Entre Nous: the European magazine for sexual and reproductive health: no. 46: reproductive health in emergency situations

(~\ \m, ~~ UNFPA THE EUROPEAN MAGAZINE FOR SEXUAL AND REPRODUCTIVE HEALTH No. 46 - Spring 2000 ENTRE NOUS The European Magazine for Sexual and Reproductive Health Entre Nous is published by: The Women's and Reproductive Health Unit WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen 0 Denmark Tel.: {+45) 3917 1451 or 1426 Fax: { +45) 3917 1850 E-mail: entrenous@who.dk Chief Editor Dr Assia Brandrup-Lukanow Editor Jeffrey V. Lazarus Administrator & Editorial Assistant Dominique Gundelach French translator 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 Women's and Reproductive Health Unit of the WHO Regional Office for Europe. Present distribu- tion figures stand at 5500 English, 2550 French, 2000 Spanish, 2000 Portuguese, 1000 Russian, 500 Hungarian. Entre Nous is produced in: Hungarian by the Department of Obstetrics and Gynaecology, University Medical School of Debrecen, P.O. Box 37, Debrecen, Hungary. Portuguese by the General Directorate for Health, Alameda Afonso Henriques 45, P-1056 Lisbon, Portugal. Russian by the WHO Information Centre for Health for the Central Asian Republics, Toktogoul str. 62, Bishkek 720021, Kyrgyzstan. Spanish by the Instituto de la Mujer, Ministe- rio de Trabajo y Asuntos Sociales, Almagro 36, 28010 Madrid, Spain. The Portuguese and Spanish issues are dis- tributed through UNFPA representatives and WHO Regional Offices to Portuguese and Spanish-speaking countries in Africa and South America. Material from Entre Nous may be freely trans- lated into any national language and reprint- ed in journals, magazines and newspapers, provided due acknowledgement 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 enquiries to the authors of signed articles. For information on WHO-supported activities and WHO documents, contact the Women's and Reproductive Health Unit at the address given above. Please order WHO publications direct from the WHO sales agent in each country or from Marketing and Dissemination, WHO, 1211 Geneva 27, Switzerland. PAGE 2 - NO. 46 - SPRING 2000 CONTENTS EDITORIAL ........................................................................ 3 New Regional Director for Europe ...................................... 4 Male Contraception: Planning for the Future - M. T. Mbizvo .... 4 Kyrgyzstan - Sexual and Reproductive Health Needs of Young People - A. Doolotova et al. .. ................................ 6 The Health of 4 Million Women at Risk in Europe ................ 7 Albania and Macedonia - UNFPA Action in Reproductive Health for Kosovar Refugees - D. Pierotti .......... 8 Kosovo - Reproductive Health in Emergencies - H. Bower .... 10 On the Ground: Reproductive Health in the Field - K. Legins .................................................................... 12-13 Women's Health in Action - Capacity-building Through country level training - T.M. Hussain .................... 14 Spotlight on Estonia - Sexual and Reproductive Health Counselling for Boys and Men - 0. Poolamets ............ 15 Resources •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 16 News .••.•.•..•.....•••••••••••••.....•••••••••••..••••••••••••.•.••••......••••••• 19 Internet Resources .......................................................... 20 Cover photo and photo p. 3: ©Michael Daugaard/2maj Photo page 4: ©Frantz Henriksen Photo page 5: ©Rod Shone/IPPF Photo page 6 : ©Dr Marat Bozgunchiev Photo page 7: ©Ms Margareta Ackerhans Photo pages 8 and 12: ©Joachim Ladefoged/2maj Photo page 10: ©Hilary Bower Photo page 14: ©Dr Balthasar Schaap Photos page 14: ©Dr Tarek Hussain Page 8 Page 12 Page 15 MEMBERS OF THE EDITORIAL BOARD Dr Alison BIGRIGG Clinical Director Family Planning and Sexual Health Directorate Glasgow, United Kingdom Dr Carlos HUEZO Medical Director International Planned Parenthood Federation (IPPF) London, United Kingdom Dr William J. HUNTER Director Public Health and Safety at Work Directorate-General for Employment, Industrial Relations and Social Affairs DG V - European Commission Luxembourg, Luxembourg Dr Malika LADJALI Senior Programme Specialist UNESCO Paris, France Mr Henning MIKKELSEN • Programme Development Officer Department of Country Planning and Programme Development, Europe Desk Joint United Nations Programme on HIV/AIDS, (UNAIDS) Geneva, Switzerland Ms Elin RANNEBERG-NILSEN UNFPA Representative United Nations Population Fund (UNFPA) Bucharest, Romania Dr Katy J. SHROFF UN FPA Representative United Nations Population Fund (UNFPA) Tirana, Albania Ms Lyn THOMAS Regional Director International Planned Parenthood Federation - European Network Brussels, Belgium Dr Ketty P. TZITZIKOSTA President Assodation of Interbalkan Women's. Cooperation Sodeties (A.I.W.C.S.) Thessaloniki, Greece © World Health Organization 2000 EDITORIAL Profound global political changes in the late 1980s have, unfortunately, triggered a large number of severe socio-economic, civil and military crises in different parts of Europe: wars in for- mer Yugoslavia, the Caucasus and Tajik- istan, as well as a critical deterioration of the economy in many countries of Eastern Europe and the former USSR. These so-called "complex humanitarian emergencies" required an immediate and effective response from the international community in order to alleviate the suf- fering of up to hundreds of thousand and even millions of people in affected coun- tries. The impact of complex emergencies always includes an increase in mortality and a decline in the general health of a population, which is obviously of concern to WHO, whose global mandate is "to act as the directing and coordinating author- ity on international health work". WHO has a specific and now already well- defined role in the comprehensive inter- national emergency humanitarian assis- tance effort, usually implemented by many partner agencies working together. WHO priority interventions usually include some combination of: • public health assessment, both rapid and more continuous, working collabo- ratively with local public health struc- tures wherever possible; • NGO co-ordination, based upon the WHO competitive advantages of close contact with governmental structures; • Post-conflict programmes and those at the interface between the humanitari- an and development aspects of inter- national assistance; • Health system reform work set in a humanitarian context, for example, currently in Kosovo and in Tajikistan where structural and functional reforms aimed at increasing the efficiency of resource utilisation within the previ- ously rigid and structurally overbur- dened health-care system, for example primary care development and pharma- ceutical reform, represent very practi- cal and immediately available humani- tarian interventions; • Supplying of drugs and medical and surgical equipment. Moreover, WHO implements specific pub- lic health programmes (water, sanitation and solid waste control, immunisation, communicable disease surveillance and control, mental health rehabilitation, etc.), based upon assessed needs. These needs arise from common features of the adverse impact of an emergency on health, especially in relation to the most EDITORIAL vulnerable population groups: women, children and the elderly. These groups suffer the most, and they usually repre- sent the majority among the displaced population during the emergency. Humanitarian health assistance to women and children as a response to emergency situations is an important area of WHO programmes. Of the refugees crossing borders in Kosovo, Chechnya and other crisis zones in Europe, the majority of the adults are women, most of reproductive age. Yet in the assistance provided, reproductive health care is often forgotten among what seems to be higher level priority concerns: communicable diseases, emer- gency surgery, and aid against cold and hunger. It nearly seems as if it is "inappropriate" to consider the provision of contracep- tives, for example, in such serious situa- tions. Yet, human relationships continue, also in times of hardship, and sexual relationships are among these, both posi- tive and negative. The range of reproduc- tive health needs is, consequently, very broad - from the need for quality antena- tal, perinatal and obstetric care in order to ensure that desired children can .be born as safely as possible under difficult conditions (this may mean providing emergency maternity care in refugee camps or strengthening existing health services to cope with larger numbers of patients), to ensuring that women will have access to appropriate contraceptives so that they will not have to resort to unsafe abortions in order to terminate an unwanted pregnancy. In an environment where contraceptives may not be avail able, the provision of emergency contra- ceptives, the so-called morning after pill, is particularly necessary. The issue of sexual violence and rape calls for a differentiated reproductive health service response, ,... from providing the correct medical care.Jo ensuring psy- chological and social~counselling if desired. ·· The danger of sexually transmitted infec- tions is again an issue which tends to not be highlighted. Providing diagnostic services and early treatment will prevent long-term complications and the further spread of infections. Older women may also have reproductive health problems - reproductive tract can- cers, osteoporosis - problems which at least deserve diagnostic attention and referral. Many NGOs and UN agencies, notably UNFPA, UNHCR and WHO are increasingly addressing reproductive health needs. In this issue of Entre Nous, the reader will find reports of this work along with descriptions of the situation in some of the most burning places. We hope that this issue will be helpful to those who have to organise health care for refugee populations. Dr Assia Brandrup-Lukanow Chief Editor, Entre Nous E-mail: abr@who.dk Dr Vladimir Verbitski Desk Officer, Partnerships in Health and Emergency Assistance E-mail: vve@who.dk NO. 46 - SPRING 2000 - PAGE 3 ~ POLICY AND PRACTICE MALE CDNTRACEPjf,lQ,~jforrhe future AVSC International and Reproductive Health Alliance Europe, in collabo-ration with the UNDP/UNFPA/WHO/ World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), convened a symposium in London, in May 1999, to discuss the future of male con- traception. Up to 35 biomedical and social science researchers, women's health advocates and service delivery specialists drawn from the international community, came together to deliberate on the status of research on male contra- ceptive methods. The main objectives of the symposium were to review progress on the research conducted so far on the development of male contraceptive methods; to articulate and better under- stand the service delivery needs regard- ing existing and potential future male contraceptive methods; and to develop a draft agenda on operations research aimed at improving service delivery for male contraception. New contraceptive technology Plenary presentations covered the status of new contraceptive technology devel- opment. In her presentation, Dr Christina Wang, the chairperson of WHO/HRP's Research Group on Methods for the Regulation of Male Fertility, reviewed progress made so far in the development NEW REGIONAL DIRECTOR FOR EUROPE Entre Nous would like to welcome Dr Marc Danzon as new WHO Regional Director for Europe "I strongly believe in WHO and its potential to advocate and sup- port health. I am committed to its ideals and Look forward to working together with people throughout the Region and beyond in making access to health for all a reality in the new millennium," stated Dr Danzon. Dr Danzon, born in France in 1947, has 25 years of experi- ence in public health. Dr Danzon has worked