members of the WHO Special Programme of Research, Development and Research Training in Human Reproduction. ' · The post-graduate course will lead to a Certificate in Reproductive Medicine and Biology and a diploma. The certificate can be obtained after two months intensive course followed by written examination. A limited number of students who have been awarded a certificate will be accepted for a diploma. The official language of the course is English. The next course will take place from 1st September to 13 October 1995. For details, please contact: Mrs M.C. Robert, Administra- tive Officer, Clinique de Steriliteet d'Endocrinologie gynecologique, HCUG, CH-1211 Geneva 14, Switzerland. Tel.: (41)-22-3824322. Fax: (41)-22-3824313. Training for research and management in family planning service provision is available at The Institute of Population Studies in Exeter, offering a range of training activities: A three-year PhD 20 programme in Applied Population Research; A one-year MA programme in Applied Population Research; MA in Family Planning Programme Administration; and short courses (12 and 16 weeks) in Family Planning Research and Management: Family Planning Programmes (January 1995) Family Planning Operations Research Design (February 1995) Collecting and Analyzing Family Planning Data (April 1995) Programme Management and Evaluation (April 1995) Determinants of Fertility (October 1995). For further information, write to: The Director, Institute of Population Studies, University of Exeter, Hoopern House, 101 Pennsylvania Road, Exeter EX4 6DT, United Kingdom. Tel. : (44) 392 57936, Fax: (44) 392 263801. Four organizations in the Netherlands have jointly taken the initiative to organize courses on Family Planning, Sexual and Reproductive Health (3weeks), that are specifically addressing the training needs in family planning sexual and reproductive health of health workers in Central and Eastern Europe. These organizations are: The Nether- lands School of Public Health, ; the Netherlands Institute of Social Sexological Research, the Netherlands Family Planning Organization (Rutgers Stichting) and theWorld Population Foundation. The 1995 course took place last February. For further information please contact The Netherlands School of Public Health (NSPH) Attn: Dr Evert Kelling, Course Coordinator FP/SRH, Maliebaan 94, 3581 ex Utrecht, The Netherlands. Tel. : (31) 30 333 755. Fax : (31) 30 334 184. Training Courses in Family Planning are organized by the Irish Family P.lanning Association (IFPA). For further ' details please write to the Irish Family Planning Association, Halfpenny Court, 36-37 Lr. Ormon Quay,Dublin 1, Ireland. Tel .: (353) 1 872 253 66. Courses in Family Planning and Women's Health are organized by the Margaret Pyke Centre in conjunction with the Faculty of Family Planning and Reproductive Health Care. Basic courses (112 June 95, 21/22 September 95 & 23/24 November 95) Advanced courses on Sex Hormones in General Practice (31 March 95 & 1 December 95). All courses are accredited for the Post- Graduate Education Allowance for GPs. For more details please write to: Heather Goodman, Training Administrator, Margaret Pyke Centre, 15 Bateman 's Buildings, Soho Square, London Wl V 6JB, United Kingdom. Tel.:(44) 171 734 9351. Human Reproduction and Public Health: Fertility, Contraception, Sexuality (19-30 June 1995) is an international 2-week course in French, providing participants with minimal competencies in public health and epidemiology. For further details please contact: Dr Patrick Thonntau, Deputy Director, Epidemiology ancf Public Health Summer School,.1NSERM U292, Hopital deBicetre, 78, rue du General Leclerc, Le Kremlin-Bicetre Cedex, France. Tel. : (33) 145-212337. Fax: (33) 145-212075 . Theoretical and Practical Demonstration and Training Course on Reproductive Health Care. This 7- day course is organized on request, in English or German, by the International Research Institute for Reproduction (IRIR). Participants should become competent in clinical investigation of antenatal and postnatal care, IUD insertion and follow-up, contraceptive choice, etc. If laparoscopy is included the course length is up to 4 weeks. For further details please contact the Director, International Research Institute for Reproduction, Kaiser Wilhelm Ring 22, 4000 Di.isseldorf, Germany. Tel.: (49) 21158 82 88. Fax: (49 21155 4832. Diploma in Reproductive Health in Developing Countries is a new course offered jointly by the Royal College of Obstetrician and Gynaecologi ts and the Liverpool School of Tropical Medicine. The course will be run in Liverpool for 10 weeks, from May to July each year. The focus of the course will be on reducing reproductive mortality and morbidity through an integrated com- munity orientated approach, appropriate to developing countrie . The course is divided into units: Health Economics, Principles of Epidemiology and Com- puting Skills, Management and Training Concepts, Appropr.iate Research Methodologies, Fainily Planning and Abortion, Infection and STDs, Antenatal Care, Labour, Special Topics including Adolescents and