THE EUROPEAN MAGAZINE FOR SEXUAL AND REPRODUCTIVE HEALTH No.79 - 2013 CHoICES AND PLANNING 2Dr Assia Brandrup- Lukanow Senior Adviser, Danish Center for Health Research and Development Faculty of Life Sciences Ms Vicky Claeys Regional Director, International Planned Parenthood Federation European Network Dr Mihai Horga Senior Advisor, East European Institute for Reproductive Health, Romania THE EntrE nous EDIToRIAL ADvISoRy BoARD Dr Evert Ketting Senior Research Fellow, Radboud University Nijmegen Department of Public Health, Netherlands Dr Manjula Lusti- Narasimhan Scientist, Director’s office HIv and Sexual and Reproductive Health Department of Reproductive Health and Research WHo headquarters, Geneva, Switzerland Prof Ruta Nadisauskiene Head, Department of obstetrics and Gynaecology Lithuanian University of Health Sciences, Kaunas, Lithuania Dr Rita Columbia Reproductive Health Advisor UNFPA Regional office for Eastern Europe and Central Asia CoNTENTS The European Magazine for Sexual and Reproductive Health Entre Nous is published by: Division of Noncommunicable Diseases and Health Promotion Sexual and Reproductive Health (incl. Maternal and newborn health) WHo Regional office for Europe UN City Marmorvej 51 DK-2100 Copenhagen Ø Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 www.euro.who.int/entrenous Chief editor Dr Gunta Lazdane Editor Dr Lisa Avery Editorial assistant Jane Persson Layout Kailow Creative, Denmark. www.kailow.dk Print Kailow Graphic Entre nous is funded by the United Nations Population Fund (UNFPA), Regional office for Eastern Europe and Central Asia, with the assistance of the World Health organization Regional office for Europe, Copenhagen, Denmark. Present distribution figures stand at: 2000 English, 2000 Spanish and 1000 Russian. Entre Nous is produced in: Russian by the WHo Regional office for Europe Rigas, RGH Baltic, Rounborg Grafiske Hus; Spanish by the Instituto de la Mujer, Ministerio de Sanidad, Servicios Sociales e Igualdad, Condesa de venadito, 34, 28027 Madrid, Spain. The Spanish issues are distributed directly through UNFPA repre sentatives and WHo regional offices to Spanish speaking countries in South America. Material from Entre nous may be freely translated into any national language and reprinted in journals, magazines and news- papers or placed on the web 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 the signed articles. For information on WHo-supported activi- ties and WHo documents, please contact Dr Gunta Lazdane, Division of Noncom- municable Diseases and Health Promotion, Sexual and Reproductive Health at the address above. Please order WHo publications directly from the WHo sales agent in each country or from Marketing and Dissemination, WHo, CH-1211, Geneva 27, Switzerland ISSN: 1014-8485 © World Health Organization 2013 Advancing contraceptive choice By Marleen temmerman 3 Family planning programmes: past, present and future By Catherine d’Arcangues 4 Differences in use of family planning in the European Region By Gunta Lazdane 6 Emergency contraception in Europe: equal access for all? By Cristina Puig and Jamie Bass 10 Identifying and overcoming barriers that adolescents in low and middle income countries face in obtaining and using contraception By Venkatraman Chandra-Mouli, Donna r. McCarraher and nancy E. Williamson 12 Impact of the Medical Eligibility Criteria for Contraceptive Use (MEC) Wheel on the quality of family planning: experiences from select countries 14 Multipurpose prevention technologies By Manjula Lusti-narasimhan, Mario Merialdi and Bethany Young Holt 18 The Barometer of Women’s Access to Modern Contraceptive Choice in 10 European Union (EU) Countries By Irene Donadio 20 Key factors influencing contraceptive use: experience from 7 eastern European and central Asian countries By Lena Luyckfasseel 22 Unmet need for family planning of people living with HIV in Europe: a neglected public health issue By Moazzam Ali and Marleen temmerman 24 Resources By Lisa Avery 26 ,, 3 No.79 - 2013 ADvANCING CoNTRACEPTIvE CHoICE Ensuring that family planning programmes are centred on rights is essential: the ability to plan for one’s self, if and when, to have children is fundamental to the health of women and their families (1). However, unintended pregnancy, resulting from unmet need for contraception, continues to threaten the lives and well-being of women, girls and their families globally. The latest estimates are that 222 million women who are married or in union, have an unmet need for modern contraception and the need is greatest where the risks of maternal mortality are highest (2). In the least de- veloped countries, 6 out of 10 individuals who do not want to get pregnant, or who want to delay the next pregnancy, are not using any modern method of contracep- tion (2). Unmet need for contraception is highest among the most vulnerable elements in society: adolescents, the poor, those living in rural areas and urban slums, people living with HIV and inter- nally displaced people. The World Health Organization, Department of Reproductive Health and Research (WHO RHR), is collaborating with partners to accelerate access to high quality contraceptive information and services for all individuals. Multiple strat- egies and rapid scale up will be essential to reducing unmet need. Strengthening health system infrastructures to minimize stockouts and ensure a comprehensive method mix that enables choice, training providers in counseling and provision of long acting and permanent methods of contraception, ensuring that policy and programmes adequately support adoles- cents unique needs and research into new contraceptive methods are all needed. At the same time, it remains critical that commitment to the rights based approach to family planning articulated in Cairo at the International Conference on Population and Development (ICPD) in 1994 is not compromised by the requirement to scale up rapidly. The 1994 ICPD articulated a clear vision about the relationships between population, development and individual well- being. The ICPD Programme of Action was remarkable in its recognition that reproductive health and rights, as well as women’s empowerment and gender equality, are cornerstones of population and development programmes. The years since the ICPD have seen a large amount of conceptual work produced demanding and defining a rights-based approach to health services including family planning. The “Every Woman, Every Child” initia- tive based on the United Nation Secretary General’s global strategy for maternal and child health and the subsequent creation of the Commission for Information and Accountability, further emphasized the importance of rights in improving health of women and children. Yet there is com- paratively little practical guidance on how to implement rights based approaches from a programme design and manage- ment perspective. Over the last year, the WHO RHR has been working to address this gap through development of a body of work to ensure accountability in reproductive health programmes. Accountability is central to ensuring that both human rights and health standards are respected, protected and fulfilled. Monitoring and evalua- tion can contribute to accountability by providing information on progress on the fulfillment of right to health obliga- tions. However, despite an international commitment to public health policies and programmes that are based on human rights and rights principles, indicators for monitoring rights in health programmes have not been widely implemented. While human rights indicators have been used to monitor some specific issues related to health, and health indicators have been used to draw attention to some rights issues, a systematic, transparent system is needed for explicitly linking human rights and health concerns and then determining their combined impact on the effectiveness and outcomes of health policies and programmes (3). An urgent need for indicators at the intersection of health and human rights exists. It is clear that to comprehensively monitor rights, a combination of policy, qualitative and quantitative indicators are needed. Furthermore, these indicators must have an explicit linkage to hu- man rights standards that are grounded in international law. A WHO advisory group has developed a methodology for identifying and prioritizing existing health indicators for use in rights analyses and has extrapolated key human rights standards for monitoring. This informa- tion is forthcoming. Identification of areas where new indicators are needed, particularly to capture the experience of marginalized individuals, has been an essential component of this work. Over the next year, the WHO RHR will lead in developing new indicators to compre- hensively monitor rights in reproductive health programmes. Advancing the right to health is central to the WHO’s mandate and choice with respect to contraception information and services is an integral component. Reproductive and sexual health informa- tion and services are essential to well- being and the attainment of individual rights. In collaboration with partners, the WHO is leading technical work to promote our collective accountability as a global community in fulfilling equitable access to information and services for all individuals. Marleen Temmerman, MD, PhD, Director, Dept. of Reproductive Health and Research, WHo headquarters, Geneva, temmermanm@who.int References 1. Dehlendorf C, Rodriques MI, Levy K et al. Disparities in family plan- ning. Am J Obstet Gynecol. 2010; 202(3):214-20. 2. Singh JD, Darroch JE. Adding it up: the costs and benefits of investing in family planning and newborn and maternal health. Estimates for 2012. New York: Guttmacher Institute and UNFPA, 2012. 3. Gruskin S, Ferguson L. Using Indica- tors to determine the contribution of human rights to public health efforts. Bull World Health Organ. 2009;87(9):714-9. Marleen Temmerman 4 FAMILy PLANNING PRoGRAMMES: PAST, PRESENT AND FUTURE It is now 50 years since modern con-traception became available and the first national family planning (FP) programmes were launched. With half a century of experience behind us, what have we learned? The most important lesson is that there is no longer any doubt that FP improves the lives of women and children; it im- proves the health of mothers by decreas- ing the numbers of high-risk pregnancies (too early in life, too close, too late in life) and the numbers of unsafe abortions; and it improves the health of children, as spacing births benefits the health of the newborn as well as that of his/her older sibling. Additionally, with enough accumu- lated experience and evaluation, one can safely say that FP brings significant socio-economic benefits as well. The best evidence for this comes from the Matlab programme in Bangladesh. There, starting in 1977, a densely populated rural area of 173 000 population was divided into a control and an intervention area. The control area received regular FP services, while the intervention area received a wide choice of contraceptives, free services and supplies, home visits by FP workers, regular follow-up, multime- dia communication, menstrual regulation services, outreach to husbands and reli- gious and other leaders. Several decades later, this experience shows that in the intervention area, there was greater work- force participation of women, greater education of their children, greater asset accumulation and greater use of preven- tive health services (1). The other lesson from the Matlab experience is that, to reap the benefits of FP, services need to be comprehensive and to meet the needs of their populations. Indeed, worldwide, over time one has wit- nessed a number of trends in the design of FP programmes, such as: Target population: Whereas early on, programmes catered for married women after they had had their first child, it became clear that pregnancies to mothers who were too young for childbearing were risky, that in many countries social norms were changing with regard to mar- riage, and most importantly, that access to FP was acknowledged as a human right to be guaranteed to all individuals, regard- less of age or status. Thus, increasingly, programmes diversified their approaches in order to serve nulliparous women and adolescents and focused their atten- tion on previously neglected popula- tions; these included populations who, too often, do not have access to health services such as the poor, migrants or refugees and also stigmatized groups such as HIV-positive women. Services: In the mid-1970s, it was esti- mated that the world population had reached 4 billion and governments were alarmed to see that its rate of growth was increasing. In response, some of the large national programmes launched in the last decades of the 20th century had clear population goals. They set targets of contraceptive use aimed at decreasing population growth rather than improving women’s health. This abuse of technol- ogy was exposed at the International Conference on Population and Develop- ment in 1994. In fact, history showed that coercion was very often counter- productive and that it was not needed. Where women have free access to family planning usage is high. However, if con- traception is to be delivered for the bene- fit of women, it should be provided as one element of women’s health. Sexually active women need access to sexual health counseling and care; to sexually transmit- ted infections (STI) services including those for HIV/AIDS and for cervical cancer screening; to pregnancy termina- tion where it is legal and to post-abortion care; and those who have undergone female genital mutilation need counseling and care. In other words, contraception should not be a stand-alone service but it needs to be delivered within a holistic approach to women’s health. Contraceptive methods: Before the 1960s, contraceptive methods available included: diaphragms and condoms, traditional methods and early forms of intrauterine devices (IUDs). The 1960s saw the de- velopment of combined pills, injectables and copper IUDs, soon to be followed by implants and emergency contraceptive pills. Women’s contraceptive needs vary according to their life stages, the society and religion they belong to, their social situation and other factors, so these devel- opments allowed them to find methods that suited them better. Indeed, evidence shows that offering a choice of method leads to greater use of contraception (2). In the late 1990s, new and improved methods were released on the market, namely: the combined patch and the combined vaginal ring, the levon orge- strel-releasing IUD, a new combined in- jectable and new generations of low-dose pills. For a variety of reasons, cost in most cases, many of these methods are not available in public sector FP programmes and remain out of reach of many women. Other needs of couples remain unmet, such as reversible methods for men. For example, other than condoms, multi-purpose technologies