twice before with WHO at the Regional Office for Europe. From 1985 to 1989, he was responsible for communica- tion and public information. Between 1989 and 1992, Dr Danzon served as director of the Comite Fran~ais d'Educa- tion pour la Sante (French Health Education Committee). In this capacity Dr Danzon organised national health promotion campaigns, led a research team and developed a national institution in charge of defining and imple- menting policies and pro- grammes for health promotion and education. PAGE 4 - NO. 46 - SPRING 2000 In 1992 Dr Danzon returned to the WHO Regional Office as Director of the new Department for Country Health Develop- ment. In this capacity, he was responsi- ble for the development of the EURO- HEALTH programme for the countries of Central and Eastern Europe. He then became director of the Health Promotion and Disease Prevention Department. The new Regional Director assumed office in February 2000 and will -serve for five years. and testing of reversible, hormonal male contraceptives. The mechanism of action for hormonal male contraception is to reduce the levels of intratesticular testosterone and suppress sperm produc- tion while maintaining' sexual function. Feasibility studies in animals and men have shown that the administration of androgens alone, combinations of gonadotrophin-releasing hormone ana- logues and androgens, and progestogen and androgen combinations, can suppress gonadotrophin secretion and spermatoge- nesis either completely to azoospermia or to a sufficiently low level of sperm con- centration to render the treated individu- als infertile. Discontinuation of the treat- ment leads to full recovery of gonadotrophin secretion and spermatoge- nesis, and a return to fertility. The advent of a safe, effective and reversible systemic method of contracep- tion for men is expected to provide a valuable addition to the range of meth- ods available to users of family planning and an attractive alternative to the limit- ed options of the condom, vasectomy and withdrawal that are the only meth- ods currently available to men. In fact, in a landmark 15-centre study conducted by WHO/HRP, the contraceptive efficacy of azoospermia induced by injections of an androgen ester was comparable to that achieved by available female hor- monal contraception. A high level of acceptability was found among both the recipients and their partners. Other research advances discussed , included the development and testing for acceptability of the non-latex condom. Non-latex condoms are more resistant to degradation and are reported to cause fewer allergic reactions. Improving on vasectomy There have also been research efforts to improve on vasectomy. The advent of no- scalpel vasectomy has gone a long way toward improving the technology of this male surgical contraceptive method. One of the alternative methods of vas occlu- sion, which was considered promising, is the percutaneous injection of liquid silicone into the lumen of the vas where it rapidly hardens to form a plug, which prevents the passage of sperm. However, recent studies of percutaneous vas occlu- sion in the Netherlands have demonstrat- ed a lower incidence of achieving azoo- spermia, than that previously reported for men in Indonesia. Scientists are exploring a variety of other approaches, including the use of plant material. These approaches still require basic research. The WHO/HRP is also sup- porting basic research leads towards male contraception. The research being sup- ported is aimed at gaining a clearer understanding of the process of sperm production in the testis and subsequent attainment of fertilizing ability by the mature spermatozoon, as a means of identifying contraceptive targets. Men As Partners (MAP) The symposium also provided an opportu- nity to inform about the AVSC Interna- tional's Men As Partners (MAP) initiative. Established in 1996, the MAP initiative has four goals: to improve men's aware- ness and support of their partners' sexual and reproductive health choices; to increase men's awareness and responsi- bility for disease protection; to increase men's use of contraceptive methods that require their participation and coopera- tion; and to improve men's access to comprehensive sexual and reproductive health services. Issues on service delivery of sexual and reproductive health services for men were also discussed. These discussions high- lighted the importance of gender issues and roles in reproductive health, includ- ing power dynamics; understanding men's motivations and preferences; knowledge on male clients' perceptions on service delivery; the need for communication strategies that are sensitive to culture; PO LI CY AND PRACTICE ~ .1ffED,~J J J-~ 1 the need to target male adolescents; and the need to involve leaders in relevant communities. Furthermore, participants recommended that the introduction of new male meth ads should be informed by experiences from programmes serving women. These have demonstrated the need for ensuring wide access to existing methods and for quality in service delivery. "Overall, participants shared a vision that included a renewed commitment to expanding access to available male contraceptive methods and supporting research for further male contraceptive development. 11 In conclusion, the symposium observed that: 1. There was need for widening the population base of men participating in male contraceptive clinical trials. 2. Studies need to document, for each possible combination, user perspectives and preferences. Such research should include men's preferences for places from which to obtain contraceptive services and information. They should also identi- fy the level of involvement that women want from men in contraception. 3. Operations research is needed on ser- vice delivery systems. This should define the extent to which service providers are prepared to work with male clients, iden- tify provider biases and appropriate counselling approaches. , Overall, participants shared a vision that included a renewed commitment to expanding access to available male con- traceptive methods and supporting research for further male contraceptive development. Dr Michael T. Mbizvo Coordinator, Technical Support to Countries and Manager, Male Reproductive Health Research, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland E-mail: mbizvom@who.int NO. 46 - SPRING 2000 - PAGE 5 - J j ~.It@J J ~~ A D O L ES C E N T H E A LT H KVRGVZ~WJ)J,s of young-people An assessment in Kyrgyzstan illustrated the power of participa- tory, qualitative approaches in determining policy, programmatic and research needs in sexual and reproductive health (SRH) and the potential for addressing the needs of other groups or other countries. The lack of awareness of the sexual and reproductive health needs of young peo- ple and the limited resources available to address them are critical issues through- out the world. In many countries, socio- economic changes have shattered tradi- tional patterns of life, young people have become underserved or marginalised and have little or no opportunity to obtain information, help or health care. These changes have resulted in traditional prac- tices and sources of information disap- pearing without newer approaches to life skills and sexual education being provid- ed in schools. In many developing coun- tries, the resources available to govern- mental departments of health and educa- tion have become grossly inadequate to meet the demands placed upon them, making partnerships between govern- mental and non-governmental organisa- tions (NGOs), critical in addressing the needs of young people. Socio-economic change in countries of the former Soviet Union has led to many of these countries, particularly the cen- tral Asian republics, experiencing such problems for the first time. The 1990s have been a period in which the health, educational and economic status of young people have deteriorated creating significant and increasing problems around their sexual and reproductive health. Health expenditures have been slashed (in Kyrgyzstan, the health expen- diture per capita fell from USD156 in 1990 to USD 9 in 1997); the prevalence of STis has risen dramatically; schooling is no longer universal; and jobs are becoming memories of the past. Reproductive Health Alliance Europe, London, at the request of the Govern- ment of Kyrgyzstan, recently facilitated and provided technical assistance for an assessment of the sexual and reproduc- tive health needs of young people in Kyr- gyzstan. This assessment was based on a rapid evaluation methodology developed PAGE 6 - NO . 46 - SPRI NG 20 00 by WHO (Simmons, Hall, Diaz, Diaz, Fajans and Satia, Studies in Family Plan- ning, 1997, 28, 79-94) and was the first time it had been used to address young people's sexual and reproductive health. The assessment was designed to define policy and programmatic needs and to identify what research was necessary to explore the feasibility, acceptability and potential impact of implementing such changes. It reviewed existing knowledge and conducted field observations to address specific questions and identify how to answer them, using a participato- ry planning process that involved stake- holders from all organizations and enti- ties involved in the sexual and reproduc- tive health field. The assessment com- prised a preparatory phase, field observa- tion and data collection, analysis and preparation of the assessment report, and workshops for the dissemination of find- ings and the development of action plans. The assessment, which was completed in September 1999, was conducted in col- laboration with the national NGO, the Association "Family and Healthy Genera- tion" and with representatives of the Ministries of Health, Education and Labour and Social Protection and the State Commission on Family, Women and Youth, NGOs and young people. Field work was conducted in June, with the assessment team travelling throughout the country meeting with young people, parents, teachers, health care providers, community leaders and other relevant people and group. The results were ana- lyzed and the findings disseminated through a national workshop in Bishkek, and regional workshops in Naryn, Issyk- kul and Osh. It was funded by DFID/Know How Fund, the Aga Kh.