Neonatal Care. For further information contact: Course Secretary (DRH), Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom. Tel.: (44) 517 089 393. Fax: (44) 517088 733. Short course in Reproductive Health Research. The Centre for Population Studies at the London School of Hygiene and Tropical Medicine will offer a 5- week short course in Reproductive Health Research. The course will introduce participants to the principles and methods of effective social and demographic research in this field , and will concentrate on the design of policy- oriented research and methods of evaluating the impact of programmes. ENTRE NOUS 28-29, May 1995 The course, which will start on 26 June and end on 28 July 1995, will be suitable for those with research interests in this field , and for managers and others who wish to commission or use research results. Enquiries to The Short Courses Office, London School of Hygiene and Tropical Medicine, Keppel Street (Gower Street), London WClE 7HT, United Kingdom . Tel. : (44) 171 927 2074, Fax: (44) 1713230638. The National School of Public Health in Rennes organize courses in the Population and Family Planning fields (Population Education, Family Planning, How to design a programme, Project Management, etc.). Participants should apply for a fellowship from organiza- tions willing to finance the training of project managers (UNFPA, UNESCO, WHO IPPF USAID, Ministry of Cooperation, etc). For further details please contact: The Director, Ecole Nationale de la Sante Publique (ENSP), Avenue du Pr. Leon Bernard, 35043 Rennes Cedex, France. Tel. : (33) 99 28 28 55 or 57. Fax: (33) 99 28 28 28. International Course (French or English) in Statistical, Epidemiological, and Operational methods applied in medicine and Public Health. A four-month intensive programme given from 1 February to 31 May each year. Further information may be obtained at the Secretarial Office, Ecole de Sante Publique, Universite Libre de Bruxelles (U.L.B.), Campus Erasme -CP 590/1, Route de Lennik 808, B-1070 Brussels, Belgium. Tel.: (32) 2 56840 19. Nancy University offers a Diploma in Public Health and Community Health for health professionals. The training can take place over one or two years. For details on the programme, please write to: Pr Jean-Pierre Deschamps, Faculte de Medecine, Department de la Sante Publique, BP 184,54505 Vandoeuvre-les-Nancy cedex, France. Sir David Owen Population Center has established a Master's Degree in Population Policies and Programmes ( one year postgraduate course frome arly October each year); a Diploma in Population Growth Studies (a nine- month postgraduate course running from early October to end of June); short courses (12 weeks): Population Dynamics and Development (October- Decmber 1995) Population Programme Management (January- March 1995). For further details write to: Sir David Owen Population Centre, University of Wales, College of Cardiff, PO Box 924, Colum Drive, Cardiff CFl 3UY, United Kingdom. Tel. : (44) 222 874 833. Fax: (44) 222 874 419. Population and Development. This three-month course runs annually from January to March, it is aimed at ENTRE NOUS 28-29, May 1995 development planner, policy-makers, researchers and population specialists in government, NGOs, and research institutions. Applications and enquiries to: The Admissions Secretary, Center for Development Studies, University of Wales, Swansea Singleton Park, Swansea SA2 8PP United Kingdom. Tel.: (44) 792 295332. Fax: (44)792 295682 The London School of Economics offers a one year full time M.Sc. in Population and Development within the framework of the new M.Sc, in Development Studies. For an application form write to: Graduate Admissions Office, London School of Economics (LSE), Houghton Street, London WC2A 2AE United Kingdom. Tel. : (44) 171 955 7159. Fax: (44) 1718311684. Population and Environment: Policy, Planning and Implementation (18 September - 8 December 1995). The aims of the course are to help participants assess population and environment interactions in different cultural and socio-economic contexts so that they can be integrated into development policy, planning and implementation; improve skills in preparing and implementing practical action plans to address the i sues involved in the context of participants ' own work and region; Develop skills in the process of Environmental Impacts Assessment in a policy context and assist the planning and management of projects that involve population and environment, for example resettlement. For application form write to: The Course Director, Population and Environment, Development & Project Planning Centre, University of Bradford, Bradford, 807 lDP, United Kingdom. Tel. : (44) 1274 385267. Fax: (44) 1274385280. International Course in Maternal and Child Health. This 12 weeks course (in French) is organized by the International Children 's Centre, (CIE/ICC) and takes place each year during the first trimester. The purpose of the course is to help health professionals to identify prob- lems, needs and demands in MCHJFP and to learn about the development, implementation, and evaluation of