offering dual protection against pregnancy and STI/ HIV, or pericoital methods, still represent a gap. Thus, there is still a great need for innovation for the development of diverse low-cost methods. Settings: Early on, FP was dispensed in hospitals, dedicated clinics, or physicians’ offices. Mobile clinics were set up to serve the more geographically dispersed rural populations. With time, programmes became aware of the need to develop a greater variety of delivery options to reach different segments of the popula- tion and accommodate their lifestyles. This has meant extending community- based distribution and provision at the doorstep, allowing pharmacies to provide contraceptives and making some methods available over-the-counter. It was also recognized that, too often, contraception was not made available to women coming to services for other reasons. To avoid missing these opportunities, an increas- ing number of countries are integrating FP with other services (i.e. antenatal care, No.73 - 2011 5 9 3 Catherine d’Arcangues postpartum care, HIV/AIDS services and immunization). Providers: Numerous studies in different settings have proven that midwives and nurse-midwives are equally competent, if not better than physicians, in providing counseling and services including IUD and implant insertions. However, many countries suffer from a severe shortage of such qualified health personnel. It is also the case that contraceptives have been extensively tested and are among the safest medications. Thus, increasingly, programmes are turning to community health workers to deliver contraception. Traditionally, they provided counseling, pills and condoms; it is now well accepted that, with training and supervision, they can safely administer injectables as well. The Ethiopian programme has even trained 15 000 rural community health extension workers (CHEWs) to insert implantable contraceptives, while leaving implant removal to services with higher- level personnel. To ensure that FP practices rely on the best, most up-to-date evidence, at all levels of FP programmes, interna- tional guidelines were harmonized and developed for the various levels of service delivery and they are updated continu- ously (3, 4). Finally, evidence shows that there are still serious misconceptions and misinformation around contraception and that an important cadre of specialists needed by FP programmes are behaviour change and communication specialists, as well as, multi-media specialists so that different communication channels can be used to inform couples. Management: Large national FP pro- grammes of developing countries were set up with the assistance of multilateral and bilateral donors. While this was welcome, it created challenges in donor coordina- tion and supply management. Over time, countries are putting in place: health information systems so that the manage- ment and distribution of commodities is demand-driven rather than supply- driven; quality control mechanisms to en- sure that products are safe to use at their delivery point; and monitoring systems to ensure a continuous supply with minimal stockouts. Several countries are taking similar measures to regulate provision of FP by the private sector. Financing: The world population has now exceeded 7 billion and the demand for contraception keeps expanding. Not only do more women manage to access FP programmes, but each year, new cohorts of young people join them with their own needs. Large national FP pro- grammes were set up with a mix of public and private financial support and, in some cases, great dependence on interna- tional funding. Over time, international funds became diverted to other priori- ties and public sector programmes had to sharpen their policies and financing mechanisms. Some focus on serving the poorer segments of population through subsidized services, developing social marketing programmes for the less poor and leaving those who can afford it to be served by the private sector. Increas- ingly, countries reserve a line in their own budget for FP and seek creative ways to finance the needs of their population. Governance: As mentioned above, FP programmes were set up at a time of great concern over excessive population growth. In many countries, the objective of population control dominated health goals to the extent that FP programmes were set up independently from the Ministry of Health and given ministe- rial status. The remarkable uptake of contraception that followed, on one hand, and the demand by women for attention to their own health, on the other, have led countries to modify their approach. The great majority signed the WHO’s reproductive health strategy (5) which re- affirms family planning as a human right. To meet this commitment, countries need to put in place policies that fully support reproductive rights, which ensure fully informed consent and that respect the decisions of clients with respect to timing and use of contraception. They need to give greater attention to equity in access to information and care and to put in place accountability mechanisms. In summary, FP programmes have evolved considerably since they were cre- ated. They can claim remarkable achieve- ments and yet, in some countries, up to 40% of women of reproductive age, mar- ried or in union, still express an unmet need for family planning. Groups most underserved globally include adolescents, migrants, urban slum dwellers, refugees and women in the postpartum period. Clearly, FP programmes need to monitor the situation of the populations they serve regularly and continue to adapt to the needs of growing numbers of individuals and couples worldwide. Catherine d’Arcangues, MD, PhD, Independent consultant, darcangues@gmail.com References 1. Bongaarts J, Cleland J, Townsend JW et al. Family planning programs for the 21st century. Rationale and design. New York: The Population Council, 2011. 2. Jain AK. Fertility reduction and the quality of family planning services. Studies in Family Planning 1989; 20 (1):1-16. 3. Planning: A Global Handbook for Pro viders (2011 update). Baltimore and Geneva: CCP and WHO, 2011. 4. A guide to family planning for commu nity health workers and their clients. Geneva: WHO, 2012. 5. Reproductive health strategy to accele rate progress towards the attainment of international development goals and targets. Global strategy adopted by the 57th World Health Assembly. Geneva: WHO, 2004. 6HBSC REGION BOYS GIRLS Czech Republic no data no data Denmark no data no data Greenland no data no data Russian Federation no data no data Turkey no data no data United States no data no data Belgium (French) no data no data Estonia 91% 89% Luxembourg 90% 84% Greece 87% 86% France 90% 82% Slovenia 85% 82% Spain 81% 85% Croatia 83% 81% Switzerland 84% 80% Portugal 80% 84% Austria 86% 77% Poland 78% 83% Wales 83% 78% Lithuania 77% 84% Ukraine 82% 79% Latvia 77% 84% Germany 84% 75% Italy 78% 78% Hungary 79% 74% Slovakia 77% 76% TFyRM* 76% - Armenia 76% - Netherlands 75% 75% Canada 75% 74% Belgium (Flemish) 79% 69% England 74% 73% Ireland 70% 77% Scotland 72% 70% Romania 79% 61% Finland 76% 63% Norway 75% 63% Iceland 71% 64% Sweden 69% 58% No data for Belgium (French), Czech Republic, Denmark, Greenland, Russian Federation, Turkey or United States. Data not presented for girls in Armenia or TFYRM* as there were too few cases. * the former Yugoslav republic of Macedonia Table 1. 15 year–olds who used a condom at last intercourse (5).What can be done and what should be done to live healthier and better? This question is asked by many: parents when their children are born; adults, usually when they or those close to them are sick; and very often by public health experts at public health discussions and health systems meetings. Background In the WHO European Region health indicators, including those of sexual and reproductive health (SRH) and family planning (FP), have improved during the last decades. However, there are widespread health inequalities between countries and within societies. The economic crisis that started in 2007 has contributed to major challenges leading to increasing unemployment and the number of people living in poverty. The search for employment has meant that many individuals need to live and work outside their countries of origin, which has lead to increased migration and a mix of differing levels of health literacy and SRH values all over Europe. These and many other factors influen- cing a healthy life are addressed in the new European health policy “Health 2020: A European policy framework supporting action across government and society for health and wellbeing” approved by all European Member States in 2012 (1). “Improving health for all and reducing health inequalities” is one of the stra- tegic objectives of this policy and calls all countries to analyze, across the life course, the complex factors contributing to health and well-being, including SRH. The impact of health-related behaviours, such as tobacco and alcohol use, diet and physical activity, has recently been on the agenda of high-level meetings in the Region. Yet, even in 2013, the year when many countries and regions are evalua- ting achievement of the goals set by the International Conference on Population and Development in Cairo in 1994, FP is still on the “waiting list” as an agenda in the WHO European Region. While, seve- ral countries have prioritized access to information and quality FP services in the bilateral collaboration agreements with the WHO Regional Office for Europe, because FP is not among the direct causes of the loss of disability-adjusted life-years it remains thought of as less of a priority issue for the majority of countries in the Region. As a result, despite its direct link to improved SRH, including maternal and child health, FP data from many countries is lacking and data on contra- ceptive prevalence in most countries of the Region are not available (2). Main data sources What do we know about access to FP and contraceptive prevalence in the Region? The best data sources to answer this ques- tion come from the Demographic Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) that have been carried out in the Region in the 21st cen- tury and have included questions on FP and reproductive health. To date, of the 203 DHS carried out globally, 10 coun- tries of the WHO European Region have been involved. In addition, in many of the eastern and central European countries where MICS have been performed, an increasing number of countries are also including data from the Roma communi- ties (3, 4). While these surveys are our most reliable data source on contracep- tion and FP, it is important to realize that questions related to SRH and FP vary from country to country and are often adapted to cultural traditions. This article attempts to present the most recent available data on the subject. DHS data from the 1990’s have not been included since it is felt that these data no longer reflect the current situation as much has changed over the last decade. Data from the 2006 MICS in Turkmeni- stan is restricted and thus, not available, and data from the Republic of Moldova, Ukraine (both MICS) and Kyrgyzstan and Tajikistan (both DHS) where surveys are ongoing are not yet available. Gender Information from more than 30 coun- tries on 15-year-olds who used condoms or pills at their last intercourse has been well documented and analyzed (5). Data show large gender differences in rates of DIFFERENCES IN USE oF FAMILy PLANNING IN THE EURoPEAN REGIoN No.79 - 2013 7 Table 2. Current use of any modern method of contraception by place of residence, percent of women age 15-49, country and year of study (3, 4). * tFYrM = the former Yugoslav republic of Macedonia ** BiH = Bosnia and Herzegovina condom and pill use among adolescents (see Table 1). The prevalence of condom use was significantly higher among boys in one third of the survey countries, but in some countries (Ireland, Latvia, Lithu- ania, Poland, Portugal and Spain) girls report higher condom use. This difference may be related to access to information and condoms or having a partner from a different age group. Some countries, for example Germany, regularly carry out surveys on youth sexuality and can moni- tor the trends, as well as, factors influenc- ing contraceptive use. In Germany, the difference between girls and boys who have not used contraception or have used “unsafe methods” during their recent sexual intercourse has decreased since 1980, when the first survey was carried out, from 14% of girls in 1980 to 3% in 2009 and from 19% to 4% of boys (6). These gender differences can also be seen in older age groups. Data from the 2007 DHS in Ukraine revealed that use of con- doms at first sexual intercourse among men and women aged 15-49 was very similar (50.1% versus 45.4%) (3). This is in contrast to data from the 2008-2009 DHS in Albania which found that 19.3% of women aged 15-49 had used a condom at last sexual intercourse, compared to 49.7% of men (3). Data on gender differences and FP remain difficult to capture, even from the DHS and MICS. For example, in some countries questions on FP are asked to both women and men aged 15-49, but in others FP questions are asked only to women. While DHS data from select countries (Albania 2008-9; Ukraine 2007; Azerbaijan 2006; Armenia 2005) do include information of having ever used contraception among women and men, men were asked only about use of male- oriented contraceptive methods, making it difficult to interpret or comment on male involvement in FP issues within re- lationships and to completely understand and/or analyze the gender role in FP (3). The role of men in FP cannot be neglected, especially as there is strong evidence that male involvement increases uptake and use of FP. Fortunately, in the most recent DHS in Armenia (2010) there is a chapter on men’s attitude toward FP. This chapter highlights the important role men have to play; 73% of men age 15-49 disagreed with the statement “Contracep- tion is a woman’s business” (3). Increas- ing male involvement was also found in the 2007 DHS from Ukraine where 93 percent of currently married women aged 15-49 reported that their husband knew about their use of contraception (3). Increasingly national reproductive health surveys (Ireland 2006; Latvia 2011; Germany 2011) are recognizing the importance of including both men and women in their surveys targeting SRH and FP and the inclusion of both sexes in the surveys reveal important similarities and differences among males and females when analyzed. Place of residence Analysis of the place of residence of cur- rent users of modern, effective methods of contraception is important for further development of the health systems ap- proach to ensure access to information and modern contraceptives to those in need. In most countries where Repro- ductive Health Surveys (RHS), DHS and MICS have been carried out recently the difference of use of modern contracep- tion in rural