Entre Nous: the European magazine for sexual and reproductive health: issue no. 1: a review of a decade's work

o f the Regional Office for Europe o f the World Health Organization, with the support o f the United Nations Fund for Population Activities (UNFPA). I t may be freely translated and reprinted. Copies may be obtained from WHO, 8 Scherfigsvej, DK-2100 Copenhagen 0. This information bulletin is published periodically by the family planning unit No. 1, January 1983 ' — V ENTRE NOUS is a publication about family planning. It seeks to promote an exchange of practical information and experience among the countries of WHO's European Region and with the Family Planning programme of the Regional Office. ENTRE NOUS focuses mainly on countries in the southern, eastern and North African part of the Region. It will feature regular sections: an editorial on an important issue or programme, country reports and news on intercountry activities supported by international agencies. JEach issue will carry a short item or two on people who have made a special contribution to their national family planning programme, and last but not least, ENTRE NOUS will give the reader access to practical resources such as family planning educational material, documents and reports. ENTRE NOUS is your publication. Send us your comments, suggestions, or a short (one page) report on a family planning activity for issue no. 2. We look forward tohearing from you. Universitetsbiblioteket, 2. afd. ( 0 1 0 - ^ ) 1 2 .0 REVIEW OF A DECADE'S WORK by Wadad Haddad (Ms) Regional Officer for Family Planning The family planning programme of the WHO Regional Office for Europe started in 1972 with a series of country projects funded by the United Nations Fund for Population Activities (UNFPA) to provide support for family planning services and the training of health personnel, at first in southern and southeastern and then also in eastern countries of the Region. Intercountry meetings were organized and studies were planned taking into account that two basically different situations exist in Europe as regards family planning. On the one hand there is a gradual decline in fertility with a constant increase in the aging population in the developed countries and on the other the developing countries are experiencing an annual growth rate of up to 3.4% and have a population half of which is under 20 years of age. Nevertheless, a few basic problems are common to most countries of thd Region. - Family planning services are not fully integrated into the general health services and receive inadequate legislative support. - Health personnel lack adequate training in family planning and sexuality, especially in how to manage family planning services and how to handle their psychosocial aspects. - Workers in family planning do not benefit from an adequate international exchange of information on their counterparts' experience with family planning services and on the results of studies. 200001631690 ISSN: 1014-8485 No. 7, January 1983 EnttkNous "Family planning refers to practices that help individuals or couples to attain certain objectives: to avoid unwanted births; to bring about wanted births; to regulate the intervals between pregnancies; to control the time at which births occur in relation to the ages of the parents; and to determine the number of children in the family. Services that make these practices possible include education and counselling on family planning; the provision of contraceptives; the management of infertility; education about sex and parenthood; and organizationally related activities such as genetic and marriage counselling, screening for malignancy, and adoption services.” (WHO Technical Report Series, no. 476, 1971). - Two high risk groups in family planning, migrants and adolescents, receive less attention than they should. - In both developed and developing countries, the traditional role of men and women is changing but the consequences of this change for contraceptive practice have not yet been fully assessed. These common problems form the background for the WHO programme in family planning and sexuality. Activities over the past ten years have focused on strengthening the family planning services of selected countries, studying the integration of family planning mainly in maternal and child health services and reviewing adolescent fertility programmes. Now the focus is more and more on promotional activities for the delivery of family planning programmes. A substantial part of the WHO programme has been directed towards manpower development in family planning in collaboration with various training institutions: 17 training courses have been organized for a total of 338 participants. Part of the international courses were conducted at the country level where they had a wide impact in terms of ensuring a greater awareness and the commitment of national authorities to the promotion of national family planning