integrated MCH programs. Applications for the 1996 course must be sent before mid-September to: Centre International de l'Enfance, Dr Michel Pechevis, Chateau de Longchamp, Bois de Boulogne, 75016 Paris, France. Tel.: (33) 1 44 30 20 00. Fax: (33)1 45 25 73 67. International Course in Health Development. A 9-month course given alternatively in French and in English at the Institut de MedecineTropical Prince Leopold. The 1996 course will be in English. The course covers subjects like Health Services Planning/Management, Operations Research and Planning, Demography, Epidemiology and Biostati tics Education and ommun- ication Methodology.For further i nformation please contact: Prof. Luc Eyckmans Director, Institut de Medecine Tropical Prince Leopold, Nationalestraat 155, B-2000 Antwerpen, Belgium. Tel. :(32) 3 247 6666, Fax: (3 ) 3 216 1431. International course; on Management Skills for Project ~ders in Developing Countries (1 week & 2 weeks versions: 13-24 March 1995 & 25-29 September 1995). For further details please write to: The Short Courses Officer, Institute of Child Health (I.C.H.), University of London, 30 Guilford Street, London United Kingdom. Tel.: (44) 71 829 8692. Fax: (44)71 831 0488. Women, Men and Development is a 12-week course organized by the Institute of Development Studies (IDS) for all those concerned with gender equality within social change 31 May-19 August 1994. Further information on IDS courses is available from : The Chairman, Teach. Area, Institute of Development Studies at the University of Sussex, Brighton BNl 9RE, United Kingdom . Tel. : (44) 273 606261. Fax: (44) 273 621202. WE SHALL BE HAPPY TO COMPLETE TIDS LIST IN THE COMING ISSUES WITH YOUR INPUTS. For further information on training, please refer to the UNFPA Directory of Training Courses on Family Planning and Reproductive Health (1994/1995) Edition. Available from : United Nations Population Fund, 220 East 42nd Street, New York, N.Y. 10017, USA. ISBN: 0-89714-160-1. Price: US$15.00. This Directory contains a total of 121 organizations worldwide offering some 273 courses in the field of family planning and reproductive health. In the near future, UNFPA will have an on-line data entry system where all changes in the training courses can be entered as they become available, and will provide read-only on-line access to the Training Directory for interested persons, training institutions and other agencies. 21 Books Health worker's manual on Family Planning Options. Western Pacific Education in Action Series No 7. WHO Regional Office the Western Pacific, Manila (1994). This excellent publication is divided in two parts: A manual provides an over- view of each of the available fertility regulation methods, explains how they work and suggests which one is best for specific groups of people. The quick reference booklet, which accompanies the manual, can be used by health workers for counselling and information during their daily activities. The manual and the booklet will be of interest to all health care providers in centres which provide health services. ISBN 92 9061 137 5. Further information can be obtained from Distribution and Sales, World Health Organization, 1211 Geneva 27, Switzerland and the Publication Unit, WHO Regional Office for the Western Pacific, P.O.Box 2932, U.N. Avenue, 1099 Manila, Philippines. Price: Sw.fr.7.00/US$5.50. Price in developing countries: Sw.fr. 5.00/ US$3.50. "-¥-·--Mo1 Health workers' manual on FAMILY PLANNING OPTIONS Female sterilization. A guide to provision of services. World Health Organization, Geneva (1992). A detailed guide to the organization and management of high quality services for female sterilization. While noting that sterilization is a highly effective methods of contraception, the book concentrates on the many issues and practical details that must be considered in order to ensure that services are voluntary, medically wise and effective, appropriate to the health care system, wellmanaged, efficient, and acceptable 22 to clients. Because the procedure involves surgery and is intended to be permanent, the book gives particular attention to the information and individualized counselling needed to ensure that each woman's decision is voluntary, fully informed, and free from inducements. ISBN 92 4 154434 1. Available from: WHO, Distribution and Sales, 1211 Geneva 27, Switzerland. Price Sw.fr .. 