Highlights 2007

Department of Reproductive Health and Research including UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP)

About the Department

The mission of the WHO Department of Reproductive Health and Research (RHR) is to help people to lead healthy sexual and reproductive lives. In pursuit of this mission the Department endeavours to strengthen the capacity of countries to enable people to promote and protect their own sexual and reproductive health and that of their partners, and to have access to, and receive, high-quality sexual and reproductive health services when needed. RHR was established in November 1998 by bringing together the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) and the former WHO Division of Reproductive Health (Technical Support) (RHT). The purpose of joining these two entities was to facilitate integration of research and policy and programme development in sexual and reproductive health within WHO.

About HRP

HRP was established in 1972 by WHO. In 1988, the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA), and The World Bank joined WHO as the Programme’s cosponsors. The four cosponsoring agencies, together with the major financial contributors and other interested parties, make up the Programme’s governing body, the Policy and Coordination Committee (PCC), which sets policy, assesses progress, and reviews and approves the Programme’s budget and programme of work. Broad strategic technical advice on the Programme’s work is provided by the Scientific and Technical Advisory Group (STAG). In 1999, STAG assumed the responsibility for reviewing, and advising on, the work of the whole Department. The Scientific and Ethical Review Group (SERG) Panel reviews all HRP projects involving human subjects and research in animals and contributes to ethical debate on matters relating to sexual and reproductive health. The Toxicology Panel is a complementary review body to the SERG Panel. It provides expertise in the evaluation of pharmacokinetic, metabolic, endocrinological, toxicological, teratogenicity, carcinogenicity and mutagenicity studies of drugs or devices developed or studied by HRP or referred to it for advice. In addition, the Programme has several specialist and regional advisory panels that provide guidance on detailed research and research capacity building strategies.

Promoting family planning

Family planning: a global handbook for providers – the fourth and final “cornerstone”(1) of evidence-based guidance for family planning – was published and distributed widely (40 000 copies). This handbook, which is being translated into 11 languages, was developed in partnership with the INFO Project at Johns Hopkins University/ Center for Communication Programs (JHU/ CCP), with the collaboration of nearly 50 other agencies.
Two information briefs for health-care providers were developed (Does hormonal contraception modify the risk of STI acquisition? and Hormonal contraception and bone health) and published on the Department’s Internet web site.

In Cape Town, South Africa, a clinic-based survey of providers and clients of HIV services (involving 285 women and 140 men) found that 81% of women and 70% of men were sexually active. About half of the respondents said that they did not wish to have another child. About 19% of the women reported experiencing a pregnancy since knowing their HIV status: 61% of those pregnancies were unplanned. As a result of this research, local health-care policy-makers are exploring ways of providing integrated family planning and HIV services.
A Phase III trial of testosterone undecanoate as a male hormonal contraceptive was completed in 2007. This study involved over 1000 Chinese couples who used testosterone undecanoate as their contraceptive method for two years. The failure rate – defined as the percentage of men whose sperm concentrations did not adequately suppress plus those who caused a pregnancy or whose sperm concentrations rebounded – was calculated at 7.05 per 100 couple–years. The method was considered acceptable; its use did not lead to any serious adverse events.
A training and job aid entitled Reproductive choices and family planning for people with HIV was finalized and published in partnership with the INFO Project and the WHO Department of HIV/AIDS. An adaptation guide was also developed by the Department and will be published on CDROM along with the training materials and electronic files for adaptation.

Improving maternal and perinatal health

Oxidative stress has been implicated as a potential cause of pre-eclampsia. To test whether pre-eclampsia could be prevented by taking antioxidants, such as vitamins C and E, a randomized controlled trial involving 1400 women, was conducted in India, Peru, South Africa and Viet Nam. The results showed that vitamins C and E supplementation is unlikely to decrease the risk of pre-eclampsia.
A paper entitled “Blood pressure dynamics during pregnancy and spontaneous preterm birth” based on the data from the WHO calcium supplementation trial for the prevention of pre-eclampsia in pregnant women with low dietary intake of calcium was published in the American Journal of Obstetrics and Gynecology. This paper reports that a rise in either systolic pressure of over 30 mm Hg, or in diastolic pressure of over 15 mm Hg, from early pregnancy to the mid-third trimester is associated with spontaneous preterm birth in a dose– response pattern.
A systematic review of maternal infection and risk of pre-eclampsia was published. This review concluded that there were no associations between pre-eclampsia and the presence of antibodies to Chlamydia pneumoniae, Helicobacter pylori, and cytomegalovirus, treated and non-treated HIV infection, and malaria. Similarly, infection with herpes simplex virus type 2, bacterial vaginosis, and Mycoplasma hominis was not associated with pre-eclampsia. However, urinary tract infection and periodontal disease in pregnancy were associated with an increased risk of pre-eclampsia.
A second systematic review on theories of pre-eclampsia and the role of angiogenic factors, published in the journal Obstetrics and Gynecology, concluded that elevation of soluble Fms-like tyrosine kinase-1 receptor (sFlt-1) and fall in placental growth factor during the third trimester are associated with pre-eclampsia.