and urban settings is small with some exceptions (see Table 2). In fact, analysis of the trends in FP use in countries where surveys have been carried out more than once over the past 10-15 years illustrates where FP programs have targeted activities at the country level to attempt to decrease inequities that may have been present between rural and ur- ban populations. For example, in Albania the percentage of modern contraceptive users remains small, but has increased in rural areas from 5.5% to 9.6% from 2002 to 2008-9, compared to urban set- tings which demonstrated only marginal changes – 11.3% versus 11.9- during the same time period (3). Interestingly, in Turkmenistan and Uzbekistan modern contraception use is higher in rural than in urban regions. The same is also true of Uzbekistan where data from 2005 showed the unmet need Gunta Lazdane 8Country/year of survey Primary or less Higher Albania 2008/2009 8.6 17.5 Albania 2002 5.8 17.2 Armenia 2010 21.4 39.1 Armenia 2005 11.1 28.9 Azerbaijan 2006 12.7 24.5 Belarus 2012 46.3 55.2 BIH* 2011/2012 6 25.3 TFyRM** 2011 7.9 21.2 Georgia 2005 18.2 34.1 Kazakhstan 2010/2011 44.7 51.5 Kyrgyzstan 2006 40 48.1 Montenegro 2005 10.9 20.4 Republic of Moldova 2005 38.3 50.9 Romania 2004 21 54.5 Serbia 2010 10.2 32.9 Tajikistan 2005 15.8 46.3 Turkey 2008 35.3 55.3 Turkey 2003 29.9 52.2 Turkmenistan 2000 52.6 53.1 Ukraine 2007 43.2 50.3 Uzbekistan 2005 54.8 57.1 Uzbekistan 2002 58.7 61.5 Country/year of survey Lowest Highest Albania 2008/2009 10.5 14.2 Albania 2002 6.2 17.8 Armenia 2010 21.4 37.7 Armenia 2005 12.4 28.6 Azerbaijan 2006 11.1 20.9 Belarus 2012 43.8 56.5 BIH* 2011/2012 7 12 TFyRM** 2011 7.5 18.5 Georgia 2005 10.5 31.1 Kazakhstan 2010/2011 44.6 55 Kyrgyzstan 2006 47.3 48.5 Montenegro 2005 7.5 22.8 Republic of Moldova 2005 36.6 51.3 Romania 2004 22.8 48.5 Serbia 2010 10.5 31.1 Tajikistan 2005 25.9 39 Turkey 2008 38 54.3 Ukraine 2007 36 52.7 Uzbekistan 2005 60.9 56 Uzbekistan 2002 60.7 62 * BiH = Bosnia and Herzegovina ** t FYrM = the former Yugoslav republic of Macedonia Table 3. Current use of any modern method of contracep- tion by education, percent of women age 15-49, country and year of study (3, 4). Table 4. Current use of any modern method of contracep- tion by wealth quintile, percent of women age 15-49, country and year of study (3, 4). for contraception was higher in the urban population (3). Education The link between education and contra- ceptive use has also been well docu- mented, with populations who have lower levels of education often having a lower propensity to use contraception. Table 3 presents the difference in current use of modern contraception by educational status across the differ- ent countries in the Region. Significant variation is present. The largest difference is seen in Tajikistan where only 13.9% of women with primary or less education currently use modern contraception com- pared to 50.7% of women with higher education - a difference of 35% (3). The smallest difference is seen in Turk- menistan where 52.6% of women with primary or lower education use modern contraception, compared to 53.1% of women with higher education – a gap of less than 1% (3). Wealth In both the DHS and MICS one can find information on use of contraception in different groups by wealth quintile. Data summarized in Table 4 present the relationship between finances and FP in different countries of the Region. House- hold income greatly impacts the use of modern contraception in Armenia, Geor- gia, Republic of Moldova, Montenegro, Romania, Serbia, Turkey and Ukraine, where the difference between the lowest and highest wealth quintile for use of contraception is 15% and greater (3, 4). In some countries (Albania, Bosnia and Herzegovina and Kyrgyzstan) the differ- ence is very low (3, 4). The relationship between wealth and FP is complex and requires more detailed study as the access to contraceptives in the European Region differs country from country – from free of charge contraception to a client provided by aid development partners (mainly UNFPA), too reimbursement of contraception by insurance, to free of charge for special population groups (young people, postpartum women, low- socio-economic status), all factors that influence the contraceptive prevalence and method mix. Ethnic minority FP is linked with cultural traditions and norms. Given the diversity of cultures that exist in Europe it is not surprising that variation in use of contraception would also be seen among different eth- nicities in the Region. The Federal Centre for Health Educa- tion (BZgA) in Cologne, Germany carried out a study “Women’s Lives – Family Planning and Migration Throughout Life” that compared the current contraceptive practice of German, Turkish, eastern and south-eastern European women living in Germany. The study clearly demon- strated that ethnic background influences the choice of contraceptive method. For example pills were more often used by German women, the intrauterine device DIFFERENCES IN USE oF FAMILy PLANNING IN THE EURoPEAN REGIoN (ContInuED) No.79 - 2013 9 Country/ year of survey Rural Urban Primary educa- tion and lower Higher education Lowest wealth quintile Highest wealth quintile Bosnia and Herzegovina 2011/2012 NA NA 4.9 18.2 5.9 7.5 Serbia 2011 6.5 4.5 3.8 10.7 4.8 9.5 Table 5. Percent of Roma women age 15-49 who are using any modern method of contraception, country and year of study (4). (IUD) by women from eastern and south- eastern Europe and Turkish women more often used surgical contraception (7). According to the 2011 MICS in The former Yugoslav Republic of Macedonia, the percentage of women aged 15-49 years who use a modern contracep- tive method differs depending on the ethnicity of household head: 14.9% if the household head is Macedonian, 9.7% if Albanian and 8.8% if another nationality (4). In Montenegro, the difference be- tween modern contraceptive use accord- ing to the ethnicity of the household head is also present, with the biggest difference being among Bosnian\Muslim (19.3%) and Albanian (14.6%) women (4). The Roma population represents one of the most marginalized ethnic minori- ties in Europe, but comparable data on their SRH and FP needs has been lacking. The MICS in Bosnia and Herzegovina (2011/12) and in Serbia (2011) specifical- ly included a section for the Roma, which is providing useful information about FP and this population. For example, in Bos- nia and Herzegovina the language spoken in the household influences the use of modern contraception (5.1% Romani language vs. 12.2% other languages) (4). When looking at other social determi- nants of health and their relationship with contraceptive use among Roma women, similar trends to those of non Roma women are seen, with lower use among those who are less educated and less wealthy (see Table 5) (4). In Serbia, while patterns of use may follow similar trends, access to FP differs, with a greater percentage of Roma women reporting unmet need for FP compared to non Roma women (10% versus 7%) (4). Conclusions More and more policy makers are focusing on strengthening high-quality people-centred health systems and tack- ling persisting health system barriers that continue to limit health promotion and availability of high quality services. Members States of the WHO European Region are starting this process by devel- oping a “Framework for Action towards PeopleCentred Coordinated/Integrated Health Services Delivery” (8). The WHO Regional Office for Europe and other partners are supporting countries with policy options and specific recommen- dations for change, through an action- oriented approach to target areas for strengthening the coordination/integra- tion of care. It is important to ensure that the Framework for Action includes FP, an important area of public health with impact on the health and well-being not only of the woman or couple, but also the health of the future generations. In order to help shape the strate- gies and actions and track progress, it is essential that data on FP is available and comparable throughout the Region. Standardized questionnaires and indica- tors should be used when any survey on SRH and FP is taking place. These surveys should also involve both sexes, with ques- tions targeted to men as well. Furthermore, the role of social determinants of health such as place of residence, education, wealth and ethnic background differs from country to country and needs to be studied and monitored to ensure that developed SRH strategies, action plans and activities are targeting those most in need. Gunta Lazdane, MD, PhD, Programme Manager, Sexual and Reproductive Health, Division of Noncommunicable Disease and Health Promotion, WHo Regional office for Europe, gla@euro.who.int References 1. Health 2010. A European policy framework supporting action across government and society for health and wellbeing. Copenhagen: WHO Regional Office for Europe, 2013. 2. Social determinants of sexual and reproductive health. Informing future research and programme implementa tion. Geneva: WHO, 2010. 3. Measure DHS [website]. (http:// measuredhs.com/What-We-Do/ Survey-Search.cfm, accessed 20 October 2013) 4. Monitoring the Situation of Children and Women [website]. UNICEF (http://www.childinfo.org/mics4_sur- veys.html , accessed 20 October 2013) 5. Currie C, Zanotti C, Morgan A et al., editors. Social determinants of health and wellbeing among young people. Health behaviour in schoolaged children (HBSC) study: International report from the 2009/2010 survey. Copenhagen: WHO Regional Office for Europe; 2012 6. Youth Sexuality. Repeat survey of 14 to 17yearolds and their parents – current focus: migration – 2010. Bundeszentrale für gesundheitliche Aufklärung; 2010 (http://publika- tionen.sexualaufklaerung.de/index. php?docid=2132 , accessed 19 Octo- ber 2013). 7. Women’s lives Family Planning and Migration Throughout Life. Interim results of a townbased study involv ing women with a Turkish, eastern European or south eastern European migration background. Cologne: BzgA, 2008-2009. 8. Roadmap. Strengthening people centred health systems in the WHO European Region. Copenhagen: WHO Regional Office for Europe, 2013. 10 EMERGENCy CoNTRACEPTIoN IN EURoPE: EqUAL ACCESS FoR ALL? Figure 1. Legal status of LNG ECPs. Developed by Aline Bohet for the ECEC. Do all women in Europe have the same access to emergency contraception (EC)? If all national repro- ductive health policies are evidence-based, the response should be yes. Women in Germany or Hungary, for instance, would need to take the same steps as women in Scotland or Norway to obtain EC. Reality, however, is a bit more complex. The truth is that, when in need of EC, Norwegian women are able to stop at the closest gas station or supermarket and buy EC pills. Scottish women just need to ask for EC pills at their local pharma- cies and can get them for free. Both will be able to obtain EC pills fast and, thus, increase their chances of preventing pregnancy after an episode of unpro- tected intercourse. Women in Germany and Hungary, on the other hand, need to see a doctor, explain that they didn’t use contraception, that the condom slipped, or that they missed a pill, and ask for a prescription for EC. Perhaps the pharma- cists will have to give them a brief talk about being more responsible when they submit the prescription but will fail to remind them that EC pills will not protect them from pregnancy if they have further unprotected intercourse in the same cycle. So the answer is no. It seems that, despite the fact that EC pills have been available in many European countries for more than 15 years, women across Europe do not have equal access to EC and, thus, to a second chance for preventing pregnancy. Data on EC in Europe is scarce and, for the data that does exist, it is not clear where EC falls in the broader array of available contraception methods or how it fits into women’s trajectories. In order to assess different regula- tions, reimbursement policies and service delivery modalities for EC, the European Consortium for Emergency Contracep- tion (ECEC) conducted a survey of key experts in 2012 and 2013 from 25 coun- tries. While the ECEC plans to gather data from all of the 53 countries comprised in the WHO definition of the European Region, so far, data has been collected and validated on access policies and prescription statuses, cost and reimburse- ment policies, guidelines and common practices and use from the following countries: Albania, Austria, Belgium, Bulgaria, Denmark, Estonia, Finland, France, Germany, Hungary, Italy, Latvia, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, and the United Kingdom (1). The findings from the surveys are presented below. What we know about EC access in Europe Levonorgestrel-only emergency contra- ceptive pills (LNG ECPs), the most widely available EC method in the region, can be purchased directly at pharmacies in 19 countries (see Figure 1). In eight of these countries (Bulgaria, Denmark, Estonia, the Netherlands, Norway, Portugal, Ro- mania, Slovakia and Sweden) the product is available over the counter, which means that no interaction is needed with the pharmacy staff to obtain EC. Despite the fact that LNG ECPs meet all the criteria for over the counter access (they have no potential for overdose or addiction, have very low toxicity, are of uniform dosage, have no major drug interactions or contraindications, pose no danger to an existing pregnancy and can correctly be self-administered) current regulations in Albania, Germany, Italy, Hungary and Poland still maintain that the user needs to first obtain a prescription from a health provider in order to buy LNG ECPs. This is also the case in Finland for women who are 15 years old or younger. In the Maltese islands, ECPs are not available and women need to resort to higher doses of regular oral contraceptive pills (termed the Yuzpe regime) if they need EC. National reimbursement policies to reduce the out-of-pocket costs of LNG ECPs are only in place in Belgium, Fin- land, France, Germany, the Netherlands and the United Kingdom. However, LNG ECPs are provided free of charge to young people in at least family planning centres and youth clinics in Finland, France, Germany, Norway, Portugal, Spain, Sweden, Switzerland and the United Kingdom. Since 2008 LNG ECPs are also provided free of charge in all pharmacies in Scotland and Wales. In Finland, France, Norway and some parts of the United Kingdom, EC can be procured in schools. In France, Norway and the United King- dom, systems to access LNG ECPs via the Internet have recently been developed and only in Norway and the Netherlands can LNG ECPs be obtained through mass No.73 - 2011 11 9 3 Jamie Bass Cristina Puig Emergency contraception (EC), also known as postcoital contraception or the morning after pill, refers to contraceptive methods that women can use to prevent pregnancy after unprotected or inadequately pro- tected sexual intercourse. Access to EC is essential for ensuring women’s