41,· • In developing countries: Sw.fr. 28, 70. Contraceptive Method Mix. Guidelines for policy and service delivery. World Health Organization, Geneva (1994). The guidelines given here contain detailed information on all currently available contraceptive methods, as well as covering client education and counselling, training and supervision of service providers, introduction of new methods, and programme evaluation. They are intended for use and adaptation by family planning programme m~gers, administrators, and policy-makers, m developing a method mix that meets the needs of clients and responds to the specific conditions of the programme. ISBN 92 4154459 7. Available from: WHO, Distribution and Sales 1211 Geneva 27, Switzerland. Pric; Sw.fr. 32,· • In developing countries: Sw.fr. 22,40. Population. French-English Glossary. A wide-ranging and easy to use demographic dictionary. It is the result of a long and thorough process of research and compilation by the Terminology Office of the Council of Europe. It is designe~ to serve as a . straightforward, precise and convement tool for demographers, ~slators, teachers and research warkers. It also covers statistical and ~gration terms connected with demography and includes an appendix listing the organizations, conferences, texts and acronyms most commonly encountered in this field. Copies may be ordered from: Council of Europe, Publishing and Documentation Service, F-67075 Strasbourg Cedex, France. Published by the Council of Europe. 498 pages. ISBN 92-871-2506-6. Price: FF198 or US$40. The International Donor Directory. This directory contains over 2 000 entries of private donor organizations in 23 countries, which provide aid to developing countries, along with sections on government aid programs, and on how to design and present projects to potential donors. Published by the International Partner- ship for Human Development, 12020 Sunrise Valley Drive, Suite 160, Reston, Virginia 22091, USA. Price US$125 plus shipping and handling: Europe: $33.00. Three new publications from the Department for Eco1;1omic and ~ocial. Information and Policy Analysis, Umted Nations: Population, Environment and Development, United Nations, New York (1994). Proceedings o~ the United Nations Expert Group Meeting on Population, Environment and Develop- ment, United Nations Headquarters 20-24 January 1992. ISBN 92-1-151265-4. Ageing and the Family, United . Nations, New York (1994). Proceedmgs of the United Nations International Conference on Ageing Populations in the Context of the Family, Kitakyushu (Japan), 15-19 October 1990. ISBN 92-1-151261-1. AIDS and the Demography of Africa, United Nations, New York (1994). The demographic impact is con- sidered for 15 countries of sub-Saharan Africa whose human immunodeficiency virus (HIV) seroprevalence was esti- mated to surpass 1 per cent for the adult population in 1990. It also reviews.the epidemioloro: ofth.e ~/AIDS. epide- mic and considers Jts likely social and economic impacts in sub-Saharan Africa. ISBN 92-1-151268-9. ENTRE NOUS 28-29, May 1995 Documents Women's Health. Towards a better World. Report of the First Meeting of the Global Commission on Women's Health, 13-15 April 1994. World Health Organization, Geneva (1994). Part I, "Global changes and emerging trends", traces the influence that current political, economic, social and techno- logical processes have had on women's health. World Health Organization. Geneva (1994). Part II, "Summary of discussions", focuses on the six issue areas in women's health that illustrate the main risk factors leading to morbidity and mortality in women of all ages (nutrition, reproductive health, the health consequences of violence, aging, lifestyle-related health conditions and work environment). Part ll,"Achievements and opportu- nities", outlines the medium and longer term areas for action for the Global Commission on Women's Health. (Ref: WHO/DGH/94.4) WOMEN'S HEALTH TOWARDS ABElTER WORLD Expanding Family Planning Options. Contraceptive Introduction Recon- sidered: A Review and Conceptual Framework. By Joanne Spicehandler and Ruth Simmons on behalf of the Task Force on Research on the Introduction and Transfer of Technologies for Fertility Regulation. World Health Organization, Geneva (1994). Dr Benagiano, Director of the Special Programme of Research, Development and Research Training in Human Reproduction explains that the Task Force has addressed the lessons learned ENTRE NOUS 28-29, May 1995 by public sector agencies in introducing contraceptive technologies into family- planning programmes. A new three stage framework has been developed by the Task Force to assist programmes in developing countries with decision- making on whether and how to introduce new methods. In addition, it proposes that the same framework can be applied to the introduction, and improved utiliz- ation, of currently availablemethods. This document is the first of a series from the Task Force, and will be followed by reports on assessments of the need for contraceptive introduction in various countries, as well as on other topics pertinent to this issue, such as the management of contraceptive products. (Ref: WHO/HRP/ITJ'/94.1) Vasectomy. What health workers need to know. Family Planning and Population, Division of Family Health. World Health Organization, Geneva (1994). This booklet provides answers to the most common questions about vasec- tomy. It offers an overview of the major points about vasectomy that health workers need to know: What vasectomy is and how it works, what are the various techniques, what are the advantages and disadvantages, what are the risks and benefits, and how to help men make well-considered choices. (Ref: WHO/FHE/FPP/94.3 Rev.l) Female Sterilization. What health workers need to know. Family Planning and Population, Division of Family Health. World