~rr Foundation, AVSC International arfd Reproductive Health Alliance Europe. The report of the assessment concluded that young people receive little or no factual information on these issues, either in school or through other chan- nels such as the mass media. They rarely go to health facilities for services and when they do they experience barriers to appropriate reception and treatment. ~ They have little to do in their spare time, many turning to intravenous drug use and sex. This is exacerbated by the fact that some of them are having to drop out of school because their families have no money. For girls, this can mean turn- ing to commercial sex work, exposing themselves to the dangers of STis and HIV. Many are concerned about the future and the lack of employment. Some are turning away from the conservative nature of society and the resurgence of religion, something that isolates them from, or creates stresses within their families, while others are seeking the support of new religious sects. Sadly, the overall effect is that young people are experiencing increasing levels of preg- nancy, abortion, STis/HIV, rape, aban- donment, suicide and intravenous drug use, as well as appearing more in the crime statistics. WOMEN'S HEALTH AND DEVELOPMENT THE HEAL TH OF 4 MILLION WOMEN AT RISK IN EUROPE "The rapidly increased migration, war and unrest during the last decades have put women and their families at a higher health risk all over the world. These health risks also apply to the more than four million women living in Europe who belong to migrant groups or ethnic minorities, "stat- ed Ms Efua Dorkenoo, representing the Department of Women's Health at the WorldHealth Organi- zation (WHO) in Geneva. To address this problem, WHO staff and women's health pro- fessionals from around Europe met in Gothenburg, Sweden, in November 1999, to outline actions to tackle the special health concerns of women from ethnic and migrant minorities in Europe. In the European Union (EU) in 1997, Austria {6.6%), Belgium (8.8%), France (6.3%), Germany (8.9%), Lux- embourg {34.1%), and Sweden (6.0%) had the largest numbers of non-nationals (both male and female) as a percentage of the total population. From 1985 to 1998, approximately 3.5 million individuals sought political asylum in the member states of the EU. These numbers, however, do not reflect the heterogeneity of ethnic and migrant minorities in Europe. Minority status may be based on religion, race, class, nation- ality or ethnic origin, depending on the culture of the country. Overall, the num- ber of non-nationals can be assumed to Action is clearly needed now and funding must be found within the government or from international donors. The immediacy for action is underlined by the compla- cency surrounding the HIV/AIDS epidem- ic which is just over the horizon, and while this does not select its victims by age, children and young people will bear the brunt of its consequences. The report, which is available in English, Kyrgyz and Russian, identified the most important recommendations and priori- tised them in terms of policies, pro- be a conservative estimate of individuals with minority status residing in EU coun- tries. Although data on the health of specific immigrant and ethnic minorities in the EU is limited, Mr Wilfried Kamphausen, the European Commission representative, said that research showed that in general the risk of illness was higher for people who had to adapt to the process of migration. These higher risks were in fact reported for all migrant groups, indepen- dent of ethnicity, and seemed particular- ly alarming for certain infectious dis- eases (mainly tuberculosis), occupational health, women's reproductive health, child health and mental health. Higher pregnancy-related morbidity, increased postnatal problems and a greater number of infant deaths and con- genital malformations are reported for minority women in all EU countries. Unwanted pregnancy is reported from some member states as being frequent among immigrant women. Also, surveys from Belgium (migrants from Morocco), the Netherlands (migrants from, Morocco, Surinam and Turkey), the United Kingdom (migrants from India and Pakistan) and grammes and research. They are aimed at all stakeholders, whether they are gov- ernmental or non-governmental; at the national or community levels; service providers or parents; or young people themselves. It also underlined the need to take a multi-sectoral approach to address the problems faced by young people. This was something accepted by the Kyrgyz government, which immedi- ately established a multi-sectoral adviso- ry group run from the President's office. For a copy of the report please contact: Sweden (migrants from Finland and East- ern Europe) report that suicide rates among children, especially girls, are three times as high as in the host popu- lation. ."; ~ Following the meetirig;" .WHO outlined five areas of work needed fo better under- stand the health needs of minority women in the EU and to best fulfil those needs: • training of health-care providers who have contact with minority women on how best to overcome linguistic and cultural barriers in communication, and to adapt the provision of services to the needs of migrants; • improved data collection, taking into account the potential risk of stigmatisation or dis- crimination for the groups covered; • strengthening health pro- motion activities by en- abling migrant groups to take responsibility for their health; • assisting the health ser- vices to recognize and adapt to the special needs of minority women; and • continued exploration of the social determinants of health among minority female populations in the EU. For more information, contact: Or Assja Brandrup-lukanow Regional Adviser for Women's and Reproductive Health WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen 0, Denmark Tel.: (+45) 39 17 14 26 Fax: ( +45) 39 17 18 18 WHO press releases can be found at: www.who.dk/ pa/cpa.htm Anara Ooolotova Kyrgyz Family Planning Alliance Bishkek, Kyrgyzstan JuUe Solo and Peter Hall Reproductive Healt h Alliance Europe 443 Highgate Studios 53-79 Highgate Road London NW5 1TL United Kingdom E-mail: phall@rhae.org Tel: {+44) 20-7267 3660 Fax: (+44) 20-7267 7610 NO. 46 · SPRING 2000 · PAGE 7 ~ Qf~ WOMEN'S HEALTH AND DEV ELOPMENT The UNFPA intervention during the Kosovo crisis was quite unique and-should serve as a model for future UNFPA interventions in emergencies. UNFPA was already operational in the region before the advent of the crisis brought on by the bombing of Serbia by NATO, allowing us to develop a comprehen- sive reproductive health (RH) approach. UNFPA was ready to assist Kosovo from September 1998. Two RH needs missions were organised shortly thereafter. A pro- ject proposal was submitted to UNFPA for a total of USD 200,000. Three implement- ing agencies were identified: WHO Regional Office for Europe, Doctors with- out Borders (MSF) Belgian and Mother Theresa. Nevertheless, the project was not PAGE 8 - NO. 46 - SPRING 2000 approved due to the deterioration of the situation and the internationalisation of the internal conflict. The bombing campaign carried out by NATO resulted in a large influx of Kosovar refugees to Albania. UNFPA, in turn, commenced activities through its office in Tirana. The office was highly instru- mental for political, medical and intera- gency local contacts. It provided basic logistical assistance in terms of availabil- ity of personnel, transport, communica- tion and even lodging accommodation as well as becoming more involved in repro- ductive health activities. At that time, the office was only staffed by a national programme officer. Since the beginning of operations, it has been reinforced administratively, first by a logistician from headquarters then by the UNFPA senior officer in charge of all emergency relief operations. The UNFPA Tirana office became the focal poiAt for all emergen- cies in Albania and Macedonia and great- ly facilitated the impJementation of all RH activities in both countries. At the beginning of the conflict a UNFPA consultant was recruited, the Director of the International Centre for Migration and Health from the International Orga- nization for Migration (IOM). He made an RH assessment needs report and UNFPA took immediate action. On 11 of April 1998 various RH subkits were provided for all levels of RH activities. These sub- kits, at a total cost of USD 121,000, cov- ered the RH needs of 350,000 refugees for a 3-6 month period. They were dis- tributed to maternity hospitals all over Albania through the Ministry of Health. They were also distributed to local and International NGOs such as Medicos del Mundo, Nesmark (local affiliate of Popu- lation Services International [PSI)) and the Albania Family Planning Association. It should be noted that sanitary pads and underwear were also immediately pro- cured. "the provision of RH supplies is not sufficient in an emergency situation,, In Macedonia, basic emergency RH sup- plies and hygienic products were provided by UNFPA and distributed by UNHCR and UNDP to women refugees. At the begin- ning of May 1999, UNFPA provided a sec- ond batch of RH kits to Albania with requested equipment including examina- tion and delivery tables. Reference maternity centres were equipped with two badly needed ultrasounds machines, donated by Siemens. But the provision of RH supplies is not sufficient in an emergency situation. UNFPA, having been recognised as RH coordinating Agency by UNHCR, hired an RH consultant for a two-month period to coordinate not only RH activities organ- ised by UNFPA but also to facilitate the implementation of RH services by the national authorities and international and local NGOs "emergency contraception in this context was useless as women sexually assaulted and raped reached Albania after days of travel,, Next, a psychologist was hired to explore and document the situation of sexual vio- lence and the systematic rape of women and adolescent girls in Kosovo. The dra· matic report has been publicised world- W O M E N ' S H E A LT H A N D D E V E L O P M E N T d ULJ !1.Lt ~ _r J "' !:J-:'.'.J wide. It should be noted that emergency contraception in this context was useless as women sexually assaulted and raped reached Albania after days of travel and had a long waiting period before being seen by a health provider. Furthermore, women were highly reluctant about exposing themselves as having been raped. On the whole, the intervention was suc- cessful. It should be underlined that for the first time UNFPA received funding from a UN consolidated appeal. All the needs were financially covered by a num- ber of bilateral donors: Japan, Denmark, Luxemburg, in addition to private dona- tions from Planned Parenthood of Ameri- ca, the Turner Foundation and even the US Committee. A total of USD 1.1 million was obtained. "Comprehensive RH activities are inexpensive because they are complementary activities of basic primary health-care services" Although it may seem like a low figure, the amount was sufficient to cover the RH needs of the 600,000 Kosovar refugees for a 3-6 month period. Comprehensive RH activities are inexpensive because they are complementary activities of basic primary health-care services. They should always be included as an integral part of basic services. The presence of an operational UNFPA office was also an essential input to reduce admin- istrative and logistical costs After three months, the conflict ended and the Kosovar population rushed back to their province. UNFPA was then con- fronted by a new challenge: how to respond to the RH needs of the Kosovar returnees and how to rehabilitate a new RH Kosovar Programme. To do this UNFPA opened up a UNFPA office in Pristina with an international representative. Lessons learnt from the Kosovo conflict First, we realised that we can be efficient and play an important role in meeting the RH needs of the populations during the emergency phase. Our action was acknowledged by our international part- ners as we were requested by UNHCR to ensure the coordination of RH activities. Our operations were greatly facilitated by a series of favourable elements: UNFPA readiness through preparatory RH missions the previous year, initial fund- ing (USD 200,000), constant assistance from a local UNFPA office with all neces- sary logistical support, immediate avail- ability of competent consultants, provi- sion of RH subkits, flexibility and adapta- tion of our supply <1.n~ equipment inputs. . ·"· - The long tradition of cooperation with the Albanian authorities should also be noted (UNFPA has been operational in RH through its Technical Support expert and funding via WHO Regional Office for Europe since 1986). The thorough knowl- edge of the country by two UNFPA staff was also an asset as was the total mobilisation of UNFPA personnel at all levels. However, the determining factor was the positive answer from the donor community regarding funding, which allowed the development of RH interven- tions. With all these favourable elements the UNFPA intervention in Albania was able to successfully respond to a severe emergency crisis. Dr Daniel Pierotti UNFPA Senfor Analyst for Emergency Relief Operations Tel: (+41) 22 979 9314/15 E-mail: unfpaero@undp.org