reproduc- tive health. Currently, there are three main types of EC methods available in Europe: Levonorg- estrel-only EC pills (LNG ECPs), EC pills con- taining ulipristal acetate (UPA ECPs) and copper intrauterine devices (IUDs) inserted up to five days after intercourse. EC can reduce the risk of pregnancy following an act of unprotected or inadequately protected intercourse by between 75% and 99%, depending on the method used. Insertion of a copper IUD is the most effective EC method, followed by UPA ECPs. LNG only EC pills reduce the risk of pregnancy by at least half and possibly by as much as 80% to 90% following an act of unprotected or inadequately protected intercourse (3). The European Consortium for Emergency Contraception (ECEC), established in 2012, is a network of organizations and individu- als working in the field of EC research, service provision and advocacy within a broader sexual and reproductive health and rights approach. our mission is to expand knowledge about and access to EC in European countries and to pro- mote the standardization of EC service delivery in the European context. visit www.ec-ec.org for more information. Text Box 1. Emergency contraception Text Box 2. The European Consortium for Emergency Contraception distribution channels like retailers and gas stations. For now, a prescription is required to buy ulipristal acetate (UPA) ECPs in all countries where it is available (UPA is still not available at all in Albania, Estonia, Malta, Switzerland and Turkey). In Italy, health providers and required health authorities are increasingly confident about UPA’s safety as long-term surveil- lance data is amassed. This is just another example of disparities in EC access poli- cies, which may be partially explained by the fact that only eight countries have clinical guidelines exclusively devoted to EC (Denmark, Finland, France, Poland, Portugal, Spain, Sweden and the United Kingdom). Can this picture get any more diverse? Apparently so. The availability of data on EC use and women’s knowledge of EC also varies greatly by country. Aside from France and the United Kingdom, very few countries have conducted studies in the past decade to assess actual use. The countries that have recently conducted studies include: Spain, where in 2012 14.7% of women of reproductive age reported to have ever used EC; Germany, where in 2011 13% of women reported to have ever used EC; and Estonia, where in 2007 21% of women reported to have ever used EC. At the regional level, a recent study examining 7170 women’s knowledge and use of EC in France, Germany, Italy, Spain and the United Kingdom found that the mean age of users was 28 years old and that 88% of women who used EC took it within the first 24 hours (2). This study also found that only 27% received information on EC from their health provider and while viewing the use of EC to be a responsi- ble act, women still felt stigmatized and judged when seeking EC treatment (2). The vast majority of women wanted more information on EC. Could guidelines help reduce inequalities? The great diversity in service delivery modalities paints to a landscape of un- equal access to EC options for European women. The gap is likely to increase with the presence of the new generation of EC pills, namely ulipristal acetate, becoming more available in many markets. With the aim of promoting the har- monization of EC services in Europe, the ECEC is developing a guide that addresses key issues that should be included in any EC clinical guideline. We hope that such a tool will facilitate the task of developing or updating national EC guidelines based on the most updated research available. When choices expand so should information to women EC choices are expanding in Europe, as well as in other parts of the world. The promotion of the use of the copper IUD for EC and the introduction in 2010 of a new EC pill containing ulipristal acetate are generating new and passionate de- bates about best pathways for treatment and most cost-effective choices at the population level. While these discussions take place we should not forget that every woman seeking EC needs to be informed of the different methods available to her, their efficacy, adverse effects, interactions and eligibility requirements so she can truly exercise choice. Developing coherent national policies on sexual and reproduc- tive health and rights, including access to EC, across Europe, would help ensure that women receive the information they need to make informed decisions and that no additional misunderstandings are created around this important contraceptive method. Cristina Puig, Coordinator, European Consortium for Emergency Contraception, Cpuig@familycareintl.org Jamie Bass, European Consortium for Emergency Contraception, jbass@familycareintl.org References 1. Data on which this article is based is available at http://www.ec-ec.org/ emergency-contraception-in-europe/ country-by-country-information-2/, retrieved on Oct 10th 2013. 2. Nappi Rosella (IT). What do women know about pregnancy risk and emer gency contraception? A European survey amongst 7170 women. 10th Congress of the European Society of Gynecology, Friday September 20th. 3. Medical and Service Delivery Guide lines, 2012. Retrieved Oct 8 2013 from http://www.cecinfo.org/custom-con- tent/uploads/2013/06/Medical-and- Service-Delivery-Guildelines-English- June-20131.pdf 12 Barriers Adolescents – especially unmarried ones - in low and middle income countries (LMIC), face barriers in obtaining and using contraception (1). While ado- lescents experience many of the same barriers that adults do when it comes to obtaining contraceptives, some are specific to them. In many poor communities of LMIC, contraceptive methods are not available to adults or to adolescents. Even when they are available, laws and policies ex- clude their provision to unmarried ado- lescents or to those under a certain age. Other access barriers include cost, health facilities that are difficult to reach and health workers who do not provide con- traceptives even though there are no legal or medical restrictions to do so. Health workers in many places refuse to provide unmarried adolescents with contracep- tive information and services because they do not approve of premarital sexual activity. Even when they do so, they limit the contraceptive methods they provide (to condoms only) wrongly believing that long acting hormonal methods and intrauterine devices are inappropriate for nulliparous women. Even when contraception is available and obtainable for adolescents, they may not use it for a variety of reasons. In many places young married women are under pressure to conceive and bear children. Contraception is considered only after a first child is born. Also, the stigma sur- rounding contraception prevents use by adolescents who are not in stable relation- ships. Proposing the use of a condom or carrying one can lead to a woman being considered ‘loose’ in many places. Finally, even when adolescents are able to get modern contraceptive methods and to use them, they may not want to do so. Adolescents in many places have misconceptions about the immediate and long-term side effects of contraceptive methods on their health and their future ability to bear children. Due to the result- ing fears and concerns they consider in- effective methods, such as withdrawal and traditional remedies, more acceptable. Furthermore, because of a poor under- standing of how contraceptives methods work and how they should be used, they use them incorrectly. Improving access and use In 2011, the WHO issued guidelines on preventing early pregnancy and poor reproductive outcomes in adolescents in developing countries (2). These guide- lines were based on reviews of published systematic reviews and of individual studies and the collective judgment of an expert panel. Increasing access to and use of contraception was one of the four outcomes to prevent early preg- nancy. The studies that met the inclusion criteria for this outcome were conducted in a number of LMIC. Some focused exclusively on condom use, while others looked at hormonal contraceptives and emergency contraception (EC). Some examined the use of contraception as a primary outcome while others examined it as secondary to outcomes such as HIV prevention or changing knowledge and attitudes. Some focused on health system actions (such as over-the-counter or clinic provision of contraception) while others focused on actions directed at community leaders and members. Collectively, they demonstrated increases in contracep- tive use (including condoms, hormonal contraceptives and EC) as a result of actions directed at multiple levels – laws and policies; individuals, families and communities; and health systems. The interventions discussed below are drawn from the WHO’s guidelines. MAKING LAWS AND POLICIES SUP- PORTIVE: In many countries, laws and policies restrict the provision of con- traception to unmarried adolescents or those below a certain age. Policy makers must intervene to reform these laws and policies to ensure that adolescents are able to obtain contraception information, counseling and services. Policy makers should also consider providing adoles- cents contraception at no or reduced cost (2). MAKING SOCIAL AND GROUP NORMS SUPPORTIVE: In many societies premarital sexual activity is not considered acceptable and there is considerable resistance to the provision of contraceptive information and services to unmarried adolescents. To overcome this barrier, it is important to improve the understanding of influential community leaders and of the community at large on adolescents’ needs for information and contraception, including the risks to their wellbeing of not responding to these needs (2). In many places, social and group norms hinder discussion between cou- ples about contraception. In addition, knowledge gaps and misconceptions prevent use or proper use of contracep- tive methods. Mass media (radio and television programmes), peer-education and inter-personal communication and information education communication materials (such as posters and leaflets) have been used successfully to commu- nicate health information to adolescents and to influence their norms. In recent years, the ways adolescents communicate have changed radically. Mobile phone technology, the Internet and social media are increasingly being used, even in LMIC. These technologies are potentially valuable for communicating contracep- tive information and options to adoles- cents conveniently and confidentially (3). IMPROVING KNOWLEDGE AND UNDERSTANDING: The evidence of the benefits of curriculum-based compre- hensive sexuality education is strong. The most successful sexuality education programmes provide accurate and age- appropriate information and in addition, develop life skills and provide support to deal with thoughts, feelings and experi- ences that accompany sexual maturity (e.g. falling in love, refusing unwanted sex proposed by a friend firmly but without creating hostility). They are also linked to contraceptive provision and services (4). Although policies requiring sexuality education for adolescents are in place in many countries, they are poorly imple- IDENTIFyING AND ovERCoMING BARRIERS THAT ADoLESCENTS IN LoW AND MIDDLE INCoME CoUNTRIES FACE IN oBTAINING AND USING CoNTRACEPTIoN No.73 - 2011 13 9 3 Nancy E. Williamson Donna R. McCarraher Venka- traman Chandra- Mouli To be considered adolescent-friendly, health services should be accessible, acceptable, equitable, appropriate and effective, as outlined below: • Accessible: Adolescents are able to ob- tain the health services that are available. • Acceptable: Adolescents are willing to obtain the health services that are available. • Equitable: All adolescents, not just some groups of adolescents, are able to obtain the health services that are available. • Appropriate: The right health services (i.e. the ones they need) are provided to them. • Effective: The right health services are provided in the right way and make a positive contribution to their health. Text Box 1. Components of adolescent friendly health services mented, if at all. Health and education policy makers and managers must ensure that curriculum-based sexuality educa- tion is widely and effectively implement- ed. Complementary efforts are needed to reach the many adolescents who are not in school. IMPROVING ACCESS TO CONTRA- CEPTION: Adolescents in many places are unwilling to visit facilities providing contraception because they view them as unfriendly. There is growing evidence of the value of making health services ado- lescent friendly (see text box 1) (5). To improve access to contraception, health facilities must be made easy to get to and welcoming, they must have unbroken stocks of a range of contracep- tive methods and adolescents must be supported to choose the ones that meet their needs and preferences by empathetic and competent health workers. Contraceptive education, counseling and provision could be integrated into other health services used by adolescents – including sexually transmitted infection management, HIV counseling and testing, comprehensive abortion care services and postpartum care. For many adolescents, contact with these services may be their first opportunity to have a face-to-face discussion about contraception with a competent person. Integration into post- partum services offers the opportunity to reach first-time mothers with informa- tion on birth spacing so they can delay a second pregnancy. In making health services adolescent friendly, it is important to build on what already exists - modifying general health facilities and building the competencies and attitudes of existing health-service providers, rather than setting up new fa- cilities and assigning some health-service providers exclusively for adolescents. Having said this, dedicated health facili- ties could be useful to reach marginal- ized groups of adolescents (such as sex workers) who may be reluctant to use a service-delivery point open to all. Even if health facilities are adolescent- friendly, they are unlikely to attract all adolescents. Therefore, contraception should be provided through a variety of outlets. Outreach to adolescents in ven- ues where they socialize can improve their access to contraceptive information and services – on the spot or through referral. Making pharmacies and shops adoles- cent friendly could greatly expand ready access to over-the-counter contraceptive methods. Some countries have begun to task-shift contraceptive services to community-level providers in response to shortages of qualified medical personnel (6). Adolescents could benefit from these efforts if confidentiality can be assured. Summary In summary, there is fairly good evidence, from research studies and small-scale and time limited projects, on effective ways of increasing access and use of contra- ception by adolescents. They include favourable laws and policies; multifaceted communication programmes directed at community leaders and members and at adolescents - that inform, educate and create supportive norms for the provision and use of contraception; accurate and age-appropriate curriculum based sexual- ity education; and the provision of a wide range of contraceptive methods through different adolescent-friendly outlets. The real challenge is to build on these small- scale and time-limited initiatives to build large scale and sustained programmes. Venkatraman Chandra-Mouli, MBBS, MSc, Dept. of Reproductive Health and Research, WHo headquarters, Geneva, chandramouliv@who.int Donna R. McCarraher, PhD, Family Health International (FHI), Durham, NC, USA, DMccarraher@fhi360.org Nancy E. Williamson, PhD, Maternal and Child Health Depart- ment, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA, nwilliamson@msn.com References 1. Bankole A, Malarcher S. Removing barriers to adolescents’ access to con- traceptive information and services. Stud Family Plann. 