Health Organization, Geneva (1994). This booklet offers an overview of the following major points about female sterilization that health workers need to know: What female sterilization is and how it works, its advantages and disadvantages, its risks and benefits and how to help women make well- considered choices. (Ref: WHOIFHE/FPP/94.2 Rev.1) An annotated bibliography of documents produced by the Division of Family Health. World Health Organization, Geneva (1994). This document is available, upon request, from the Division of Family Health, World Health Organization, 1211 Geneva 27, Switzerland. Annotated Bibliography of documents relating to Safe Motherhood. Safe Motherhood Initiative, World Health Organization, Geneva (1994). The aim in compiling this Annotated Bibliography is to increase awareness of the problems of maternal mortality and morbidity and to disseminate infor- .. RESOURCES mation about possible solutions to these problems. It represents a selection of the most relevant contributions from the United Nations Development Program- me (UNDP), the United Nations Children's Fund (UNICEF), the United Nations Population Fund (UNFPA), the World Bank, the World Health Organi- zation (WHO), the International Planned Parenthood Federation (IPPF), the Popu- lation Council, who are the co-sponsors of the Safe Motherhood Initiative. Women's Lives and Experiences. A decade of research finding from the Demographic and Health Surveys Program (DHS), (1994). This report summarizes 10 years of survey research on women's well-being in more than 40 developing countries. During this period, the DHS program interviewed over 360,000 women. The report includes information on different dimensions of women's lives, including education, relationships, childbearing, children and home life. Further information from: Macro Inter- national Inc. DHS Program, 11785 Beltsville Drive, Suite 300,Calverton, MD 20705 USA Tel (301)572-0200. Fax: (301) 572-0999. Magazines IPPF Medical Bulletin appears every two months in English, French and Spanish. It covers advances in contra- ception and related matters and carries review articles (See extracts from the December issue under "Technology" p 19). Available free of charge from: Interna- tional Planned Parenthood Federation, Regents College, Inner Circle, Regents Park, London NWI4NS, United King- dom. 23 Wall charts Choosing a Contraceptive: Considerations for Youth. This chart presents in a very clear ways all contraceptive methods available, the advantages related to adolescent use, the disadvantages and recommended practices. Global Migration: People on the Move. Financing the Future: Meeting the Demand for Family Planning. Those three charts are available from: Population Action International, 1120 19th Street, N.W., Suite 550, Washington, D.C. 20036 USA. World Population 1994 & Urban Agglomerations 1994. Both wall charts are available from the Population Division of the Department for Economic and Social Information and Policy Analysis, United Nations, New York, NY 10017, USA. Investing in Women's Health: Central and Eastern Europe This book is one of the first fruits of the Investing in Women's health Initiative. Coor- dinators from 11 pilot countries and 1 pilot city in the eastern half of the WHO European Region gathered data for the first-ever"country profiles" on women's health and the factors that influence it. This book makes a comparative analysis of the profiles. It takes a broad view of women's health, extending beyond the traditional focus on reproductive issues to embrace the whole life cycle. It describes not only health status and health care services but also women's posi-· tion in society and tlie influt!m;es of daily life an the environment on their health. It cohcludes by indicating the directions for future action, which should include improving the amount and quality of the data on women. This book makes gripping and vital reading for anyone interested in women's health, health in the CCEE and NIS, equity, healthy public policy, or the opportunities for beneficial change in the eastern countries of the European Region. ISBN 92 890 1319 2 Price: Sw.fr. 11.- /t can be ordered from: Distribution and Sales World Health Organization CH-1211 Geneva 27 Switzerland. a ta bases The 1994 Revision of the official United Nations world population estimates and projections is now available on diskette for IBM- compatible microcomputers (Annual Population 1950-2050 Price: $75, Demographic Indicators 1950-2050 Price: $1,?0, Age patterns of Fertility;(990-1995 Price $ 75, etc.) and on::jijlgnetic tape for mainframe computers (World Popu- lation 1950-2050 Price: $500). These population estimates and projections provide the standard and consistent set of population figures which are used throughout the United Nations system as the basis for activities requiring population information as an input. Persons interested in further information about these databases should write to the Chief, Estimates and Projection Section, Population Division (DC2-1918), United Nations, New York, NY 10017, USA. ENTRE NOUS 28-29 May 1995