E rra tum The correct name and mailing address of CFFC is: Catholics for a Free Choice 1436 U Street NW, Suite 301 Washington DC 20009-3997 E-mail : cffc@catholicsforchoice.org NO. 46 · SPRING 2000 - PAGE 9 ~J J]:JJ ~ J !:J 1 ~ P O LI C Y A N D P R A C T IC E KDSD)($oductive health in emerg-encies Kosovo's "emergency" is unusual. Although it started in the refugee camps of spring 1999, the real challenges in reproductive health can be found back in Kosovo where, in June, the population and international and local doctors faced not only the traumatic fallout of two years of overt rape and terror, but the accumulated damage to practice and atti- tudes created by a decade of suspicion, isolation and neglect. This combination has left the territory with some of the worst reproductive out- comes in the Western world, including an infant mortality rate estimated at between 30 and 50 per 1000 births, a high rate of infertility and an enormously high rate of abortion - one for every 1.7 live births. Unlike more traditional emer- gency situations where it is war or natural calamity alone that has dramatic consequences on levels of health and health care, in Kosovo the role of the war was to focus international attention on the disastrous health-care sit- uation that had been 10 years in the making. As a result the Kosovo crisis has presented humanitarian agencies with some unique problems. Number one, says Dr Olivier Brasseur, head of mission for the United Nations Population Fund who, along the World Health Organization, NGOs such as CARE, International Rescue Committee, International Medical Corps working in the field of reproductive health care and the vast majority of the almost 1 million Kosovar Albanian refugees, returned to Kosovo in the first few days after the NATO take over, is that "every single health institution has been left in decay". "Of course on top of this there was both systematic and random destruction of equipment coupled with looting of facili- ties, but the essential structures of the health service are in crisis now, largely because of 10 years of neglect, not war- fare". Secondly, the Albanians who now almost completely staff the health service, have been excluded from the state health care system, and the rest of the world, for the past 10 years. "They have worked in a parallel system, lacking adequate equip- ment and information on new practice. And thirdly," adds Brasseur, "despite the outward impression of very modern young women in the streets of Pristina, Kosovars still largely subscribe to a remarkably outdated status of women in society". A fourth factor dogging reproductive health in the province, according to Dr Helene Lefevre-Cholay, WHO's reproduc- tive health adviser in Pristina, is that there has been no development of pre- ventative care in the six hospitals or 20 health houses with gynaecological ser- vices. "The vast majority of women receive no ante-natal or post natal care, no newborn checks, no contraceptive counselling. Even in the very few places it is offered, preventative care is not taken up because the culture is not to visit the doctor before labour. The result is high rates of prematurity, infant death and health complications for women." There is also the fact that family plan- ning has in the past been seen by many Albanians as a tool of state genocide. Add to this estimates that between 10,000 and 20,000 women and girls were raped in the two years before NATO's arrival in the province, and the compli- cated nature of Kosovo's reproductive health needs and perceptions requires little further emphasis. "Reproductive health is a priority right from the beginning of any emergency. But in Kosovo it has been even more of a priority partly because of the amount and intensity of the sexual violence," says Brasseur. In these circumstances, humanitarian agencies have a complex role, one which combines the traditional emergency activities of drug and equipment supply and immediate clinical care with those more connected to development, such as training and advocacy. PAGE 10 - NO. 46 - SPRING 2000 "A crisis like this is an opportunity because of all the change going on," says Lefevre-Cholay. "We can provide emer- gency supplies for reproductive health - like condoms or equipment - relatively easily, but when you i.tart thinking about policy and changing atptudes it needs time. Awareness and t1se of family plan- ning, for example, 'is a long term process. In emergencies, it is not the first thing people think of. The first is to survive, to take care of their children, not to die in childbirth". The latter has been one of the most acute challenges for the international community. Sim- ply getting generators, heat- ing, running water, food blan- kets into maternity units in health houses where women were giving birth in sub-zero temperatures proved tricky, largely since the drawback of such a large humanitarian influx (some 300 NGOs cur- rently and every possible UN agency) is that everyone thinks someone else is taking care of the obvious and it is easy for early promises to be forgotten. Other emergency aspects have gone more smoothly. UNFPA and WHO rapidly distributed large numbers of reproductive health kits with ongoing supplies taken care of by Pharmaciens sans Frontieres and soon United Nations Mission in Koso- vo Health Department. Contraceptive drugs and devices were included in the kits and though demand has been low (less than 10 per cent of women are thought to have used contraception due to a combination of lack of knowledge ~ and unwillingness due to past suspicions) according to IRC's reproductive health nurses, women even at rural level are now eager for information and excited that contraception methods will be avail- able Emergency contraception, however, has not been a priority issue either in the camps or after the return, despite the level of sexual violence, since most women who were raped in Kosovo ended up walking for days before they reached the border or anywhere that could pro- vide such medication. The kits also included equipment that would, among other uses, facilitate safer abortion - an important requirement since termination is the main method of controlling family size. It is advocacy - both to women and health professionals, however, that Brasseur and lefevre-Cholay see as the most significant, though longer term, target of attention in this particular emergency, since the breakdown in ser- vices offer a window of opportunity to try and change old practices and atti- tudes. Kosovar women, says Brasseur, are right now receptive to talking about reproduc- tive health, not least because they believe it will help them improve health and their status in society. But advocates need to tread carefully. Gynaecological examination and counseling hold hidden pitfalls for many women related to the systematic sexual and physical abuse committed in the province. Reports also suggest significant numbers of women fear to speak of their experiences due to the risk of being ostracised from their families or communities, while those who do speak out, even supported by their families, expose themselves to danger from revenge attacks or to prevent them becoming potential witnesses for the International Criminal Tribunal for the Former Yugoslavia. In this area, it is proving crucial for international agencies to work with local organizations, several of whom remained in Kosovo throughout the crisis. The Cen- tre for Protection of Women and Children, for example, with the help of Italian donor ADAB, has opened six centres offering gynaecological and reproductive health services as well as psycho-social support in the areas worst affected by atrocities, and hopes to gain funding for a further eight. Director Sevdie Ahmeti, a human rights worker who spent the bombardment hiding in a cow byre, says trust is the most important factor in offering reproductive health ser- vices for these women, many of whom initially may not initially feel able to submit even to a doctor's examination. Unfortunately, too, women remain vul- nerable to violence despite the cessation of hostilities, says Brasseur. "Women have been the targets of a premeditated systematic war strategy that has created a tremendous trauma. But, on top of this, women were the ones who had to stay in the house while their husbands had to run. Many men feel a tremendous amount of guilt which in turn produces anger and aggression within the family." Unemployment (around 50% currently), loss of purpose, lack of money among a predominantly young male population simply compounds the problem. Against this background, humanitarian organizations have taken what might be considered unusual steps for an emer- gency response. Just two months to the day after NATO troops rolled into the country, a group of local clinicians aided by UNFPA, WHO, CARE and others had drawn up a 10-point Kosovo Reproductive Health Policy (see box) aimed at guiding reproductive health in the territory into the 20th century, though probably not before the 21st. PO LI CY AND PRACTICE E.! J J ~J @) J ~-P J2J "There has been no proper education of women, particularly young women and girls, of what they should expect from reproductive health and their reproduc- tive rights, SUCH AS the fact that cou- ples have a right to have as many children as they want when they want them, " says Brasseur. "It took five years, not two months in an emergency, to get the international community to agree on a policy anything like as comprehensive as this one which covers everything from political to clinical issues on one side of A4." Building on this, the key players have established a National Committee for Healthy Families made up largely of nationals and including obstetricians, gynaecologists, neonatalists and repre- sentatives of the Institute of Public Health and of local women's groups as well as a sociologist, and a journalist. Its aim is to advise UNMIK and later the elected government on all issues related to reproductive health and to family health with the first priority the develop- ment of a strategy to remove the "wish- ful thinking and approach the most urgent challenges pragmatically". One element of this strategy must be to start working on unhelpful practices and attitudes. Women have not only had no access to quality reproductive care, but in the past, for Albanians at least, quali- ty care has not been available except in the limited infrastructure of the parallel system. So not only do services need to be built-up, but expectations and under- standing. Kosovo Reproductive Health Policy: Principles 1. Policies, strategic plan and all aspects of the implementation of the reproductive health services in Kosovo shall respect all human rights. They shall protect women and children against violence. 2. Reproductive health services shall be acces- sible to all, irrespective of age, gender, ethnic, religious status or other diversities. Reproduc- tive health services shall meet health needs of throughout Life-cycle, including the needs of adolescents. They shall address inequities due to poverty, gender and other factors and ensure equity of access to information and care. 3. All relevant sectors, including non-govern- mental organizations, especially women's, youth and professional organizations, shall be involved through ongoing participatory process in the design, implementation, quality, moni- toring and evaluation of policies and programs, to ensure that sexual and reproductive health information and services meet people's needs and respect their human rights, including their right to access to good quality services. 4. ALL couples and individuals in Kosovo have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, education and means to do so. They shall have the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. 