programmes. They also strengthened local teaching in family planning. The training activities have led to the current development of a series of teaching modules: Sexology intended for the Teaching of Health Professionals; The Role of Health Professionals when dealing with Psychosocial Problems of Family Planning Clients; Immigrants and their Special Needs in relation to Sexuality and Family Planning intended for Health Professionals, as well as a Teaching Kit on Sexually Transmitted Diseases - Recent Developments, and a Handbook for Trainers on the teaching/learning of certain psychosocial aspects of family planning. Modules on other topics will also be prepared in the future. The WHO programme in family planning and sexuality has been actively involved in studies and research including a Country Case Study for Improved Family Planning Programmes, a Multinational Pilot Study on the Evaluation of Family Planning Programmes in Hungary, Spain and Portugal, a study on Family Planning Legislation in countries of the Mediterranean, a study on the Teaching of Family Planning in Schools of Medicine and Nursing/Midwifery and a study on Family Planning and Sex Education for Young People. Studies on Portuguese Adolescent Sexual Development, Reproductive Health and Health Service Interaction and on the Identification of Risk Factors to Maternal and Fetal Health in Adolescent Mothers in Turkey are in progress. These studies are jointly undertaken by the Family Planning Unit of the WHO Regional Office for Europe and the Family Health Division of WHO Headquarters. - 2 No. l t January 1983 In the years to come the family planning programme will give special attention to the in-country training of professionals in the management and teaching of family planning, as well as to strengthening the research capabilities of personnel and institutions where appropriate. The programme will also emphasize’activities that meet the special needs of vulnerable groups such as migrants, young people and women. It is clear that family planning as one of the components of the primary health care approach is an essential element in achieving WHO's goal of health for all by the year 2000. CountryReports PORTUGUESE MIGRANT COMMUNITIES TO GET EDUCATIONAL MATERIAL There are considerable Portuguese communities in France, the Federal Republic of Germany, the United Kingdom, and Scandinavia. The health-related problems of the women of these communities are obviously aggravated by differences in culture and by the language barrier. The official PORTUGUESE COMMISSION ON THE STATUS OF WOMEN recently implemented a three-year family planning information, education and communication project with United Nations Fund for Population Activities (UNFPA) and government funding. Among other activities this project has produced educational materials for those working in community-based projects with Portuguese migrants. The educational materials have all been extensively pre-tested and distributed in Portugal where they met approval. In spite of the high illiteracy rate, more prevalent among the over-forties, evaluation has shoyn that the permanence of the written word is of great value and that individuals or couples feel "honoured" at being presented with appropriate written material to take home and peruse at leisure and show family and friends. The following educational material is available: - "Planeamento familiar - o que 5?" (What is family planning?), an illustrated brochure on all aspects of family planning including information on contraceptive methods. For potential and actual accepters of low literacy. A colour slide-strip with cassette sound-track based on the above brochure is also available, with a written script-guide for the presentator. (Approximate cost of the kit, £35, to be ordered directly from Centro de Produqao Audio-Visual, Rua Duque de Saldanha, 2 - 7. D - 1000 Lisboa. Tel. 573341.) - Four illustrated brochures entitled "Planeamento Familiar, mdtodos" (Family planning methods) in the form of question and answer on different contraceptive methods for potential and actual users of low literacy: . "A pilula" (The Pill). . "0 dispositivo intra-uterino, DIU ou aparelho" (The IUD). • "0 diafragma e o preservative masculino" (The cap and the condom). . "Os espermicidas" (Spermicides). - Finally, "Um Filho nas Vossas Maos", (Your baby and you) is an illustrated book with simple and practical information on family planning, pregnancy, childbirth and particularly baby-care (up to two years old)• Written by Manuel Abecasio, a well-known Portuguese paediatrician. For pregnant women and young parents of medium literacy. There is special emphasis on the role of the father and his involvement in pregnancy and childrearing. Samples of this written material can be obtained free of charge by writing to Comissao da Condijao Feminina, Av. Elias Garcia, 12- 1 . , 1093 Lisboa Codex, Portugal. The Commission on the Status of Women grants free copyright of the material for reprint or adaptation purposes, provided the source is mentioned. 