Controlling sexually transmitted infections (STIs) and reproductive tract infections (RTIs)

In 2006, the World Health Assembly adopted the Global strategy for the prevention and control of sexually transmitted infections: 2006–2015. In June 2007, a meeting of experts was held in Geneva, Switzerland, to develop a global action plan for implementation of the Strategy. Based on this plan, and with technical assistance from the Department, the WHO Regional Offices have developed (Regional Offices for the Eastern Mediterranean, South-East Asia and the Western Pacific), or are in the process of developing (Regional Offices for Africa, the Americas, and Europe), their respective regional plans for the implementation of the Strategy.
Comprehensive cervical cancer control: a guide to essential practice was published in 2006. In 2007, this comprehensive guide to the prevention, screening, treatment and palliation of cervical cancer was translated into all six official languages of WHO.
The Programme is conducting a large randomized controlled trial (the Kesho Bora study) to optimize the use of antiretroviral treatment during pregnancy to preserve the health of the mother, minimize side-effects and reduce the risk of vertical transmission of HIV. In 2007, recruitment of study participants was initiated in two new sites in South Africa (Durban and KwaMsane), in addition to Bobo Dioulasso in Burkina Faso and Mombasa and Nairobi in Kenya, bringing the total number of study sites to five. By the end of November 2007, the study had recruited a total of 645 HIV-positive pregnant women, 75% of whom have indicated that they wish to breastfeed their baby.
During the “Women Deliver” Conference, held in London, United Kingdom, on 18–20 October 2007, Ministers of Health from Mongolia and Nigeria and Directors of the WHO Departments of Making Pregnancy Safer and of Reproductive Health and Research launched an initiative for the global elimination of congenital syphilis. A statement of commitment to the initiative prepared by the United Nations Population Fund (UNFPA) and WHO was endorsed by several countries and governmental and nongovernmental organizations.
Meetings were convened in the WHO South-East Asia, Western Pacific and European Regions to develop action plans for the strengthening of cervical cancer prevention programmes, taking into account the newly licensed HPV vaccines. A new “Community of Practice” on HPV vaccines was established as an online, global network of stakeholders for the prevention of HPV-related diseases (http://hpv-vaccines. net/home/default.ashx?returnurl = %2f).
Collaboration between the Department and the Department of HIV/AIDS on the use of male circumcision to prevent HIV transmission was strengthened. In addition, a United Nations agencies strategic planning meeting was held in Geneva, Switzerland, to agree on the plans and roles of each agency in this area, including specific responsibilities of the Department.
Work on a technical manual on male circumcision under local anaesthesia was completed. A meeting of experts was held to define quality standards for male circumcision services, and a guide on enhancing the quality of male circumcision services was developed. A review entitled “Male circumcision: global trends and determinants of prevalence, safety and acceptability” was published in collaboration with UNAIDS.

Preventing unsafe abortion

In collaboration with the Guttmacher Institute, global and regional incidence rates of safe and unsafe abortion were estimated for 2003 and a paper was published in The Lancet. The Programme also published a new document entitled Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003 (Fifth edition).
The new estimates show that 42 million abortions took place in 2003, down from 46 million in 1995, with nearly half of them (20 million) having been terminated unsafely. Some 67 000 women worldwide die each year due to complications of unsafe Fourth edition Unsafe abortion Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003 5 Fifth edition abortion. Up to 97% of all unsafe abortions occurred in developing countries. These findings were presented at a press conference organised by The Lancet as well as during the “Women Deliver” Conference in October 2007 and were widely disseminated by the mass media.
A randomized controlled trial involving 2181 women compared two doses of mifepristone (200 mg versus 100 mg) and two intervals (24 hours versus 48 hours) between the administration of mifepristone and misoprostol. The study found that the 100 mg dose of mifepristone followed 24 hours later by 0.8 mg vaginal misoprostol achieved complete abortion in 93% of women with pregnancy of up to 63 days. Efficacy of the two doses of mifepristone was similar.
The Programme collaborated with Ipas to conduct a regional workshop on applying the Strategic Approach(1) to reducing unsafe abortion and strengthening sexual and reproductive health services in sub-Saharan Africa. Among others, the workshop participants included country teams from Malawi, Nigeria, Uganda, and Zambia. These teams developed action plans for conducting strategic assessments and related activities to reduce unsafe abortion, to which Ipas and the Programme will provide financial and technical support.
A set of papers was published in a supplement to the International Journal of Gynecology and Obstetrics on the use of misoprostol for various indications in obstetrics and gynaecology. Based on a meeting of experts organized by the Programme in February 2007 at the Bellagio Study and Conference Centre in Italy, these papers provide the available evidence and guidance on how to use misoprostol for nine clinical indications.
A booklet entitled Frequently asked clinical questions about medical abortion was published in 2006. Since then, over 30 000 copies have been distributed. In 2007, the booklet was translated into Spanish and work was under way on a French version.