5. Men and women in Kosovo have the right to be informed and to have access to safe, effec- tive, affordable and acceptable methods of fam - ily planning of their choice, as well as other Part of this is being addressed through training initiatives such as the five day crash course run by UNFPA and CARE aimed at sensitizing 1400 health care staff to the potential, and essentials, of reproductive health care. "It was to remind people that there are such things as antenatal care, uterus measurement, post natal care, family planning." notes Brasseur. But this is just the tip of the iceberg. Long term, a.'cultural shift will have to be effected .tlirough professional training and public education - initia- tives in both of which are under develop- ment. Reproductive health is arguably the most acute challenge in the Kosovo "emer- gency" with some very tangible benefits on offer if agencies and local profession- als make progress. But they will need to shoulder change from many quarters. In one hospital during winter, for example, babies and mothers were turning blue- lipped with the cold, while staff refused to use the blankets provided because they have no sheets - a phenomenon perhaps of a very European emergency, where people who are accustomed to better circumstances try to apply their old expectations and standards to entire- ly unfamiliar acute hardship. Hilary Bower Information officer with the WHO Humanitarian Assistan e Office in Kosovo. E-mail: hbower26@hotmail.com methods of their choice for regulation of fertili - ty which are not against the law. 6. Reproductive health services shall be avail- able at, and integrated into, all levels of the Kosovo health care system, especially at prima- ry care level. links should exist with relevant sectors of civil society, including education and social welfare. 7. Reproductive health services shall: ' • reduce maternal and infant mortality and morbidity, • provide adequate high quality care, • ensure effective referral mechanisms across services and levels of care, • provide adequate information, education, prevention and care for reproductive tract diseases, STDs and HIV/AIDS. • prevent violence against women and chil- dren through education, care and legal protection, • ensure informed, voluntary and free contra- ceptive method choice, • respect privacy, confidentially and comfort, • and establish fully functioning information management system. 8. Personnel involved in reproductive health shall undergo appropriate pre-service and in- service training and supervision to fulfil the missions of reproductive health services in Kosovo. 9. An adequate level of funding should be pro- vided through public and/or private sources to ensure of sustainable provision of services. 10. This policy will form the foundation for forthcoming laws and regulations enforcing the reproductive rights of men/women in Kosovo. NO. 46 • SPRING 2000 - PAGE 11 -:;.. flJ dJ :::J I J'~_J!.Cf~ PO LI CY AND PRACTICE ON THE GROU~efiJoductive health in the field Humanitarian work in _the area of sexual and reproductive health is a relatively new and growing movement beckoning for the experience and knowledge of women. This is the voice of one woman who has found herself in the highly political arena of sexual and reproductive health in emergency situations. Q: The new millennium is here. Every- body was, and is, reflecting on last year, the last century and their lives. As a professional working in the area of women's and reproductive health in emergency situations, is there cause for celebration when we look at the past, or do we really need to make some centennial resolutions? A: Well, we need to do both. You don't know where you are going unless you know where you have been. Lets concen- trate on the Balkans. Women's health jump started in the Balkans in 1991. The first comprehensive women's and repro- ductive health initiative in the region was implemented in Romania. The initial catalyst for this programme was pro- pelled by the televised coverage of AIDS babies (1990), revealing the hardships of Romanians, particularly women and chil- dren. After the creation of this aware- ness, the first sustainable democracy building initiatives were started, and along with that came the first reproduc- tive health initiatives. There were approximately ten abortions to every Live birth in Russia during 1991, and abortion was the main means of fer- tility control. Have things changed today? Judging success really requires a specific Look at each of the former Com- munist countries, Looking at where we have been and where we are going. One reason to celebrate, however, is that USD ten million was earmarked for women in Kosovo. This reflects a view that women's health is important, and that skimming the surface is not the way of the future. PAGE 12 - NO. 46 - SPRING 2000 f extreme importance, though, if we are really interested in promoting and pro tecting women's health, including sexual and reproductive health, is the need to begin a dialogue on the effects of pro- natalism on sexual and reproductive • health. Effective policy cannot be creat- ed if this dialogue is unspoken; a goal for the future. Q: Approximately how many non-gov- ernmental organisations are contribut- ing to the field of sexual and reproduc- tive health in the conflict regions of the Balkans? A: There are approximately 285 NGOs in Kosovo and 100 national NGOs. Civil soci- ety is being constructed. Many of the NGOs that are in Kosovo were previously in Albania. During the Kosovo war, Last- ing only 78 days, Albania had approxi- mately 479,000 refugees, the largest number compared to the Former Yugoslav Republic of Macedonia and Montenegro. There were 189 NGOs, of the 189, 34 were coordinated by the coordinating body of UNHCR, of those 34, 12 NGOs were working in the health and sanita- tion sectors, of those 12, 4 were working in Women's and Reproductive Health. [Note: data obtained from UNHCR by interviewer] Q: What are the major areas of repro- ductive health being covered? A: It is difficult to say because govern- mental and non-governmental organiza- tions have different programmes in the areas of safe motherhood, input to sexu- ally-based violence, prevention of STis and AIDS, and family planning. Coordina- tion in an emergency situation is always a major component of effective interven- tions, especially in the area of reproduc- tive health, as it is such a new compo- nent of humanitarian programmes. Q: Major areas being neglected? A: Infusing sexual and reproductive health into health initiatives during emergency situations is a needed step if we are to see reproductive health gain the Legitimacy that it needs. Q: For those NGOs interested in work- ing in the area of sexual and reproduc- tive health in the Balkans, what will be the first obstacle to providing help to the women and girls that need it? A: Pro-natalism. Additionally, since 1991 the Kosvars have not been allowed to go to medical school; and, given the devas- tation of the war upon the populations, finding a core group of Kosovars to take responsibility will be a process. The lives of the women are also unique, both before and after the war. Women often live with their in-Laws, and the mother-in-law dictates the life of the young wife. Additionally, the absence of men from many households has placed added pressures on women. These factors will have to be confronted when initiat- ing any programmes in sexual and repro- ductive health. Q: Also what are the opportunities pre- sented? A: Always, when you are in an emergency there are horrible problems but there are amazing opportunities, it is kaleidoscop- ic. You need to keep your eyes fixed on the open windows and take advantage of the opportunity. The reproductive health consortium (six non-governmental orga- nizations working together, mostly in Africa), has been quite effective in tak- ing advantage of these "windows of opportunity" to influence the lives of women. Of course, the first thing to do will be to provide the basics: water, electricity, san- POLICY AND PRACTICE -=---1l' .. W:flf1i;::.1 J:1~ 1 itation. However, there is a very literate population of women, as in most former Communist countries. This is an incredi- ble advantage. Primary health care should belong to general practitioners, as they are the front line physicians, and a high percent- age of GPs are women in the ex-Commu- nist countries. However, since these GPs are usually women, their political power is not as established as the male medical specialists, the OB/GYNs. It becomes a question of money, and there- fore a complex agenda. Q: Winston Churchill said of the Balkan peoples: "They have more history than they can handle". Today, do you see this long history affecting Balkan women's perceptions of their own reproductive health needs? A: "One for the family and one to replace who the Serbs killed." This is a quote I heard while in Kosovo. Also, I heard a story about a young man. He was the youngest of five boys in a Loving family. The young man fought with the KLA along with his brothers. After returning from the war, he raped his wife, and she became pregnant. The young wife did not want to have a child because of financial reasons, as there was no roof on the house. So, the young women had to get an abortion. By the way, this guy likes his wife. As is the case in many countries in con- flict, the boy child is favoured. Unless the society celebrates the birth of a girl child we have a long way to go. We need one hundred per cent of Kosovo not just fifty per cent to rebuild the basic fabric of society. "Emergency contraception was advertised on the radio and trained personnel distributed it" Q: You would think emergency contra- ception would be ideal to use in an emergency situation. Is this only a coincidence of language? A: If you don't celebrate the girl child you have sexual violence against women, you have AIDS, you have a majority of the problems we have in the world. You have to start working at the grass roots. It takes a great deal of time. The populations are decreasing in Eastern Europe and this has a significant effect on how women's roles are defined. It complicates the egalitarian role we want women to have. It is i . incredibly com- plex issue. ~ ... · By the way, emerge11.e~('tontraception was used in the Kosovo emergency. Emer- gency contraception was advertised on the radio and trained personnel distrib- uted it. Humanitarian agencies also gave out 3-month supplies of pills and condoms. Q: Finally, what phase are we in when we look at the process of fully inte- grating women's health into overall humanitarian responses? A: Women will not have children in a cri · sis situation. That is the end of the story, they just won't. There are both Darwinian and social constructionist theories on the fact that women avoid having children when their lives are in danger. Therefore, something else is going on. How can women have equal say or power in a rela- tionship when their voices are muted by their socially ordained roles? Women's equality is at the root of this issue. Humanitarian agencies were positioned at the starting gate when the whistle blew in this complex emergency called Kosovo, giving reproductive health an opportunity to inculcate the important tenants: safe motherhood, family plan- ning, prevention of gender-based vio- lence and the prevention of STis includ- ing HIV/AIDS, into the overall primary health-care system currently under design. There was no recipe to follow which offered an open window beckoning us to design how to integrate reproduc- tive health and all its tenants into the ' baseline fabric of primary health care. In order for humanitarian agencies to address the sexual and reproductive health needs of a