3 No. 1, January 1983 EntreNous MOROCCO AND WHO TO COLLABORATE MOROCCO’S NATIONAL CENTRE ON HUMAN REPRODUCTION AND FAMILY PLANNING in Rabat serves a large urban population with in-patient and out-patient clinics for obstetrics, gynaecology and family planningo It is also a referral centre for the surrounding rural areas. The Centre is linked both to the Ministry of Health and to the Medical Faculty of Rabat, with staff from both. Among its many activities, the Centre is heavily involved in training health personnel and in clinical research. Part of the research and training activities of the Centre will be intensified in the coming years as a result of a collaborative agreement signed in 1982 between the Centre and the WHO European Office. The agreement stipulates that the Centre will develop a record system for collecting clinical data on patients, which will permit the study of biological and sociocultural risk factors in pregnancy, delivery and post partum among women coming for care to the Centre. Problems of menstruation and contraception among adolescents will also be analyzed and studies will be carried out on the growth and sexual maturation of both boys and girls. These studies are important because the legal age for marriage in Morocco is 15 years, and the average age 17 to 18 years. 90% of women are married by the age of 19.a V « . In addition, research questions such as how to develop programmes for adolescents including family planning services and family life education will be examined. With respect to training, the collaborative agreement between the National Centre and the WHO European Office provides for two interregional workshops, in addition to the current training programmes for Moroccan health personnel, and one interregional seminar for francophone African and European participants. From 2*2 November to 4 December 1982 the Centre will act as host to 11 participants, (eight from the WHO European Region and three from the WHO African Region) in order to study ways and means of improving research methods concerning adolescent reproductive health. Training teachers of medical students in methods of teaching family planning will be the subject of a second interregional workshop to be organized in 1983 by the National Centre in Rabat with WHO assistance. Finally, in 1984, the National Centre will hold an interregional seminar on family planning in primary health care. a Professor T. Alaoui, Head of the National Centre; unpublished observations, 1980. SUPPORT FOR FAMILY PLANNING IN NAVARRA At the initiative of the DIRECTORATE OF HEALTH OF THE NAVARRA DEPUTATION (SPAIN), a series of regulations on sex education and family planning were proposed and passed by the Regional Parliament in 1981. The regulations provide for the recognition of sex education and family planning as essential elements of the health of the public and also establish two centres of family planning and sexual education. The centres have a multidisciplinary team composed of a gynaecologist, a psychologist, three nurses, an educator and coordinator. Also included in the staff are seven health educators attached to primary health centres in villages of the Navarra Province. According to Dr Josefina Ripoil, coordinator of the centre in Pamplona, the staff will offer contraceptive services along with sexual education in and outside the centre when it opens in December 1982. In the centre, patients ^will be informed about and receive available contraceptives. The staff also has an extensive programme in education about sexuality for different groups outside the centre: primary and secondary school teachers; young people of 14 years and 17-18 years; parents (through the schools’ parents - 4 - EntreNojs No. 1, January 1983 associations); and women (through existing centres for the promotion of women). Contacts are made with youth organizations, and programmes on sex education are organized for nurses and physicians. (Write: "Centros de Orientation Familiar y Educacion Sexual” (COFES), Diputacion Foral de Navarra, Iturrama No. 9, Pamplona, Spain.) DANISH YOUNGSTERS VISIT FAMILY PLANNING CLINICS About 60 classes of 15-16 year olds visit the family planning clinic in the city of COPENHAGEN each year. School teachers arrange these visits as part of the compulsory course on sex education in schools and as a way of introducing adolescents to family planning. During the visit, students get acquainted with the clinic and a nurse gives an introduction to the various methods of contraception. The total visit lasts approximately an hour. A few youngsters call the clinic after the visit for a personal appointment. A similar approach to introducing adolescents to family planning has now been adopted in six (out of the 26) country clinics in Denmark. (Source: Danish Family Planning Association, Aureh^jvej 2, 2900 Hellerup, Denmark.) TRAINING