2010. 41, 2, 117- 124. 2. WHO Guidelines on preventing early pregnancy and poor reproductive outcomes in adolescents in developing countries. Geneva: WHO, 2011. 3. Guse K, Levine D, Martins S et al. Interventions using new digital media to improve adolescent sexual health: A systematic review. J Adolescent Health. 2012. 51 (6): 535-43. 4. Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs: their impact on sexual behaviors of young people throughout the world. J Ado lescent Health 2007; 40(3): 206-17. 5. Quality Assessment Guidebook. A guide to assessing health services for adolescent clients. Geneva: WHO, 2009. 6. Janowitz B, Stanback J, Boyer B. Task sharing in family planning. Stud Family Plann 2012;41(1):57-62. 14 Example of MEC wheel in local language from Uzbekistan IMPACT oF THE MEDICAL ELIGIBILITy CRITERIA FoR CoNTRACEPTIvE USE (MEC) WHEEL oN THE qUALITy oF FAMILy PLANNING: ExPERIENCES FRoM SELECT CoUNTRIES The MEC wheel is based on the Medical Eligibility Criteria for Contraceptive Use (MEC), 3rd edi- tion and its 2008 Update, one of WHO’s evidence-based guidelines. This wheel contains the medical eligibility criteria for starting use of six common types of contraceptive methods and provides family planning providers with easily accessible information on what various contraceptive methods can be used safely and effectively by women presenting with known medical or physical conditions. In this article four countries from the WHO European Region share their experience with the wheel and its impact on the quality of family planning (FP) in their country. Uzbekistan Since the introduction of health care system reforms in 1998, the issue of sexual and reproductive health (SRH) has become a key focus of national plans and actions. With a population of ap- proximately 29.5 million, of which 50% is under the age of 25, SRH services are a major priority for health. Different health conditions, common among women of fertile age in Uzbeki- stan, create serious barriers for health care providers in expanding the use of different modern contraceptives due to lack of access to information sources on evidence-based counseling. In spite of an increasing contraceptive prevalence rate (64.88%) in the country, 80% of modern contraceptive users still prefer intrauter- ine devices and there is still low demand and use of hormonal methods and inject- able contraceptives. The situation can be partly explained by a lack of knowledge and skills of the health care providers, as well as, their limited access to the WHO sources published in the local language. The UNFPA has played a key role in helping to address this issue. Being a main supplier of reproductive health commod- ities, in particular of modern contracep- tives, the UNFPA, promotes an evidence based SRH programme nationwide and also supports training on integrated SRH services where FP, logistics and No.73 - 2011 15 9 3 manage ment and information systems for contraceptives are key aspects focused on for quality improvement. In collaboration with the WHO, a series of evidence based guidelines and quality improvement tools for FP were also introduced and imple- mented. More than 5000 health care providers improved their capacities in counseling, client oriented approaches to SRH and FP since the first guidelines on “Medical Eligibility Criteria for Contracep tives Use” and the “Selected practice recom mendations for contraceptive use” were published by the WHO in 1996. The UNFPA has also played a key role in the adaptation and provision of technical assistance in producing these guidelines in the local language, which was recognized by the Ministry of Health and a wide audience of health care professionals. Since the MEC Wheel was published by the WHO and the Russian version became available in Uzbekistan, a tangible increase in the demand for this tool was observed. However, the UNFPA monitoring missions to regions where the UNFPA-supported training for general practitioners and nurses took place showed that the rural health care providers made limited use of the Russian version due to language barriers. Thus, in 2013 the adaptation of the MEC Wheel into the Uzbek language was agreed upon and included in the UNFPA’s an- nual work plan. The Uzbek version was prepared in close consultation with local experts and health care providers. The publication process fully conformed to the WHO copyright requirements and permission of the WHO’s Department of Reproductive Health and Research was granted. Seven thousand (7000) copies of the Uzbek version of the MEC Wheel were published and distributed during training for general practitioners and nurses in 2013. The training programme included the learning session on “how” and “who” can use the wheel. The Uzbek version is designed in the same format and instruc- tions as explained in the 3rd edition by the WHO (2004 and 2008). Six methods of contraception and 19 health conditions can be considered when clients decide to begin using a method. Feedback received from health care providers shows that the tool helped them to increase the quality of counseling and to find answers to fre- quently raised questions by clients during follow-up visits. Furthermore, following the introduction of the MEC wheel into the local language an increase in the proportion of hormonal method users and an increase in the number of clients preferring effective and safe methods were documented in health records at rural practices. Access to an Uzbek language source of the information and the possibility of using it in daily practice contributed sub- stantially to increasing mid-level health care personnel’s confidence in conducting FP counseling, which is crucial as such personnel still play a key role in the provi- sion of FP services in the rural area. Romania Romanian editions of all the WHO evidence-based guidance documents, including the MEC wheel, were published and disseminated by the East Euro- pean Institute for Reproductive Health (EEIRH). These evidence-based tools provided guidance to the National Family Planning Programme in the prepara- tion of guidelines for service delivery of contraception and have been used by policy-makers, FP programme managers and the scientific community. The Romanian Family Planning Pro- gramme has developed and implemented national policies and tools that incorpo- rate WHO recommendations on current best practice. The WHO cornerstones were included in the Technical Norms of the National Family Planning Programme and embedded in the programme activities at three levels: training of the FP providers, provision of free-of-charge contraceptives and information, educa- tion and counseling and behaviour com- munication and change (IEC/BCC). Curricula that included the WHO cornerstone information and MEC wheel were developed and accredited for Training of Trainers, basic FP training for primary health care providers (family physicians and nurses), FP specialists and post-abortion contraception. IEC/BCC activities featured key messages from the WHO cornerstones through posters, bro- chures, flyers and media was also targeted through a specific campaign including MEC and Standard Practice Recommen- dations presentation and distribution to media professionals. The impact of the WHO cornerstones was documented by EEIRH through a survey which identified perceptions of physicians who received the WHO docu- ments about: content and usefulness, impact on quality of services offered, dissemination process and suggestions that would improve further dissemina- tion activities. These activities have been made possible through a model partnership be- tween the UN agencies (WHO, UNFPA, UNICEF), USAID/JSI and the Romanian Government and civil society. Ukraine The Together for Health (TfH) project (2005 – 2011), funded by the U.S. Agency for International Development (USAID) and implemented by JSI Research and Training Institute, Inc.(JSI), developed the reference manual “Family planning” and a basic five day in-service training curriculum in line with the latest interna- tional standards, recommendations and approaches. The main reference materials used were the Medical Eligibility Criteria for Contraceptive Use (WHO, 2004, 2009) and FP: a Global Handbook for Providers (WHO and USAID, 2007). It was used during trainings and other events for health providers. TfH team together with local partners, national and local trainers identified challenges in the FP practices of trained health providers and their needs for ad- ditional training materials and job aids that would improve the quality of FP services, particularly primary health care providers. The MEC wheel was the most requested job aid by health care providers and partner organizations. In the opinion of health providers 16 Дүйнөлүк Саламаттык сактоо уюму Ыкманын колдонулушуна бардык абалдарда жол берилет Эрежеге карата, ыкма пациентке туура келбесе жана ага ылайыктуу бойго бүтүрбөөчү каражаттар жеткиликтүү болбогон учурлардан тышкары бул ыкманы колдонууга жол берилбейт. Бул ыкма колдонулбаш керек. Контрацепция усулдарын колдонуу үчүн кабыл алынган медициналык белгилер боюнча ДСУнун дискограммасы Дискограммада сунушталган маалымат “Контрацепция усулдарын колдонуу үчүн кабыл алынган медициналык белгилер” аттуу ДСУнун колдонмосуна негизделген, үчүнчү басылыш, 2004-ж. жана жаңыланган версиясы 2008-ж. Эрежеге жараша бул ыкманы колдонууга болот А йк ал ы ш ты ры лг ан о ра лд ы к б ой го бү тү рб өө чү кар ажа ттар (КОК) жа на а йк ал ы ш ты ры лг ан ин ъе кц ия лы к б ой го бүт үрб өөч ү ка ража ттар (К ИК) Айкалыштырылган оралдык бойго бүтүрбөөчү караж аттар (КО К) жана айкалыштырылган инъекциялык бойго бүтүрбөөчү каражаттар (КИК) П ро ге ст ог ен ка та ры нд агы ор алд ык б ойго Прогестоген катарындагы оралды к бойго МО ПА ПД жан а НЭЭ Им пл ант атта р Ту ту му нд а ж ез бар ЖКС бү түр бө өчү кар ажат тар МОПАПД жана НЭЭ Имплантаттар Тутумунда жез бар Ж КС бүтүрбөөчү каражаттар Үй-бүлөнүн ден соолугун сактоо суроолору боюнча коммуникация өнөктөштүгүнүн Джон Хопкинс Университетинин коммуникациялык программалар борборунун Гана Университетинин Медициналык мектебинин шериктештиги менен иштелип чыкты. Дүйнөлүк Саламаттык сактоо уюму, 2009. Кызматташтыкта иштелип чыкты: Бардык ыкмалар үчүн 1 жана 2 категорияларына карата тиешелүүлүк абалы (ыкма колдонулушу мүмкүн) Аталган абалдарга түшүнүк берүү A Тутумунда жез болгон ЖКС < 48 саат төрөттөн кийин же > 4 жума. B Эгерде кийинки кош бойлуулук болбосо, ЖКС = 2. C Же ириңдүү цервициттин (жатындын моюнчасынын сезгениши) башка түрлөрү. D Эгерде бул абал ЖКС колдонулган чөйрөдө пайда болсо, ЖКСти колдонууну дарылоо чөйрөсүндө улантууга болот. E ЖЖЖИ жана ВИЧ-инфекцияны жуктуруунун жогорку коркунучунда ар дайым презерватив колдонууну сунуш кылыңыз. F Гонорея жана хламидиоздун козгогучтарынын таасиринин мүмкүнчүлүгү жогору болгондо = 3. G АРВ дарылоо курсун өтүп жатканда = 2, Тутумунда Ритонавир бар АРВ дарылоо курсун өтүп жатканда = 03. H АРВ-терапиядан клиникалык натыйжа болбогон СПИД оорулуу адамдарда = 3 коюу үчүн I Тамекини өтө көп чеккен адамдар үчүн КОК = 4. Тамекини өтө көп чекпеген адамдар үчүн да КОКту колдонууда = 2. J Эгерде артериялык кан басымын өлчөөгө мүмкүнчүлүк жок болсо жана анамнезинде гепертензия тууралуу маалыматтар болбосо, каалаган ыкманы колдонууга болот. K Ошол эле категория көзөмөлдө турган гипертензияга да тиешелүү. L Коркунуч факторлору: улуураак жаш курагы, тамеки чегүү, диабет жана гипертензияны камтыйт. M Шакый очоктук өзгөчө неврологиялык белгилери менен коштолоорун билүү үчүн төмөнкү суроону бериңиз: “Сиздин башыңыз катуу ооруганга чейин сиздин көзүңүзгө жапжарык тийген так көрүнөбү?” N Очоктук неврологиялык белгилери жок шакый жана жашы ≥ 35 болсо: КОК жана КИК = 2. Очоктук неврологиялык белгилери жок шакый жана жашы < 35 болсо: КОК жана КИК = 3. O Татаалдашкан диабетте жана > 20 жыл диабет болсо: КОК, КИК, МОПАПД жана НЭЭ = 3-4. P КОК = 3. КИК = 2. Q Фенитоин, карбамазепин, барбитурат, примидон, топирамат, окскарбазепин. Ламотригин үчүн КОК/КИК = 3. Башка ыкмалар = 1. R Клиникалык абалдын жайында эмес болгонунда ЖКС = 3 S Жатын көңдөйүнүн деформация болушунда ЖКС колдонуу мүмкүнчүлүгү жок болот. T Жашы > 45 = 2. U Антикооаулянттык (кандын уюушуна тоскоолдук көрсөтүүчү заттар) терапияны кабыл алуу учурунда = 2. V МОПАПД = 1. НЭЭ = 2. Example of MEC wheel in local language from Kyrgyzstan IMPACT oF THE MEDICAL ELIGIBILITy CRITERIA FoR CoNTRACEPTIvE USE (MEC) WHEEL oN THE qUALITy oF FAMILy PLANNING: ExPERIENCES FRoM SELECT CoUNTRIES (ContInuED) the MEC wheel is an easy to use tool in selecting the appropriate contraceptive method during the client’s visit, taking into account medical criteria and the cli- ent’s wants and needs. To help providers apply the correct eligibility criteria when providing or prescribing contraceptives, TfH trans- lated and printed the MEC wheel into Ukrainian. This was done under a formal cooperation agreement between WHO and John Snow International (JSI). Four thousand (4000) copies of the wheel were printed and it was used during trainings for primary health care providers, as well as, during other continuing medical education events, where the wheel was used as a tool to help providers follow the Medical Eligibility Criteria and remind them which clients were eligible/not eligi- ble for the various contraceptive methods. Health providers who participated in the clinical courses demonstrated sub- stantial improvements in their knowl- edge, with average scores on pre-tests at the start of the training standing at 58% to 92% on post-tests at the end of the training. Women’s satisfaction with the FP/RH services they received improved over time according to project surveys of women leaving project-assisted health fa- cilities in seven regions. After about 20-24 months of project interventions, 68.9% said the quality of services was good, compared with only 54.7% before the project came - an increase of about 14%. Kyrgyzstan According to the results of the strate- gic assessment of unwanted pregnancy