population in crises there has to be a continued effort to realise the broad implications for repro- ductive health upon a society and how women's health needs, including repro- ductive health, when fulfilled, benefit the entire population. Kenneth E. legjns Technical Adviser, IEC Women's and Reproductive Health Programme WHO European Regional Office E-mail: entrenous@who.dk NO. 4 6 - SPRING 2000 - PAGE 13 POLICY AND PRACTICE WOIVIEN~SbitH,§ AL..TH IN ACTICIN .. .. - -capacity- t tng-clirougn count ry leveftratntng- One of the main aims of The Women's and Reproductive health Programme at the WHO Regional Office for Europe is to develop human resources in the Member States by improving service providers' skills, knowledge and techniques in reproductive health and family planning. We believe that greater emphasis must be given to upgrading pre- and in-service training curricula and strategies, as well as better preparing providers to deliver high-quality services from the clients' perspective. Our programme provides trainings as a component of joint UNFPA/WHO projects and regular activities in the different coun- tries of the European region. Trainings on clinical as well as pub- lic health aspects of reproductive health and family planning (modern contraception) including strategies of design, imple- mentation and evaluation of services are the main area covered. Other areas include minority women, adolescent health and vio- lence as a public health issue. Moreover, countries are regularly updated with current information on reproductive health and family planning. Some of the trainings and workshops which were undertaken dur- ing 1999-2000 are listed below: • Strengthening of sn Prevention and Care in Reproductive Health Services, in Tashkent, Uzbekistan, 2-4 June 1999. • IEC workshop, Sarajevo, Bosnia and Herzegovina, September 1999. • Training to prepare medical protocol on all contraceptives, Ashgabat, Turkmenistan, 6-16 September 1999. • Workshop on Family Planning, Reproductive Health and sn Prevention, at the Kazakhstan School of Public Health, Almaty, Kazahstan, 4-8 October 1999. • Workshop on the Role of Paramedical Providers and Coun- selling Skills in Improvement of Family Reproductive Health, in Ashgabat, Turkmenistan, 7-13 October 1999. • Two workshops on Post-Abortion Contraceptives and Counselling, in Dushanbe and in Khodjent, Tajikistan, 12-20 October 1999. PAGE 14 - NO. 46 - SPRING 2000 • Two trainings on Rapid Evaluation Methods, Dushanbe, Tajikistan, 20-30 October 1999. • Training on Rapid Evaluation Methods, Ashgabat, Turkmenistan, 8-20 November 1999. • Workshop on Evaluation and Management -of Reproductive Health/Family Planning Services, Yerevan; .Armenia, 13-18 December 1999. • Workshop on Adolescent Health, RH/FP, Tashkent, Uzbekistan, 8-11 January 2000. • Workshop on Contraceptive Technology and Reproductive Health, Yerevan, Armenia, 16-20 January 2000. Dr Tarek Mahmud Hussain Short Term Professional Women's and Reproductive Health Programme WHO Regional Office for Europe Tel: (+45) 391712 53 E-mail: tmh@who.dk SPOTLIGHT Estonia is a little country in north-east- ern Europe. It is located between Latvia, Russia, Finland and Sweden. Of its 1.4 million inhabitant, about 65% of them are Estonians and the rest are mainly Russians who migrated into Estonia dur- ing the Soviet occupation between 1944 and 1991. Estonia restored its indepen- dence in 1991 and has been an associat- ed member of the European Union since 1995. Estonian Family Planning Association, youth counselling centres The Estonian Family Planning Association (FPA) was founded in 1994 and has been an associated member of IPPF since 1995. Currently, there are 15 youth coun- MEN'S HEALTH selling centres all over Estonia, estab- lished and run by local active members of the FPA. At the start, most of the youth coun- selling centres' clients were young females. Boys rarely attended the clinics, be it alone or together with girls. The main aspects of individual coun- selling are: • Contraception; • Diagnosis and treatment of STis; • Counselling in the case of sexual problems; • Diagnosis and counselling in the case of pregnancy. In addition to individual counselling, all the counselling centres are involved in sexual education for school children. The groups are varied, including boys of all ages, army recruits, children from orphanages, disabled young people, etc. In 1996 special counselling hours for boys started in Pelgulinna Youth Coun- selling Centre in Tallinn, and for a period in Tartu Youth Counselling Centre as well. Boys primarily seek counselling for diag- nosing and treatment of STis, problems concerning the advent of sexual life, pre- mature ejaculation, counselling in the case of sexual problems, doubts ("Am I nor- mal?''), risk factors con- cerning fertility, etc. The rate of incidence of STis is relatively high in Estonia (interesting- ly, there are few diag- nosed cases of HIV infection, only 80 at the end of 1999, see Tables). However, there is good news based on the Nordic-Baltic Mili- tary Recruitments Fer- tility Study (1999). Fer- tility markers were sat- isfactory among Eston- ian participants accord- ing to preliminary results. Leaflet for boys in Estonia Since 1996, the FPA has organised educa- tional courses for the youth counselling centres' workers, one of which was dedi- cated to boys' sexual ~~ucation and counselling (lecturer~-.trom RFSU, the Swedish Family Pta.rmiog Association). During the last three·years the reproduc- tive health of boys and men has been one of the topics of several seminars organised by the FPA for different target groups including school health educators, school health personnel, physicians, etc. Different questions for different age groups: In pre-puberty (7-10 years) • Gender differences; • Sexual anatomy, physiology; • Sexual intercourse. In puberty • Sexual development; • Masturbation; • Sexual identity. In late adolescence: • Contraception; • STis and HIV prevention; • Starting sexual life. New developments In December 1998, Internet and e-mail counselling was initiated by the members of the Family Planning Association who work in Tartu Youth Counselling Centre (www.amor.ee). On the homepage there is basic information about sexuality, STis, contraception, youth counselling centres, etc., both in Estonian and Russ- .ian. There were about 32,000 hits on the homepage from January 1999, to January 2000. It's interesting to note that slight- ly more than half of the questions are from boys, mainly about: • masturbation 30%; • premature ejaculation 20%; • STis 15%; • genitals 10%; • intimate relations 10%; • female orgasm 10%; • other topics 5%. The Family Planning Association pub- lished a leaflet in Estonian and Russian for boys on the following topics: • Male sexuality; • Contraception; • Male sexual anatomy and physiology; • STis, etc. NO. 46 - SPRING 2000 - PAGE 15 ::... JlJ dJ@J .r J~.lfil PO LI CY AND PRACTICE This year, a book about male reproductive health will be published by the FPA. The authors are from the FPA and the book shall be distributed among medical per- sonnel, decision-makers, journalists and educators. Why special programmes for and about boys and men? • We believe that involving more men in family planning issues has a positive impact on father-child relations in the future. We can see positive changes in this respect (that men want to be involved) during the last ten years. For example, until the • The average life expectancy for Eston- ian men is 66. This is ten years below that of women . The suicide rate among males is also very high. • In everyday clinical practice we have better results if we solve problems of sexuality (premature ejaculation, orgasmic problems, etc.) and infertility risk factors as early as possible. The same is true about diagnoses and treatment of STis. Some international data demonstrate that an enjoyable sex life at a younger age determines the person's sexual activity at an older age. beginning of the 1990s men were not allowed Ganarrhaea In Eatania and neighbouring cauntrlea to assist their wives during deliveries, but by now more than half of the babies are born with their fathers present. 250~--------- -------- ~ """" ESTONIA " - LAMA It is also more common that male partners obtain emergency con- traception in the event ••• '• • • •• nNLAND : ........ / ~.~ .:::::: WJ~N . .... ...... ... ······ ........... . ................ ········· .. .. 100 that a condom ruptures, 50 for instance. -------... -----.. .... ·:.::.:.::.:.:~.:.:.."7.:,':.i.:,":..~.=.u.a .. -----. 0 '---- - ---======:===~====="--~'-----' • A better understanding 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 of the changes that boys undergo during puberty enables parents to avoid mis- takes when their children are teenagers. • Better results of (treatment of) repro- ductive health of women if it is possi- ble to also reach men, especially in the Previously, in the case of SRH problems men could only seek advice from urologists, der- mato-venerologists or psychiatrists. Now, fortunately, a new speciality - andrology - is rapidly developing in Estonia dealing with men "from birth to death". Chlamydlaala In Estonia and F inland Men need counselling about sexuality and fertili - ty as much as women, and in the future we will have more possibilities to do that in the era of male contraception, improved erectile dysfunction treat- ment, etc. Hopefully, the need for male sexual and reproductive health coun- selling will be acknowl- edged by society and men themselves will become more ready and willing to seek help. """ '' mDNIA 350 ' ••••••••••• •""•""" " "" •••• nNLAND "··········· ... 300 250 ····--....... // .......... . . --------- ~ 200 --........ .~ --:~-----------········· 150 100 50 0 ..... ~ ............ .. ·· . ' ' ' ' ' ' . 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 case of sexual problems, genital infec- tion, infertility, etc. • Men need (in many cases) to have male counsellors who are able to understand certain problems. • Better awareness throughout society about male sexual and reproductive health (SRH) issues creates an atmos- phere where it becomes natural and easy to meet with a counsellor. Olev Poolamets Urologist-andrologist Board Member of the Estonian Family Planning Association olevpo@cut.ee olevpo@hot.ee PAGE 16 - NO. 46 - SPRING 2000 UN DOCUMENTS Integrating STI Management into Fam- ily Planning Services: What Are the Benefits? (by Karl Dehne and Rachel Snow, WHO 1999) is an Occasional Paper focusing on the increasing global need for better access to quality reproductive health services. The integration of sexu- ally transmitted infect4>ris (STls) and family planning (FP) services is regarded as an important criteria for improving the health of women. Comprehensive RH needs are often not met in family plan- ning clinics. This review, commissioned by WHO, documents current experience with the integration of STI management into FP services, in order to clarify the public health benefit of this integration and highlight the operational changes. Contact World Health Organization Marketing & Dissemination 20 Avenue Appia CH-1211 Geneva 27 Switzerland Providing Behavior Change Among Providers and Communities to Support Safe Motherhood: an Integrated Approach to IEC (Information, Educa- tion and Communication) - A guide for Program Planners (MotherCare 1999, pp 14) is a short document exemplifying the application of a new framework developed by the Department of Repro- ductive Health and Adolescent Health at WHO in collaboration with the WHO pro- grammes of Child and Adolescent Health, Women's Health, HIV/AIDS and Health Systems. The framework was developed to gain a consensus about how to sys- tematically assess the healthiest behav- iours as well as interventions that