SCHOOLTEACHERS IN SEX EDUCATION The staff of the RUTGERS STICHTING (THE FAMILY PLANNING ASSOCIATION OF THE NETHERLANDS) feels that in most schools special sex educators are not the best solution to the need for sex education of adolescents. Teachers themselves must be able to deal with questions of sexual development among 12-16 year olds. In practice some teachers agree with this view but they don’t feel quite skilled and sensitive enough to be sex educators themselves. The Rutgers Stichting therefore now offers a ttaining programme in the teaching of sex education, which consists of six consecutive sessions of approximately four hours each and is offered on Saturdays or weekdays in the evening. The main aim of the training is to make teachers aware of two things: first, that sexuality is a personal matter, so that the educator must be made aware of his or her own sexuality, his or her own experience, attitudes and morals; and second that teaching sex education requires skill in talking about sexual topics with adolescents as well as knowledge of the facts. The programme does not promise teachers that they will become skilful sex educators, although some of them do. Others learn some methods and tricks to cope with their pupils’ questions. Others learn that they have trouble showing their own feelings and convictions• The family planning workers located near the teachers’ schools get feedback on the training programme from the teachers, and they may at times join the teachers in organizing sessions on sex education for the students. (Source: Rutgers Stichting; P.B. 17430, 2502 CK The Hague, The Netherlands.) IntercountryNews UNFPA BUDGET FOR 1982: MORE GOES TO FAMILY PLANNING Allocations by‘the United Nations Fund for Population Activities (UNFPA) to family planning programmes will be higher this year than in 1981. The UNFPA Governing Council at its 1981 session had put family planning first among its priorities for the work of UNFPA. "Grave concern", therefore, about the apparent downward trend represented by the 1981 figures was expressed at the meeting in June 1982. The UNFPA programme budget as a whole will remain at its 1982 level of $116.5 million until the end of 1985, unless UNFPA’s income increases substantially between 1983 and 1985. In 1982 UNFPA's resources will amount to about $136 million, and annual increases No. 1, January 1983 of 10% are projected for the following three years. This decision was made following a review and reassessment presented to the UNFPA Governing Council in June. Executive Director Rafael M. Salas told the Council, ’’This conservative programming approach means that allocations to projects once they are made can remain firm with less risk of being reprogrammed or rephased into future years due to resource constraints.” (Source: Population, No. 7, July 1982.) FAMILY PLANNING LEGISLATION IN MEDITERRANEAN COUNTRIES In 1981 the European Office of WHO initiated a study on family planning legislation in seven countries of the Mediterranean: Spain, Portugal, Morocco, Tunisia, Italy, Greece and Turkey. The study, which is now completed, reports significant changes in the laws affecting family planning over the past decade, such as: permitting the distribution, importation, manufacture and advertisement of all types of contraceptives; introducing maternity benefits and time off for breastfeeding; integrating family planning services into existing health services; and removing procedures for sterilization and abortion from criminal law and treating them as medical issues. During this same period, most of the countries studied have moved from a pro-natalist policy to a fertility regulation policy which emphasizes the health benefits to the mother and child. Governments have come to believe that uncontrolled population growth places an undesirable limit on the potential for socioeconomic development. These countries have also started to acknowledge the right of people to control the number and spacing of their children. The study will soon be available as a WHO publication, in the EURO Reports and Studies series. FAMILY PLANNING AND SEX EDUCATION OF YOUNG PEOPLE Another study, which assessed the current sex education programmes and family planning services for young people in the Region, will be available soon as a WHO publication. Highlights of the study will appear in the next issue of ENTRE NOUS. To follow up on this study, the Family Planning unit of the European Office of WHO organized a meeting of people working in programmes for young people, on 1-5 November 1982, at the Regional Office to discuss the situation in the Region, to review obstacles, and to develop strategies for strengthening or developing family planning and sex education for the young. The Report of the Working Group on Family Planning and Sex Education of Young People, 1-5 November, 1982, is available on request. UNESCO'S FEATURES SERVICE Information is important in the development of women's