conducted by the Ministry of Health, the WHO and the UNFPA in 2011, the knowledge of health professionals and general population about FP and contra- ception was low with a lot of misconcep- tions. In 2012, the UNFPA with the WHO experts carried out a training of train- ers on FP for health care providers to establish oblast teams on FP among health care providers and strengthen their knowledge. This was part of the UNFPA’s mandate to work closely with No.73 - 2011 17 9 3 Example of MEC wheel in local language from Kyrgyzstan Medical eligibility criteria for contraceptive use, WHO, 2010. Available in English, French and Spanish at: http://www.who.int/reproductive- health/publications/family_planning/ 9789241563888/en/index.html СЕПСИС РАК шишигинин ЦИН Жыны стык ж олдо рунан Кич и жа мба ш ча рас ыны н ор ган дар ын ын Ж ын ыс ты к ж ол до р а рк ыл уу В ИЧ /СП ИД Т ам ек и ч егү ү Г ип ер тен зия К Кур ч ка рма ган тере ң вен алар дагы Жүрөк кан-тамыр оорулары Баш оорулары ДИАБЕТ БООРДУН ООРУЛАРЫ ДАРЫ КАРАЖАТТАРЫ НЫ Н БАШ КА АБАЛДАР ЖАШЫ Анамнезде Төрөттөн кийинки киил игишүү опе рациял ык менен шакыйМ каражаттар Q жашка чейин Төрөттөн кийин Сүт бездеринин Жатын Б елгис из Азы ркы Ана мне зде Гон оре я Ба шк а Жо гор ку В ИЧ -ин фе кц ия Жа шы < 3 5 Жа шы > 3 5 140 -15 9/ > 1 60/ >10 0 А нам нез де А зырк ы Уз ак уба кытка Ин сульт Жүрөктүн Көптөгөн Шакый эмес Очоктук Азыркы Боордун Курч кармаган Рифампицин/ Тарамыш АРВ-терапия Семирүү Жатындын Менархеден (этек 40 жаш жана Төрөгөн эмес 6 жумага чейин 6 жумадан жана бойдон (азыркы моюнчасынын себ ептер ден учу рда Хл ами дио зС ЖЖ ЖИ к ор кун уч таг ы ж е С ПИ Д 90 -99 учур да чейин кыймы л и шемикалык коркунуч башкалары неврологиялык учурда шишиктери вирустуу сарык Рифабутин тырышууга каршы фибромасы кирдин келгенинен) андан жогору 6 айга чейин алдыруудан кийин учурда) (терапиясыз) ж ана ва гин ит ЖЖ ЖИ Е ара кети че ктелген оорусу факторлору белгилери (гепатит) кай бир баштап 18 түрлөрү кан ке түү с уук т ийи п се зген үү о ору лар ы жу гуу чу ин фе кц ия ла р кан ды н та мыр да у юшу (тром боз) БИРГЕ АРАКЕТТЕШ ҮҮСҮ төрөттүн болушу мезгил (Эмчек сүтүн эмизүү) the Ministry of Health and other partners to strengthen knowledge and skills of health service providers in delivering good quality counseling and services to ensure a greater access to range of mod- ern contraceptives. The Medical Eligibility Criteria for Contraceptive Use and Practice Recommendations for Contraceptive Use were guidelines used as one aspect of im- proving the quality of reproductive health care. The WHO MEC wheel became the most popular tool on the course and was used in various interactive training sessions. The decision making tools for health care providers and community also played a key role in enhancing the client’s experience. After the national training, the UNFPA supported implementation of the cascade training at the oblast and rayon level, followed by on-job monitoring of the knowledge and practical skills of local service providers in 2013. One of the achievements was the fact that doctors use the MEC wheel in the Kyrgyz lan- guage at the grassroots level. “For us, service providers, this tool in the Kyrgyz Language is easy to use dur- ing the counseling on FP. For providers it is a ‘cheat sheet’. Many participants of the monitoring noted that this tool can save time and there is confidence in the provision of the contraceptive,” said the National Coordinator on FP, Dr. Elmira Maksutova. During the monitoring visits the doctors said that “we used to have this tool on hand in Russian, but we did not know how to use it.” Thus the MEC wheek in Kyrgyz and the conducted trainings at district levels for health care providers have enabled many to understand and get detailed in- structions which has lead to an improved consulting process for both client and provider. 18 MULTIPURPoSE PREvENTIoN TECHNoLoGIES Figure 1: MPTs are in various stages of development (1). source: CAMI and the Initiative for Multipurpose Prevention technologies ©2013 http://www.cami-health.org/resources Sexually active women can be exposed to the risk of unintended pregnancy and sexually transmit- ted infections (STIs), including HIV. Condoms, both male and female, are cur- rently the only methods that provide si- multaneous protection against these risks. Condom use, either alone or in addition to another reliable contraceptive method, has increased substantially over the last 20 years, particularly among unmarried women, but condom use among mar- ried couples or stable partnerships has remained at very low rates. Both male and female condoms in particular need to be made available, accessible and promoted for correct and consistent use. An alternative and novel approach focuses on the development of other multi-purpose prevention technologies, or MPTs. These new products are being developed to simultaneously address, but not be limited to, more than one sexual and reproductive health prevention need of women. As such these products reflect the needs of women within a life-course approach since the sexual and reproduc- tive health needs and goals of women change and evolve over time. Although the only approved products currently available are male or female condoms, with innovative designs and concepts, the development of other safe and effective MPTs is now not only tech- nically feasible, but researchers world- wide are at various stages of product development. Current research is focused on promising innovations that include microbicides (delivered as gels, films, or tablets), as well as, vaginal rings and single sized diaphragms that release con- traceptive products, and/or HIV preven- tive products and/or products to prevent a variety of STIs (see Figure 1). In theory, the combinations and pos- sibilities for MPTs are diverse and will address the varying needs of women according to stage of life, socio-cultural norms and regions in which they live (see Figure 2). Ideally, a suite of MPT prod- ucts and strategies will be available. For example, MPTs could range from coitally dependent use because of infrequent need to long lasting delivery methods that could provide more continuous protec- tion. Additionally the range of products provides the potential for various combi- nations of indications such as contracep- tion and HIV protection, HIV and herpes simplex virus (HSV) protection, and/ or contraception and protection against other STIs, either viral or bacterial. At present, the contraceptive features women have to choose from are limited, therefore research into novel delivery mechanisms and products are important to support women’s sexual and reproductive health choices. The product most advanced in clinical testing is 1% tenofovir (TFV) gel for which there is evidence for impact against HIV and herpes simplex virus type 2 (HSV-2) infections from one trial and a confirmatory Phase 3 trial is cur- rently underway in South Africa. Work to combine the active ingredient TFV with a contraceptive in a vaginal ring delivery system is being pursued by CONRAD (a leading organization in reproductive health research) and the University of Utah. Several approaches are also being pursued by the Population Council, including research on combined gels and ring technologies. The International Partnership for Microbicides (IPM) has recently launched an HIV prevention trial of its novel dapivirine-releasing vaginal ring and has started pre-clinical work to combine this with the contraceptive progestin levonorgestrel. With the recent success of the oral pre-exposure prophy- laxis HIV prevention trials, a co-formu- lated combined oral contraceptive with the antiretrovirals tenofovir and emtric- itabine can be envisaged. Long-acting injectable antiretrovirals for treatment of HIV infection are in early phases of development, but could also be envisaged in the long term, in combination with an injectable progestin contraceptive. MPTs could achieve meaningful reduc- tions in terms of cost of goods and lead to significant efficiencies in product delivery and access when compared to efforts necessary for delivery of multiple prod- ucts targeting separate indications. The development of MPT products is tech- nologically complex, expensive and risky, but also represents a powerful means of achieving high public health impact in at- risk populations around the world. In many instances, the conceptual development of new MPTs builds upon proven, successful models. For instance, incorporating folic acid into common food items or iron supplementation into oral contraceptive pills have been effective ways to enable patients to benefit without extra effort on their part and to increase uptake of the product. No.73 - 2011 19 ` 9 3 Bethany Young Holt Mario Merialdi Manjula Lusti- Narasim- han Figure 2: Promising combinations and possibilities for MPT product development and delivery. source: CAMI and the Initiative for Multipurpose Prevention technologies ©2013 http://www.cami-health.org/resources MPT Complexities and Challenges The multidisciplinary approach of the MPT fi eld creates several challenges in- cluding at regulatory and funding levels. While there has been progress in the areas of contraceptive research and HIV and STI prevention and treatment, donor proposals for research grants are often framed by health issues – in this instance reproductive health or HIV or other STIs. In addition, funding cycles will need to cover a multiple-year approach to address the complicated nature of MPT develop- ment, regulatory approval and introduc- tion. This would reduce research ‘silos’, funding gaps and duplication of research efforts, while targeting funding to priority research. While large scale clinical trials of MPT products will require meaningful levels of fi nancial support, more modest funding and in-kind support can make signifi cant contributions to innovative basic science research, communication and advocacy efforts and understanding the potential market and demand issues that will be critical for MPT success. Increased collaboration and a widening of funding frameworks from single issues to a more comprehensive sexual and repro- ductive health framework will invigorate scientifi cally innovative and successful approaches for MPT development. Regulatory issues also pose chal- lenges, since MPTs involve more than one indication and have complex chemistry, manufacturing and controls requirements and demonstrations of effi cacy. MPTs may also combine drugs, formulations or devices that are already approved or that have not yet been approved by a national regulatory authority. The regulatory review processes for such products may be complicated. Despite biological, behavioural, and physiological linkages between the risk for unintended pregnancy and STIs and the evolving sexual and reproductive health goals and needs of women over time, health care remains siloed and strengthening linkages to provide a com- prehensive approach to women’s health will be critical to achieving international goals and targets in the coming years. MPTs provide an innovative approach to addressing the multiple sexual and repro- ductive health needs of women over time. The success of this new class of MPT products requires an integrated mix of expertise and advocacy, as well as, a sound evidence-based argument for their need and plausibility as a product category. Manjula Lusti-Narasimhan, MD, Dept. Reproductive Health and Research, WHo headquarters, Geneva, lustinarasimhanm@who.int Mario Merialdi, MD, MPH, PhD, Coordinator, Human Reproduction, Dept. Reproductive Health and Research, WHo headquarters, Geneva, merialdim@who.int Bethany Young Holt, MPH, PhD, Executive Director, Coalition Advancing Multipurpose Innovations (CAMI), Principal Investigator, Public Health Institute, USA, byh@cami-health.org 20 THE BARoMETER oF WoMEN’S ACCESS To MoDERN CoNTRACEPTIvE CHoICE IN 10 EURoPEAN UNIoN (EU) CoUNTRIES Barometer of Women’s Access to Modern Contra- ceptive Choice in 10 EU Countries, IPPF EN, 2013. Available in English at: http://www.ippfen.org/ resources/barometer-womens-access-modern- contraceptive-choice “Women’s access to modern contraceptive choice is a crucial component of health, gender equality, employment and education which are at the same time the pillars and drivers of a prosperous and healthy society.” – Katarina Nevedalova, Member of the European Parliament The International Planned Parenthood Federation European Network’s (IPPF EN) landmark research study, “the Barometer of Women’s Access to Modern Contraceptive Choice in 10 EU Coun- tries,” launched in the European Parlia- ment in June 2013, provides an overview of factors influencing access to contracep- tive choice in Bulgaria, the Czech Repu- blic, France, Germany, Italy, Lithuania, the Netherlands, Poland, Spain and Sweden. The study evaluates and rates countries on policy benchmarks including: policy making and strategy; general awareness; education for young people; education of healthcare processionals; individualized counseling; reimbursement; prevention of discrimination; and empowerment of women. Results IPPF EN Member Associations and na- tional experts gathered information and ranked countries on each of the policy benchmarks. Figure 1 shows how each country scored on each benchmark in accordance with a rating system de- signed to enable comparisons within and between countries. The report presents key findings on both barriers and good practices and makes recommendations for improving access to modern contra- ceptive choice. On policy and strategy for example, the study revealed that, of the countries studied, only Germany, the Netherlands and France have implemented com- prehensive national policy frameworks on sexual and reproductive health and rights (SRHR). In contrast, in the Czech Republic, Lithuania and Italy, SRHR are practically absent from institutional agen- das. Generally, SRHR policy measures are scattered and limited often lacking political attention and financial support. The level of stakeholder involvement varies significantly across countries and monitoring and evaluation of SRHR policies are poorly developed in almost all countries examined. While all countries examined have developed national policies supporting gender equality and women’s participa- tion in professional and social lives, only in a few countries do these polices include a component on SRHR. For example, in Sweden and France, gender equality poli- cies specifically address SRHR, including measures to improve access to modern contraceptive choice. Comprehensive sexuality education is essential for empowering young people to make informed decisions and access services for their reproductive health. There is great variation in the quality of education received by young people in Europe. Comprehensive sexuality education is mandatory in only half of the countries studied. France is the only country of those studied that provides comprehen- sive sexuality education based on specific content guidelines. Specific training courses for teachers are offered only in France, Germany, Spain and Sweden. Even in Sweden, “the quality of sexual ity education can differ substantially from one school to another,” said Hans Olsson of the Swedish Association for Sexuality Education. Religion is still a barrier in many coun- tries, influencing individual teachers and influencing policy. “Information about contraception cannot be presented as an acceptable alternative to abstinence,” said a representative of the Ministry of Sci- ence and Education in Lithuania, which was the country with the lowest score on the comprehensive sexuality education benchmark. Individualized counseling, another benchmark highlighted in the study, is critical for promoting access to con- traceptive choice but in most countries studied, there is a lack of awareness of individualized counseling as a key com- ponent of sexual and reproductive health services and stakeholders called for im- proved availability and quality of services. Accessibility was rated as high only in the Netherlands. In Lithuania and the Czech Republic counseling is rarely provided and no quality standards exist. Of the 10 countries studied, only Denmark, Sweden and the Netherlands include training on individualized counseling in medical curricula and postgraduate programmes. “There are still myths and lack of know ledge amongst healthcare professionals with regards to some modern contracep tive methods,” said Lena Marions of the Obstetrics and Gynaecology department at Karolinska University Hospital in Stockholm. 