can promote and support them. The frame- ~ work is in the process of being applied to behaviours associated with maternal and newborn health and will soon be used in behaviours related to family planning and STis. Contact Department of Reproductive Health and Research World Health Organization 20 Avenue Appia CH-1211 Geneva 27 Switzerland Reproductive Health Project Coordina- tors Meeting (WHO 2000, pp 56) was held in Copenhagen at the World Health Organization Regional Office for Europe on 22-24 April 1999. The scope and purpose of the annual meeting was to share experiences regarding project progress encountered in the implementa- tion of reproductive health (RH) projects in countries; to discuss new technical developments in RH; to discuss coopera- tion between institutions; to discuss future steps of project implementation and to make recommendations for improved execution. Contact The WHO Regional Office for Europe Women's and Reproductive Health Scherfigsvej 8 DK-2100 Copenhagen O Denmark The Special Programme of Research, Development and Research Training in Human Reproduction Annual Technical Report (WHO 1999, pp 287) covers all aspects of the programme's work includ- ing fertility regulation, unsafe abortion, maternal health, reproductive tract infec- tions (including cervical cancer) and pro- gramming and integration in reproductive health. The programme also carries out activities to strengthen the capabilities of developing countries to meet their own research needs and to enable them to participated in the global effort in reproductive health research. Contact UNDP/UNFPA/WHP/World Bank Special Programme of Research Development and Research Training in Human Reproduction World Health Organization CH-1211 Geneva 27 Switzerland Pilot Approaches in Adolescent Repro- ductive Health is a report on a WHO meeting held in Lisbon, Portugal, on 8-9 April 1999. Adolescent health involves different professional perspectives and is of high public health importance, partic- ularly reproductive health. More coordi- nated action in this field is required internationally, nationally, subnationally and at other levels of government. This Meeting aimed to build consensus with RESOURCES selected partners in the Member States and WHO partners on action regarding adolescent reproductive health. Partici- pants discussed a strategy for pilot approaches on adolescent reproductive health in the WHO European Region and identified areas of concrete cooperation with WHO and other partners. Contact The WHO Regional Office for Europe Women's and Reproductive Health Scherfigsvej 8 DK-2100 Copenhagen O Denmark ADDITIONAL DOCUMENTS Advancing the Role of Midlevel Providers in Abortion and Postabortion Care. A Global Review and Key Future Actions (Bord et. al., Ipas: Issues in Abortion Care 6, 1999, pp 30) responds to the challenge of decreasing maternal mortality and bringing health services closer to where women live. This docu- ment builds on the recommendations of the World Health Organization regarding skills and responsibilities at the primary level. It reviews the critical components that can enable midlevel providers to improve women's access to abortion or post-abortion care, and offers policy and programmatic examples from seve'ral countries. Contact I pas 300 Market Street, Suite 200 Chapel Hill, NC 27516 USA Fax: (+1) 919 929-0258 E-mail: ipas@ipas.org The Implications of Health Sector Reform for Reproductive Health and Rights (Population Council and Center for Health and Gender Equity 1999, pp 104) is a report of a meeting of the Working Group for Reproductive Health and Family Planning. The meeting's main purpose was to examine what is known about the effects of reproductive health (RH) reforms on access to good quality RH care. Interim conclusions include the fact that reproductive rights and gender equality concerns have not yet become a central part of the health sector reform discou~e, 11or a central focus of implement~tJtftl. Although there is a long case analysis-of Zambia, both the initial overview and the questions for clarification in each section are extremely useful. Contact Center for Health and Gender Equity 6930 carroll avenue, Suite 910 Takoma park, MD 20912 USA Fax: (+1) 301 270 2052 E-mail: rlogan@genderhealth.org Medicine and Law (Yozmot Ltd. and the World Association for Medical Law. Vol. 18 No. 2 & 3, 1999) focuses in this vol- ume on legal and ethical aspects of reproductive and sexual health in Central and Eastern Europe. Edited by Professor Rebecca J. Cook and Professor Bernard M. Dickens, both of the Faculty of Law, University of Toronto, the papers pub- lished consider the present state of reproductive rights in countries of Central and Eastern Europe and address prospects of protecting and promoting such rights, and obstacles to advancement. Human rights perspectives were drawn primarily from legal rights recognised in leading international human rights conventions that countries in Central and Eastern Europe have accepted, by ratification of the conventions, and have undertaken to respect through provisions of their domestic legal systems. A subscription to the publication Medicine and Law cost • USO 160 for four yearly issues. Contact Yozmot Ltd. PO Box 56055 Tel Aviv 1560 Israel Fax: +972 3 528 5397 E-mail: books@yozmot.com www.yozmot.com Migrants: HIV Testing and Counselling A manual for IOM counsellors (Alessio Panza. IOM) provides information on understanding HIV issues commonly needed in daily counselling and guide- lines (accompanied by checklists) for counsellors. The focus is on settings where HIV counselling is mainly addressed to newly diagnosed HIV posi- tive individuals to help them to under- stand and adjust to their new situation. NO. 46 - SPRING 2000 • PAGE 17 dJ J d1 a J J~ .![ffi RESOURCES Contact International Organization for Migration (IOM} 17 route des Morillons CH-1211 Geneva 19 Switzerland Hith e re ! ·· ~ r e , hy 1 • ,_ ,_ , ~ oisovt ,, .... ~ " ) : " -· ' l > -~ ... J ' •• ( .,. .,...-:._•• c.,.- :. ;• ·• *1 - · ...... .. , .... . x~ .. ,. ~ • .·-,~ ,. , ~, "'II. .- ,:: .. • •• • ;• ........ ,. 'I#- .:: ~.' : ,! .. ,...; ... ·~ ...... 1-........ ,..c,- • a;'.:;r: I. I •" :.,,...,,.., .. X-press - The IPPF newsletter for young people (IPPF 1999, pp 6) is a newsletter written by young people, for young peo- ple, about what young people are doing in the field of sexual and reproductive health. X-press functions as a sort of notice board with local news items, invi- tations to youth events or personal opinions about particular issues as well as photographs or pictures about youth projects. They welcome inspiring ideas, articles and news about events. Contact X-press International Planned Parenthood Federation Regents college Inner Circle Regents Park UK-London NWl 4NS E-mail: araphael@ippf.org Slide Presentations Modules in English, French or Spanish on the most current information related to reproductive health, designed for use in seminars, workshops and the training of physicians, nurses and medical students is now online (www.fhi .org/en/ctu/adoltpm/ main.html). The material is used and recommended by world-renowned experts in the field of contraception. Family health International (FHI) is committed to helping women and men have access to safe, effective, acceptable and afford- able family planning methods to ensure that they achieve their desired number and spacing of children; preventing the spread of HIV/AIDS and other sexually transmitted diseases (STDs); and improv- ing the health of women and children. Contact Family Health International P.O. Box 13950 Research Triangle Park, NC 27709 U.S.A. Tel: (+1) 919 544-7040 Fax: (+1) 919 544-7261 www.fhi.org ARTICLES Health Considerations in Rural-Urban Migration (Migration and Health 2/1999) draws on UNFPA reports to discuss, among other subjects, reproductive health in terms of rural to urban migra- tion. Although focusing on causes for migration, the article does mention, for example, that "HIV infections.may be a greater risk for migrants in urban envi- ronments than at their rural origin". IOM can also be contacted for more resources. Contact International Organization for Migration (IOM} 17 route des Morillons CH-1211 Geneva 19 Switzerland Prioritizing Reproductive Health for Refugees (Karen Otsea in Initiatives in Reproductive Health Policy Vol. 3 No. 1 September 1999 Ipas) is a call to action based on the fact that women and chil- dren constitute the majority of the esti- mated 30 million refugees in the world today. It asserts that reproductive health care can save refugee women's Lives and should be given increased importance in emergency refugee assistance efforts. Contact I pas 300 Market Street, Suite 200 Chapel Hill, NC 27516 USA Fax: (+1) 919 929-0258 E-mail: ipas@ipas.org TRAINING Advanced Summer Course on Public Health and Humanitarian Aid (Brussels, 17-28 July 2000) and Optional Course on Computer Publication in Disaster Management (10-14 July 2000) will be organised by the Centre for Research on the Epidemiology of Disasters (CRED). The course fees which include all documentation, software, professor fees (but not travel and lodging) are USO 1500 for the two week course and USO 500 for the computer application module. It is hoped that there will be some fel- lowships for participants from developing countries. Contact CRED Caroline Michellier Tel: (+32) 2 764-3369 E-mail: caroline.michellier@epid.ucl.ac. be PAGE 18 - NO. 46 - SPRING 2000 Institute of Social and Preventive Med- icine of the University of Basel will be offering several interesting courses on health including: measurement of quality of Life in health care and cancer epidemi- ology. Contact Institut secretariat, MPH Institut fiir Sozial- und Praventivmedizin Der Universitat Basel "'· Steinengraven 49, CH-405 t ·Basel Tel: (+61) 267 60 66 . Fax: (+61) 267 61 90 E-mail: sdispm@bs.ch www.unibas.ch/ispmbs The Master of Philosophy in Internation- al Community Health degree at the Uni- versity of Oslo is a full two-year programme with admissions every August. The aim of the programme is to train students in International Community Health research and interventions. Theoretical courses include women's and reproductive health. Contact Master of Philosophy in International Community Health Institute of General Practice and Community Medicine PO Box 1130 Bli ndern N-0318 Oslo Tel: (+47) 22 85 05 50 Fax: (+47) 22 85 06 72 E-mail: k.i.sandberg@samfunnsmed.uio.no g.a.bjune@loks.uio.no Highlights from The Emergency Contraceptive Newsletter (amsocec@aol.com) UNFPA Provides EC to Countries in Crisis Since 1994, UNFPA has provided emer- gency contraception to selected coun- tries in crisis through grants of Postinor 1 and 2 from Gedeon Richter and PC4 from Schering. PC4 is included as part of ' an emergency kit that has been provided Albania and Macedonia among other countries. Other emergency kits contain combined oral contraceptives and IUDs which both could be used as emergency contraceptives if needed. In Albania, the climate is highly favourable to the dissemination of emer- gency contraception, which has recently been explicitly Legalised. EC is now offi- cially part of the national reproductive health programme. However, in general there is not a great demand of EC in cri- sis areas with high rates of reported rape. Often, the time elapsed between the rape and the potential prescription of EC is too Long. EC will only reduce unwanted pregnancies due to rape if women are aware of the treatment, know where it is available, and are able to receive treatment in time. l Contact: Daniel Pierotti UNFPA/ERO 9 Chemin des Anemones Chatelaine 1219 Geneva, Switzerland Tel: {+41) 22 917-8314 Fax: {+41) 22 917-8049 E-mail: unfpaero@undp.org British Pregnancy Advisory Service (BPAS) Provides EC to