capacity for participation and self-determination in all spheres of life, including family planning. UNESCO started with the support of UNFPA a FEATURES SERVICE of women and population. The service consists of a network of writers who produce written material from their national or local perspective. Issues covered include, for example, health, fertility, nutrition, education, legal status and so on. In the region of Latin America, the Caribbean, Africa and the Arab States, a coordinator edits and distributes the features to regional news agencies. National and local newspapers and magazines then publish the material. People In December 1981, Dr GiiLER KANRA was appointed Deputy Director General of the Family Planning and Maternal and Child Health Department of the Ministry of Health and Social Assistance. She is acting for Dr Tandogan Tokgoz who is now in the National Consultative Assembly. The appointment is in recognition of Professor Kanra's keen interest in and contribution to Turkey's family planning - 6 Em^Nous No. 1, January 1983 programme. Professor of Paediatrics at the Hacettepe University Children’s Hospital in Ankara since 1979, Dr Kanra developed primary health care services in the provinces of RIZE and VAN in eastern Turkey and the first family planning services were introduced there in 1977 and 1979. She plans to establish family planning services as part of primary health care in all rural areas of Turkey, and is currently involved in establishing such services in five provinces in Eastern Turkey, which she hopes to expand to the 17 provinces of that region. CONSTANCE HOLLERAN, a nurse practitioner for many years and currently Executive Director of the Geneva-based International Council of Nurses (ICN) actively promotes the involvement of nursing personnel in primary health care and family planning. According to Miss HOLLERAN, any family or maternal and child health programme of quality must include education and services appropriate and acceptable to the people being served. Family planning is an integral part of all such programmes. Nurses and all other health personnel participating in these programmes must be prepared to understand the pros and cons of each method of family planning, the cultural practices of the people being served, and must be open and completely honest in presenting the options to the clients. The need for the "informed consent" of clients/patients, which means making a personal choice in the light of all the known facts, is essential. To the ICN, professional preparation and personal choice of the client in family planning programmes is very important. ^ etin^ R eviewed FAMILY PLANNING IN THE 80s Family planning achievements over the past two decades have been remarkable. Today, out of nearly 900 million couples worldwide, over 270 million are using modern contraception, 90 million in the developing countries. There are 118 governments that officially support the provision of family planning information and services to their people. An international consensus has also emerged that access to contraceptive services is a universal human right. Family planning contributes significantly to the improved health of women and children. In many societies, rapid population growth threatens national development goals, and family planning is considered a crucial factor in advancing social and economic development. These were some of the conclusions reached at the INTERNATIONAL CONFERENCE ON FAMILY PLANNING held in JAKARTA, Indonesia, on 26-30 April 1981. Participants from African, Asian, Latin American and Middle Eastern countries felt that despite these achievements, family planning programmes face formidable challenges. The present demand for services far outstrips available resources, and this demand is increasing. More than 500 million couples of childbearing age in developing countries currently need access to family planning information and services. This number will nearly double by the year 2000. Four components of an overall strategic approach for the future were identified at the Conference. First, family planning programmes must respond more effectively to the perspectives and needs of the people they serve. Second, they should engage local communities in the design and provision of these services. Third, family planning must be more fully integrated into other community services. Fourth, the status of women should be improved and men must take a more active role in family planning decision-making and practice. These approaches will require the strengthening of actual family planning operations which implies political commitment to obtain the necessary financial and human resources for family planning. Current national expenditure is estimated at $1 billion, or less than 50 cents per person. Current international contributions are estimated at $500 million. The Conference urged that these levels of expenditure be doubled, to reach a total of $3 billion and emphasized the crucial role of non-governmental organizations in mobilizing community resources for family planning. 