21 No.79 - 2013 Irene Donadio Figure 1. Overall Scoring by Policy Area and Country The Barometer also highlighted that financial constraints are still a barrier for many people in Europe who want to access contraception. “The biggest barrier, especially for people in difficult economic situations, is not access to healthcare but access to a choice of modern contraceptives tailored to their needs, as reimbursement for the wide range of modern contraceptives is limited due to the government’s financial constraints,” said Anna Korzan of the So- ciety for Family Development in Poland. None of the countries studied offered full reimbursement of modern contracep- tive methods and related health services and only half of them (Spain, France, Denmark, the Netherlands and Sweden) offered partial reimbursement. While stakeholders recognize that young people face significant financial barriers in ac- cessing contraceptives, only Germany, the Netherlands, Sweden and France offer special reimbursement schemes for them. Austerity measures are beginning to make matters worse in some countries. “The current budget cuts at national and re gional level represent a new major obstacle for the effective implementation of policy measures to prevent unintended pregnan cies,” said Justa Montero of the Spanish IPPF Member Association, Federacion de Planificacion Familiar Estatal. Conclusion and recommmendations Comparing the status of different coun- tries gives the opportunity to highlight good practices and specifies areas for further work. The report Barometer of Women’s Access to Contraceptive Choice in 10 EU Countries (available on the web at: http://ippfen.org/news/barometer- womens-access-modern-contraceptive- choice), gave stakeholders in the countries covered a way to show how their country measured up in comparison with others and aided in stimulating dialogue about priority areas for work. The European Region has seen considerable progress on access to modern contraceptive choice and the prevention of unintended pregnancies and is home to many good policies and practices. However, con- siderable work is still needed to address existing gaps and prevent backtracking in countries facing austerity measures. In this regard the report makes a number of policy recommendations aimed to empower women and young adults to benefit from appropriate contraceptive methods and access quality sexual and reproductive healthcare and information with the advice and support from health- care professionals: • Develop targeted, comprehensive SRHR policy frameworks, in close collaboration with key stakeholders and the scientific community; • Increase general awareness of modern contraceptive choice through public awareness campaigns; • Establish mandatory sexuality educa- tion at schools, including information on modern contraceptive choice; • Ensure the provision of individual- ized counseling and quality services on SRHR; • Establish targeted measures to over- come inequalities in women’s access to all methods of contraception; • Work towards the prevention of discrimination and stigmatization around SRHR; and • Ensure adequate policy integration and consistency by adopting tar- geted measures to improve access to contraceptive choice within broader employment, education and non- discrimination policies. The Barometer on Women’s Access to Modern Contraceptive Choice in 10 EU Countries was produced with support from Bayer HealthCare. Irene Donadio, Manager, Public Affairs, IPPF EN, idonadio@ippfen.org 22 Bo sn ia a nd H er ze go vi na Ru ss ia n Fe de ra o n Re pu bl ic o f M ol do va* Figure 1: Contracep- tive prevalence rates in selected European and central Asian countries, traditional and modern methods of contraception (1). * tFYr of Macedonia = the former Yugoslav republic of Macedonia Contraceptive prevalence* in the eastern European and central Asian Region Controlling her fertility is a key priority for most women and the use of modern contraceptive methods is essential to achieving this aim. While the use of mod- ern methods of contraception is quite high in western Europe, it is considerably lower in many other European coun- tries (1). According to the 2012 United Nations Population Fund (UNFPA) State of the world population report, the United Kingdom and Portugal have the highest percentage of women relying on modern contraception (89% and 84% respectively) (1). In the least developed countries** in the world the average use of modern contraception stands at 28%. There are, however, seven countries in eastern Europe (Albania, Armenia, Azer- baijan, Bosnia and Herzegovina, Georgia, the Former Yugoslav Republic (TFYR) of Macedonia and Serbia) which have levels lower than this average and another 11 countries have a prevalence of modern contraceptive use that is lower than the average for less-developed regions*** which stands at 56% (see Figure 1). The figures are even more dramatic if traditional methods of contraception are included in the calculations of contracep- tive prevalence. In many countries, a large proportion of women try to avoid preg- nancy but rely on traditional methods to do so. In Albania, for example, 59% of women rely on traditional methods of contraception to delay a pregnancy, while only 10% use modern methods. It is worth noting that these are national-level figures and they do not illustrate the vast differences between rural and urban areas in each country (see Figure 1). The International Planned Parenthood Federation European Network (IPPF EN) and its member associations believe that women do not use modern methods of contraception for several reasons such as incorrect information, poor counseling, high costs and lack of choice. In an effort to gather evidence to gain a better under- standing on the factors that influence women’s access to and use of modern methods of contraception, the IPPF EN member associations of Armenia, Bosnia and Herzegovina, Bulgaria, TFYR of Macedonia, Serbia and Kazakhstan and a partner organization in Azerbaijan, un- dertook in 2011 a qualitative analysis of behavioural patterns and cultural norms influencing contraceptive access and use. The study was conducted in collaboration with and funded by the UNFPA eastern European and central Asian Regional Office. A key aspect of the study was its focus on the client perspective and his/her reasons for (not) using modern methods of contraception. This qualitative analysis was based on focus-group discussions in defined population groups, as well as in- terviews with key informants from a vari- ety of groups including service providers, governments, donors and pharmaceutical companies. Seven key factors were found to influ- ence contraceptive behaviour, demand and access: • An overarching factor is the lack of commitment of policy-makers and government agencies to contracep- tive security. Interviews with national policy-mak- ers, institutions, programme officials and donors indicated that lack of government commitment is a critical obstacle to advances in contraceptive security in each of the seven countries in the study. Even in countries where policies and programmes are in place, there are no adequate funding or im- plementation plans to translate them into action. • In general, there is huge misin- formation and distrust towards modern (hormonal) methods of contraception, fuelled by misinfor- mation and myths. Oral contraception was categorized as harmful to a woman’s health in fifty of the seventy focus groups held dur- ing this study, cutting across ethnic, economic and geographic lines. Fear seems to be rooted in a mixture of known side-effects of certain contra- ceptives that can be managed with support from a health care worker and imagined consequences that have no basis in reality. There is little doubt that concerns about safety contribute significantly to the non-use of mod- ern contraception across the whole Region. Findings also suggest that the safety factor contributes to the popu- larity of withdrawal in the countries of the Region. Withdrawal is often not the method of choice, but rather of default. Withdrawal is considered ‘normal’ for married couples and those in long-term relationships. • Young people face particular barri- ers limiting their access to contra- ception. Certain tendencies regarding the contraceptive knowledge, attitudes and behaviour of young people were apparent. Young people’s access to services is hampered by cost, but first and foremost by a lack of confiden- KEy FACToRS INFLUENCING CoNTRACEPTIvE USE: ExPERIENCE FRoM 7 EASTERN EURoPEAN AND CENTRAL ASIAN CoUNTRIES No.79 - 2013 23 Lena Luyck- fasseel tiality and lack of youth-friendly services. • The provider, viewed by (potential) clients as a trustworthy source of information and service for family planning, is not always providing correct and up-to-date information on contraceptive methods and is thus often a major source of misin- formation, often confirming rather than dispelling myths. Study results suggest that many gynaecologists base their professional advice about modern contraceptives on misinformation, outdated infor- mation and on their own personal opinions rather than on evidence- based medicine. Demanding a range of expensive and unnecessary tests before prescribing a modern method of fertility control is also widespread. These practices increase the cost of contraception and reinforce the myth that there is something inherently risky about modern family planning methods. Primary health care reforms across the Region followed by privati- zation of gynaecological health care has increased client costs for services in many places and has also affected the number of providers in certain places. Exacerbating the situation in many countries are policies that limit the types of providers allowed to prescribe contraception. Often only a gynaecologist can prescribe contra- ception. Study findings across the seven countries indicate that counseling is rarely, if ever, provided. Providers lack the skills; have poor motivation or no time to counsel women on contracep- tive choice. • A limited range of modern methods of contraception is available on the market in these countries. Choice is mainly limited to condoms, pills and intrauterine devices. A limited range of contraceptives available on the market, as well as supply-chain issues causing frequent stock-outs, are factors in non-use of modern contraception in several countries. While pharmacies are often widespread, small pharmacies often do not stock many, or at times any, contraceptives. The situation is related to insufficient demand for contraception and the pharmacists’ unwillingness to invest money in contraceptive products. • Affordability is a factor particularly present in Kazakhstan, where mod- ern methods of contraceptives are relatively expensive. In other countries, affordability is the main barrier for certain groups and segments of society. Other factors, such as unnecessary tests and services add to the cost. Cost, however, is not the deter- mining factor in use or non-use of modern contraception and in no country is it the only factor. That said however, contraceptives not being covered by national insurance funds is one of the key factors determining lack of accessibility for the poorest, the unemployed, the uninsured, the young with no access to cash and the housewives dependent on money from their husbands or mother-in- laws. In particular, modern methods are unaffordable for low-income couples, those in rural areas and sexu- ally active young people who depend financially on their parents or other relatives. • Societal expectations regarding sex and sexuality and gender power dynamics were another important factor that influence contraceptive choice. Study findings suggest that pockets of conservatism exist within each surveyed country, where it is not possible to talk openly about anything related to sex and sexuality and soci- ety dictates strict patterns of sexual and reproductive behaviour. These taboos prevent women from receiv- ing the information they need to make sound contraceptive decisions. Gender power dynamics were appar- ent in focus group discussions across the countries. Often the criterion for a “good” contraceptive was that a method could be used without the hus- band’s knowledge. The findings of this qualitative study were presented to high level government offi- cials from 16 countries in eastern Europe and central Asia. The meeting aimed to promote the development of nationally owned reproductive health commodities security strategies and policies addressing the family planning needs of vulnerable populations, based on sharing of evi- dence, in order to accelerate the achieve- ments of the ICPD Plan of Action and MDG 5b. The participants acknowledged the need for governments to increase and allocate the necessary budget for family planning and endorsed a set of recom- mendations addressing the 7 key factors identified in this study as influencing con- traceptive use and access. The full set of recommendations, the study report and a summarizing factsheet can be accessed on the IPPF EN website: http://www.ippfen. org/en/Resources/Publications/Key+facto rs+influencing+contraceptive+use.htm Lena Luyckfasseel, Programme manager, IPPF European Network, Regional office, lluyckfasseel@ippfen.org Special notes: * Contraceptive prevalence is the % of women of reproductive age using a method of contraception, composed of those