Women in Advance Following the WHO study that showed emergency contraception was 50% more effective if taken within 12 hours of having unprotected sex, the British Pregnancy Advisory Service (BPAS) launched a program to provide EC to women in advance of need. The pro- gramme, started in July 1999, advises women to call a special hotline number and book an appointment with a physi- cian where she will be advised about emergency contraception. After receiving this consultation, she can obtain EC sup- plies to keep on hand in case of need. The programme has become so popular in some areas that BPAS has set up "walk- in" services so that women do not need to make appointments to receive the counselling and ECP supply in advance. Previously, women were only able to receive emergency contraception by pre- scription after seeing a health profes- sional within three days after unprotect- ed sex. For many women whose physi- cians or clinics do not provide extended hours or are not open over the weekend, the time constraint created a barrier to access. BPAS has a network of 40 clinics around Britain. Contact: Ann Furedi Director of Communications, BPAS Austy Manor, Wootton Wawen Solihull, West Midlands, 895 6BX United Kingdom Tel: {+44) 156-4 79-4935 Fax:{+44) 171-637-1378 E-mail: comm@bpas.demonco.uk Women in Scotland Receive Free EC Kits in Advance The Lothian Primary Care NHS Trust Family Planning and Well Women Service of Scotland has recently begun a programme to provide free emer- gency contraception kits to women in advance of need. In 1997 researchers found that women were more likely to use the method if they had it on hand at home than if they had to go and see a physician to receive a prescription. Since it must be prescribed within 72 hours of unprotected sex, this policy has created barriers to access for women during weekends and holidays when doctors are not available. In total, approximately 85,000 women ages 16 to 29 will be pro- vided with ECPs to take home for use when needed. This programme will con- tinue for two more years and changes in RESOURCES abortion rates will be evaluated at the end. Contact: Anna Glasier Lothian Primary Care, NHS Trust Family Planning and Well Woman Services 18 Dean Terrace Edinburgh, EH4 lNL United Kingdom Tel: {+44) 131 343-6243 Fax:{+44) 131 332-2931 Reducing Nausea Associated With Emergency Contraception Family Health International recently fielded a study to determine if treatment with meclizine would reduce the incidence of nausea and vomiting associated with the Yuzpe regimen of emergency contraception. Women were randomised to receive treatment of 50 mg meclizine one hour before the first ECP dose, Yuzpe treat- ment and placebo or Yuzpe alone. The risk of nausea and vomiting dropped sig- nificantly if women took the Yuzpe regi- men following treatment with meclizine (nausea from 64.2% to 47.2% and vomit- ing from 12.8% to 4.6%). However, meclizine did significantly increase the rate of drowsiness (from 15.6% to 30.6%). The study found no placebo effect. Brand names for meclizine in the US include Bonine and Dramamine II. Contact: Elizabeth Raymond Family Health International PO Box 13950 Research Triangle Park, NC 27709 Tel: {+1) 919 544-7040 Fax. {+1) 208 275-6440 E-mail: eraymond@fhi.or NEWS Bangladesh TV Drama Promotes f'rl;> ~; Integrated Ser- f:r-1 ~ vices Johns Hop- kins University Population Com- munication Ser- vices provided technical assis- tance for the pro- duction of a TV drama which inspired a greater understanding and respect for health workers. A survey revealed that overall health knowledge was significantly related to the number of episodes watched. In fact, married women who saw the drama were 1.6 times more likely to use a modern contraceptive than women who did not watch the show. To learn more about the Green Umbrella Campaign contact: The Bangladesh Center for Communication Programs (bccp@cite- choo.net) or Johns Hopkins University (www.jhuccp.org) CPE Proposes Japan to Host World Population Conference 2004 The Council on Population Education (CPE) urges the Japanese government, parliamen- tarians and the UN to support calls for the next World Population Conference (2004), to be held in Japan. CPE considers this important because Asia is home to two- thirds of the world's population yet there has never been a World Population Confer- ence in Asia. Moreover, the experiences of many Asian countries which have reduced high birth and death ~tes provide useful examples for others t!Rt are taking the path towards demogrcfpfiic transition. For more information visit JOICFP's web site at http://www.bekkoame.ne.jp/i/joicfp HIV/ AIDS in the Baltic Sea Region A meeting on HIV/AIDS in the Baltic Sea Region was convened on 7-8 December 1999 in Helsinki, Finland, to facilitate a common understanding of the dynamics of the HIV epidemic in the region, assess the capacity to respond as well as improve communication and coordination among the different partners. UNAIDS will play a key role coordinating information exchange and support at the regional and global lev- els. It is hoped that in addition to combat- ing HIV/AIDS, the "Northern Dimension" coordination will give a new boost to pub- lic health issues in the region. For more information see www.unaids.org. Women Want More Contraceptive Choices Two out of three contraceptive pill users in the US, Europe and Japan reported in a sur- vey carried out in 1999 of 2,500 women that they do not like having to take the pill every day. Statistics compiled by the Alan Guttmacher Institute show that use of the diaphragm and the intrauterine device fell to all-time lows between 1988 and 1995. As women age and, presumably, move into monogamous relationships, use of condoms and the pil\ falls. But the need for family planning continues. Andrew Kaunitz, pro- fessor of obstetrics and gynaecology at the University of Florida Health Science Center, ' was lead investigator in a recent study of Lunelle, the newest drug on the contracep- tive horizon. Lunelle is an injectable con- traceptive that contains both oestrogen and progestin. It is similar to Depo Provera, the other hormonal birth control injection, which has been available since 1992. Lunelle,however, has fewer side effects and permits a quicker return to fertility when a woman stops using it. Lunelle, now being considered by the 4s Food and Drug Admin- istration for approval, is expected to be available to American consumers by the end of this year. NO. 46 - SPRING 2000 - PAGE 19 Gender and Emergencies, Department for International Development, Great Britain (DFID) http://ourworld.compuserve.com/ home- pages/guytempler/ This is a preliminary web site to be incor- porated into an overall DFIO emergency site and is for the use of programmers in need assessment and implementation tools, practices and background docu- mentation on gender and disasters. As the authors state, "Disasters not only bring a sharper focus to existing gender divisions and inequalities, but also open up possibilities of change, for better or worse. If aid interventions are not aware of basic gender differences and only meet men's or women's needs, they have failed. Equally important, crises them- selves change gender identities and gen- der roles." Relief Web http://wwwnotes.reliefweb.int/ The definitive source of press releases, up-to-date migration maps and NGO activities in the field of international humanitarian work. Often saturated with information (some old), but easily reme- died by a careful search. An interesting press release by UNFPA alludes to the type of information obtainable to the careful reader, "Or. Sjedullah Hoxha, head of obstetrics and gynaecology at Pristi- na's main hospital, shakes his head and Laughs. He tells us he's had many visits from humanitarian workers to his clinic, they always promise to send equipment but it never seems to arrive. He says goodbye, hurries back inside and starts climbing the five flights of stairs up to the wards". THE UNITED NATIONS The United Nations High Commission on Refugees (UNHCR) acts as the coordinating UN agency during refugee crises, http://www. unhcr.ch/ . UNHCR has a select bibliography of academic, applied and governmental publications regarding women in refugee crises, http://www. unhcr.ch/ refworld/ refbjb/biblio/needs.htm. Other UN agencies involved in reproductive health are: UNICEF http://www.unicef.org UNFPA http://www.unfoa.org WHO http://www.who.ch THE NON-GOVERNMENTAL SECTOR Non-Governmental agencies play a key role in the implementation of programs. Some of the main contributors to Repro- ductive Health are: Reproductive Health for Refugee Consortium www.RHRC.org This site is an excellent resource. The Consortium has created a website with access to tools, publications and research for programmers. Four members - Ameri- can Refugee Committee (ARC), CARE, International Red Cross (IRC) and Mary Stopes International (MSI) - focus specif- ically on the provision of reproductive health services to refugees. JSI R&T and Columbia University are primarily involved in project research, staff train- ing and technical assistance. The Women's Commission, an expert resource and advocacy organization, plays a coor- dinating role for the Consortium; it also provides technical assistance to three Local nongovernmental organizations (NGOs) that are providing refugee repro- ductive health services. International Committee of the Red Cross http://www.icrc.org/ Doctors Without Borders (Medicines Sans Frontiers) http: //www.msf.org / Relief International http://www.ri .org /opening.htm CARE http: //www.care.org / www.fhi .org/en /ctu /adoltom /main.html Reproductive Health of Young Adults Training Presentation Module: Contracep- tion, Pregnancy and Sexually Transmitted Infections A training module on reproductive health issues affecting young adults has been produced by Family Health International (FHI) in collaboration with the FOCUS on Young Adults Project It is designed for use in seminars, workshops and other training events for physicians, nurses and medical students. The Web version includes 83 colour slides, a narrative, a summary fact sheet, nqte-taking pages, and a questionnaire to_f,e-completed after viewing the pres~ntation on the Web. "Reproductive Health of Young Adults" is part of FHI's training presentation series on contraceptive technology and repro- ductive health. Ten additional training modules are also available in English, French and Spanish. For more informa- tion on the series, including a List of top- ics covered, and to order, go to: http://www.fhi.org/en/ctu/ ctu.html or contact Ms. Carol Smith, FHI, PO Box 13950, Research Triangle Park, NC 27709, USA (csmith@fhi.org) . WOMEN'S VOICES t:,tt»://www.peacenetorg/balkans/jndex3.htmt Peace Net has Links to other sites which aim to support women who have been through the Balkan Crises and other humanitarian crises. (See Human Rights Watch for more information about women and violence: http: //www.hrw.org / hrw/worldreoort99/e urope/ ). Contributors to this site include Balkan women support groups around the world, women aid groups, films about women and violence, Yugoslav writers and other cultural dimensions of international women's experiences. World Council of Muslim Women • http: //www.connect.ab.ca/-Lfahlman/wc omwf.htm A non-profit organisation dedicated as a Living memorial to the women of Bosnia and other women who have suffered the degradation of rape, torture and death. Muslim Women's Homepage http: //www.jan na h .org /sisters/ "I hope the information here will pique your interest and help you to understand the true stance Islam takes on gender issues and the role of women." Compiled by Kenneth E. Legins Technical Adviser, IEC Women's and Reproductive Health Programme WHO Regional Office for Europe