7 No. 1, January 1983 EntreNous The Conference was hosted by the Indonesian government and sponsored by the UNFPA, the International Planned Parenthood Federation (IPPF) and the Population Council. A report of the Conference is available in English (shortly in French and Spanish), and the recommendations can be obtained in English, French, Spanish and Arabic. Write to Distribution Centre, IPPF, 18-20 Lower Regent Street, London SWIY 4PW, United Kingdom (no charge, except in case of bulk order, where there will be a postage charge). Educational A ids The UNIONE ITALIANO CENTRI EDUCAZIONE MATRIMONIALE PREMATRIMONIALE (UICEMP) has prepared a series of leaflets on contraception methods: la pillola (the Pill), il diaframma (the diaphragm), il preservative (the condom), gli spermicidi (spermicides), i metodi naturali (natural methods) and la spirali (the coil). These are now available from the UICEMP office. Leaflets on other topics dealing with pregnancy and delivery, hereditary diseases, sexually transmitted diseases and a booklet on family planning for adolescents will follow. The texts of the leaflets were prepared by non-medical staff. They answer questions frequently asked by people when they are deciding on a contraceptive method. Clinic clients reacted positively after reading the leaflets. The UICEMP prepared the materials to remedy the paucity of educational material on the subject of family planning in Italy. The family planning agency hopes that the Italian state family planning clinics will use the material or produce their own. (Source: UICEMP, yia E. Chiesa 1, 20122 Milano, Italy.X Wiia t To Wri te For The INTERNATIONAL CLEARINGHOUSE ON ADOLESCENT FERTILITY in Washington, DC, USA, publishes twice a year a very readable newsletter in English and French on programmes and events concerning adolescent fertility. It is called INFORMATION SUMMARY or BULLETIN D'INFORMATION. About 6000 individuals and agencies are involved in the Clearinghouse’s international network and 87% are from developing countries. Write to International Clearinghouse, 2031 Florida Ave. NW, Washington, DC 20009, USA, for a copy. UNFPA’S INFO PACK Answers to WHAT IS UNFPA? WHAT DOES IT DO? are contained in an information pack prepared by the United Nations Fund for Population Activities (UNFPA). There is a fact sheet about the aims and objectives of the Fund, its programmes and an explanation of the needs approach. Funding and information about priority countries is included. Another fact sheet gives data about the world population today together with graphical explanations. A separate chart explains the Fund’s spending. A world population wall chart presents world and country figures about population, crude birth and death rates,, gross reproduction rates, and life expectancy at birth. At present the information pack is available in English only, free of charge. French, Spanish and Arabic versions are contemplated. For a copy write to: Principal Liaison Office, UNFPA, Palais des Nations, 1211 Geneva 10, Switzerland. WHO PUBLICATIONS ON CONTRACEPTIVE METHODS WHO headquarters in Geneva has published five informative booklets on contraceptive methods for clinicians, health workers and health service administrators in recent years. They are based on a critical review of research, field trials and expert group 8 - EmisNous No, 1, January 1983 recommendations, yet they remain compact and readableo Each booklet has its particular use as suggested in the title. - Induced abortions guidelines for the provision of care and services. WHO offset publications, no. 49, 1979. English and French, 69 pages, Sw.Fr. 6. - Female sterilization; guidelines for the development of services (second edition)• WHO offset publication, no. 26, 1980. 47 pages, English and French, Sw.Fr. 4. - Gray, R.H., et al. Manual for the provision of intrauterine devices (IUDs). 1980. 51 pages, English, French and Spanish, Sw.Fr. 10. - Oral contraceptives; technical and safety aspects. WHO offset publications, no. 64, 1982. 45 pages, English and French (being translated into Spanish), Sw.Fr. 4. - Injectable hormonal contraceptives: technical and safety aspects. WHO offset publications, no. 65, 1982. 45 pages, English and French (being translated into Spanish), Sw.Fr. 4. "OPEN FILE11 For fast access to what is going on in family planning in the world, IPPF publishes twice a month the IPPF OPEN FILE. The newsletter summarizes information from newspapers, journals, documents and correspondence received at IPPF International Office, 18-20 Lower Regent Street, London SW1Y 4PW, United Kingdom (available in English only). Publications and reports, unless mentioned otherwise, may be obtained by writing to Family Planning Unit, WHO Regional Of ce for Europe, Scherfigsvej 8, DK-2100 Copenhagen 0, Denmark. L inquiries are welcomed. - 9 -ISSN: 1014-8485