who use modern or tradi- tional methods. ** Least developed countries according to standard United Nations designation. *** Less developed regions comprise all regions of Africa, Latin America and the Caribbean, Asia (excluding Japan), Melanesia, Micronesia and Polynesia. References 1. State of the World Population 2012. New York: UNFPA, 2012. Available at: www.unfpa.org/public/home/publica- tions/pid/12511. Accessed 15 October 2013 24 Reproductive choices and family planning for people living with HIV, Counselling tool, WHO, 2007. Designed to help health care providers counsel PLHIV on family planning and sexual and reproductive health, this very useful tool also empowers PLHIV to make and exercise informed, appropriate decisions about their sexual and reproductive health and lives. Available in English, Spanish and French at: http://www.who.int/reproductivehealth/publications/family_planning/9241595132/en/index.html UNMET NEED FoR FAMILy PLANNING oF PEoPLE LIvING WITH HIv IN EURoPE: A NEGLECTED PUBLIC HEALTH ISSUE In 2011, an estimated 34 million people worldwide were living with HIV(1). Over the last 20 years, sig- nificant improvements in the survival of HIV-infected patients treated with highly active antiretroviral therapy (HAART) have changed the perception of diagnosis of HIV from invariably fatal to a medi- cally manageable chronic disease (2). In resource-rich settings, people living with HIV (PLHIV) may live on aver- age 35 additional years after their HIV diagnosis (3). In Europe, the prevalence of HIV and the proportion of women with newly acquired HIV continue to rise. In 2011, the estimated number of PLHIV in Europe was 2 300 000. In the same year, there were 27 963 new HIV infec- tions officially reported among men and women in the European Union/European Economic Area region. As many as 75.8% of the new cases were aged between 20 and 49 years — the fertile age group, as defined by the official HIV/AIDS surveil- lance system adopted by the European Centre for Disease Prevention and Con- trol (4). The HIV epidemic in Ukraine is the fastest growing in Europe, with 1.63% of the population estimated to be HIV positive (5). It has been suggested that owing to low access to, and uptake of, HIV testing and counseling in Europe, especially among the populations most at risk of infection and transmission, all HIV cases are not diagnosed (6). In the context of the changed perspec- tive of HIV as a medically manageable chronic disease, it is reasonable to expect that PLHIV will have sexual and repro- ductive aspirations just like the rest of the population. Of course, most infected people have a strong fear of transmitting HIV to the partner or child, as shown by a study in Denmark (7), but for that reason alone, many infected people will need sexual and reproductive health services, especially advice related to safe contracep- tion. And, since the vast majority of PL- HIV are of reproductive age, they will also need health-care services for safe planned, as well as, unintended pregnancies. Preventing unintended pregnancies is a key goal of efforts to expand contra- ceptive use among women living with HIV. Several authors have highlighted the substantial contribution that family planning can make to reducing mother- No.79 - 2013 Marleen Temmer- man Moazzam Ali 25 to-child transmission of HIV (MTCT) by decreasing the frequency of unintended pregnancies among women living with HIV (8, 9). A study in Ukraine reported an unac- ceptably high proportion of the study population of post-natal HIV-positive women were using ineffective or unreli- able methods of contraception, or none at all, and thus were at risk of future unintended pregnancy. The study also reported that use of oral contraceptives, injectable contraceptives and intrauterine devices (IUDs) was low and many report- ed lack of affordability as a key barrier to accessing family planning services (10). Unintended pregnancy among HIV- infected women may elevate risk of both MTCT and infant abandonment, particularly by marginalized women (e.g. injection drug users, illegal migrants). A recent United States-based study found rates as high as 86% of unplanned pregnancies among women living with HIV who conceived after their HIV di- agnosis. Some western European studies have indicated that around half (51–58%) of pregnancies among HIV-infected women are unintended (11), whereas in a Russian survey of HIV-positive women, 54% of those who had recently completed their pregnancy reported that it was unintended (12). Recently, a multicentre study of PLHIV consulting HIV outpatient-clinics in 13 European countries (Austria, Belgium, the Czech Republic, Germany, Greece, Hungary, Italy, Latvia, Poland, Portugal, Slovakia, Spain and the United Kingdom) (13) indicated that the proportion of women with an unmet need for fam- ily planning was much higher (28% not wanting to become pregnant) than that in the general population in Europe (less than 10% in most European countries). It also reported that almost one third of women who had become pregnant since their HIV diagnosis had had their preg- nancy terminated. These findings strongly highlight the need for both adequate con- traceptive provision to prevent abortions and for post abortion and post-partum contraceptive counseling to women living with HIV. Moazzam Ali, Epidemiologist, Dept. of Reproductive Health and Research, WHo headquarters, Geneva, alimoa@who.int Marleen Temmerman, MD, PhD, Director, Dept. of Reproductive Health and Research, WHo headquarters, Geneva, temmermanm@who.int References 1. Global Report, UNAIDS Report on the Global AIDS Epidemic 2012. New York: UNAIDS, 2012. Available at: http://www.unaids.org/en/media/ unaids/contentassets/documents/ epidemiology/2012/gr2012/ 20121120_UNAIDS_Global_Re- port_2012_with_annexes_en.pdf. 2. Lohse N, Hansen AB, Gerstoft J et al. Improved survival in HIV-infected persons: consequences and per- spectives. J Antimicrob Chemother 2007;60: 461–3. 3. Finocchario-K, Essler S, Sweat MD et al. Understanding high fertil- ity desires and intentions among a sample of urban women living with HIV in the United States. AIDS Behav 2010;14:1106–14 . 4. ECDC/WHO. HIV/AIDS Surveillance in Europe, 2011. Accessed 27 March 2013 from: http://www.ecdc.europa. eu/ 5. 2008 Report on the Global AIDS Epi demic. Geneva: UNAIDS, 2008. 6. WHO. Regional Office for Europe. http://www.euro.who.int/en/health- topics/communicable-diseases/hi- vaids/data-and-statistics 7. Laursen T, Kesmodel U, Højgaard A et al. Reproductive patterns and fertility wishes among HIV-infected patients: survey from six outpatient clinics in Denmark. Int J Infect Dis 2013;17: e851–e856. 8. Reynolds HW, Steiner MJ, Cates W: Contraception’s proved poten- tial to fight HIV. Sex Transm Infect 2005;81:184–185. 9. Sweat MD, O’Reilly KR, Schmid GP et al. Cost-effectiveness of nevirapine to prevent mother-to-child HIV trans- mission in eight African countries. AIDS 2004;18:1661–1671. 10. J. Saxton R, Malyuta I, Semenenko I et al. Previous reproductive history and post-natal family planning among HIV-infected women in Ukraine. Hum Reprod 2010;25 (9) 2366–2373. 11. Floridia M, Tamburrini E, Bucceri A et al. Pregnancy outcomes and antiretroviral treatment in a national cohort of pregnant women with HIV: overall rates and differences according to nationality. BJOG 2007;114:896– 900. 12. Vartapetova N, Karpushkina A, Ful- lem A et al. Family planning needs of HIV-positive women in Russia: data of the Maternal and Child Health Ini- tiative. WEPE0835. XVI International AIDS Conference, Toronto, Canada, 13–18 August, 2006. 13. Nöstlinger C, Desjardins F, Dec J. Child desire in women and men living with HIV attending HIV outpatient clinics: Evidence from a European multicentre study. Eur J Contracep Repr 2013;18:251–263. 26 RESoURCES Task shifting to improve access to contraceptive methods, WHO, 2013. A perfect summary for decision makers working to improve access to FP, outlining the WHO recommendations on the cadres ranging from lay health workers to mid-level providers that may be trained and supported to pro- vide increased access to contraceptive methods safely. Available in English and French at: http://www.who.int/reproductivehealth/publications/family_planning/task_shifting_access_ contraceptives/en/index.html Programming strategies for postpartum family planning, WHO, 2013. Designed for programme planners and managers, this excellent resource outlines how to integrate FP into existing postpartum programmes as part of national strategies. Available in English at: http://www.who.int/reproductivehealth/publications/family_planning/ppfp_strategies/en/index.html Selected practice recommendations for contraceptive use, Second edition, WHO, 2004. This guide provides guidance on how to provide contraceptives, with the goals of maximizing effectiveness and managing side effects and other problems. The 2008 update on the guideline summarizes changes made based on new evidence and is also available at the following link. Available in English, French, Arabic, Spanish, Romanian and Russian at: http://www.who.int/reproductivehealth/publications/family_planning/9241562846index/en/index.html Family planning: a global handbook for providers, 2011 Update, Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs, USAID and WHO, 2011. An essential resource for health care providers providing FP, this handbook provides practical guidance on all ma- jor contraceptive methods to allow better care for all people. Available in Arabic, Chichewa, English, Farsi, French, Hindi, Portuguese, Romanian, Russian, Spanish, Tajik at: http://www.who.int/reproductivehealth/publications/family_planning/9780978856304/en/index.html State of World Population 2012. By Choice, Not By Chance: Family Planning, Human Rights and Development, UNFPA, 2012. The 2012 report analyzes FP challenges, data and trends to understand who is denied access and why, emphasiz- ing the social and economic impact of family planning as well as the costs and savings of making it available to everyone who needs it. Available in English, French, Russian, Arabic and Spanish at: http://www.unfpa.org/public/publications/swps Contraceptive Commodities for Women’s Health. Key Data and Findings, UNFPA, 2012. This report highlights the importance of improving access to contraceptive commodities to achieve reproductive health for all and provides a review of three contraceptive commodities that are considered to be overlooked or underutilized: the female condom, hormonal implants and emergency contraception. Available in English at: http://www.unfpa.org/public/home/publications/pubs_rh The Rights to Contraceptive Information and Services for Women and Adolescents. Briefing Paper, UNFPA and the Center for Reproductive Rights, 2011. A practical guide, this briefing paper assesses the benefits of contraceptive access, lays out the human rights frame- work and provides an overview of how to apply a human rights-based approach to the provision of contraceptive information and services. Available in English at: http://www.unfpa.org/public/home/publications/pid/7267 The Global Programme to Enhance Reproductive Health Commodity Security, Annual Report, 2012, UNFPA, 2012. This annual report describes results and good practices in 46 countries of the UNFPA flagship thematic fund to achieve reproductive health commodity security and build global momentum in FP. Available in English at: http://www.unfpa.org/public/home/publications/pubs_rh 27 No.79 - 2013 Lisa Avery Reducing Unmet Need for Family Planning. Evidence-based Strategies and Approaches, PATH and UNFPA, 2008. A quick read, this publication offers clear suggestions for programme managers to address unmet need for family planning in the face of current political, financial and health-systems challenges. Available in Engish at: https://www.unfpa.org/public/home/publications/pid/1386 From evidence to policy: expanding access to family planning, WHO and HRP, 2012. Developed to inform the Family Planning Summit held in London in July 2012, this excellent series of policy briefs summarizes the latest evidence on family planning as a critical health and development issue and a key intervention for the survival of women and children. Available in English at: http://www.who.int/reproductivehealth/publications/family_planning/policybriefs/en/index.html The Lancet Series on Family Planning, The Lancet, 2012. The new Lancet Series brings together the latest thinking and evidence on FP, showing how lack of access to FP carries a huge price, not only in terms of women’s and children’s health and survival but also in economic terms. Available in English at: http://www.thelancet.com/series/family-planning Women’s Lives, Women’s Voices: Empowering women to ensure family planning coverage, quality and equity, Report, CARE, 2012. Launched prior to the London Family Planning Summit, this report provides an excellent overview of the current status and challenges facing FP and outlines strategic approaches that will help reduce the unmet need for FP globally. Available in English at: http://www.care.org.au/document.doc?id=884 Revising unmet need for family planning, DHS Analytical Studies No. 25, Bradley SK, Croft T,Fishel J and Westof C, 2012. Using data from 169 DHS conducted in 70 countries over the last 20 years, this report presents a new standard definition of unmet need that can be consistently applied over time and across countries and shows the impact of the revising the definition on estimated levels of unmet need. Available in English at: http://www.measuredhs.com/publications/publication-as25-analytical-studies.cfm Upcoming Events 13th Congress of the European Society of Contraception and Reproductive Health: Challenges in Sexual and Reproductive Health May 28–31, 2014 — Lisbon, Portugal North American Forum on Family Planning October 10–13, 2014 — Miami, Florida 7th Asia Pacific Conference on Reproductive and Sexual Health and Rights January 21–24, 2014 — Manila, Philippines Useful websites International Planned Parenthood Federation European Network (IPPF EN): www. ippfen.org CONRAD: Leaders in Reproductive Health and HIV Prevention: www.conrad.org European Consortium for Emergency Contraception: www.ec-ec.org Center for Reproductive Rights: www.reproductiverights.org Measure Evaluation: www.cpc.unc.edu/measure UNFPA: www. unfpa.org WHO Family Planning: www.who.int/topics/family_planning/en CARE International: www.care-international.org The European Magazine for Sexual and Reproductive Health WHO Regional Office for Europe Division of Noncommunicable Diseases and Health Promotion Sexual and Reproductive Health (incl. Maternal and newborn health) UN City Marmorvej 51 DK-2100 Copenhagen Ø Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 www.euro.who.int/entrenous
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Entre Nous: the European magazine for sexual and reproductive health: no. 79: choices and planning
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