Gender, reproductive rights, sexual health and adolescence

With the ultimate aim of generating information on best practices related to sexuality counselling, four programmes were studied in Brazil, India, Kenya and Uganda in which sexuality counselling has been integrated successfully into some aspect of reproductive health services. Initial data show that key factors in the success of such integration are the existence of trained dedicated counsellors and an organizational culture that fosters respect of human rights and recognizes that discussions and counselling on sex and sexuality are an important dimension of high-quality sexual and reproductive health services.
Data collection was completed for the quantitative phase of a four-country (Indonesia, Mozambique, South Africa and Thailand) study on gender, sexuality and vaginal practices. Conducted as household survey to estimate the prevalence rates of vaginal practices in those countries, the study suggests that a significant number of women use products to effect changes in their vagina, particularly in relation to menstruation. In Mozambique and South Africa, women engage in the more abrasive practices of vaginal cleansing and insertion of substances. Findings from the earlier qualitative phase of the study had revealed that women use a variety of vaginal practices for the purposes of both personal hygiene and sexual performance.
The Programme’s social science and operations research initiative on adolescent sexual and reproductive health, involving 50 projects in 28 countries, continued to yield important information for policy formulation, broadening the provision of quality services, and increasing access to services for those who are most in need. Results from the following studies became available: (i) violence and non-consensual sex (Nigeria); (ii) knowledge, attitudes and risk-taking behaviour with regard to sexual and reproductive health (Islamic Republic of Iran); (iii) poverty and social vulnerability during pregnancy among adolescents (Bangladesh, Brazil); (iv) gender and sexual and reproductive health (Paraguay); (v) providers’ perspectives on family planning and abortion among adolescents (Argentina); (vi) parent-child communication on sexual and reproductive matters (China); and (vii) the impact of community-based interventions for sexual and reproductive health (China).
Field tests of the tool, Using human rights for maternal and neonatal health: a tool for strengthening laws and policies, were conducted during the period 2005–2007 in Brazil, Indonesia and Mozambique. Key recommendations from the field tests have been implemented in all three countries. Currently, the tool is being revised to focus on the five core components of sexual and reproductive health as outlined in the WHO Global Reproductive Health Strategy.
The Department has worked with three international networks of people living with HIV to develop policy and programmatic guidance for health systems on the needs and rights of people living with HIV for sexual and reproductive health care. Six papers reviewing evidence to date on different aspects of the issue were published in 2007 as a special issue of the journal Reproductive Health Matters, and a draft document on guidance for health systems was prepared. An international consultation on people living with HIV was held in Amsterdam, The Netherlands, in December 2007 at which the key issues for health systems, as well as for laws, policies and advocacy, were debated and recommendations made. These recommendations will be used for finalizing the health systems guidance in the first part of 2008.
A joint WHO/UNFPA technical consultation in March 2007 identified indicators for monitoring progress towards the goal of universal access to sexual and reproductive health at country level. However, gaps in the indicators were identified in the area of promoting sexual health. A further working group meeting on sexual health indicators took place in September 2007 to elaborate and refine a set of proposed indicators on sexual health and sexuality, sexual violence and female genital mutilation.
The Department continued to prepare reports on the sexual and reproductive health situation in selected countries for the various Treaty Monitoring Bodies. To provide practical guidance to WHO staff involved in this process, a handbook entitled Women’s health and human rights: monitoring the implementation of CEDAW on the Committee on the Elimination of All Forms of Discrimination Against Women (CEDAW) was published in collaboration with the WHO Department of Gender, Women and Health.
A new inter-agency statement on the elimination of female genital mutilation was prepared in collaboration with various United Nations agencies and other partners. The statement will be appended to a resolution on female genital mutilation to be discussed by the WHO Executive Board in January 2008 and possibly forwarded for adoption to the World Health Assembly in May 2008.
Results of the study on female genital mutilation and obstetric outcome were published in 2006 and received much media coverage. During 2007, the findings were presented in many international forums, including the United Nations Conference on the Status of Women (New York, USA) and the “Women Deliver” Conference (London, United Kingdom). One key recommendation to emerge from these meetings has been that WHO should assist the affected countries by making available to healthcare personnel training materials on how to deal with complications of female genital mutilation.

Technical cooperation with countries Inter-regional activities

An external evaluation was carried out of the WHO-UNFPA Strategic Partnership Programme (SPP) before finalizing plans for the second stage of SPP. The evaluation found that the concept of SPP had met with practically universal approval, especially in the countries where it was implemented, and the programme itself was viewed favourably within both UNFPA and WHO. The programme had helped to foster much-needed linkages between reproductive health and STIs, usually handled separately at country level.
The third global SPP implementation review workshop was held in Geneva, Switzerland, in May 2007. Achievements of SPP, lessons learnt, and future implementation needs at regional and country levels were discussed and recommendations made for global and regional plans for future collaboration.
SPP funds have been used to translate into French a full set of guidelines of the Department, covering maternal and newborn health, family planning and STIs. To introduce these guidelines to policy-makers and programme managers in French-speaking African countries, a regional SPP workshop was held in Cotonou, Benin, in December 2007. The workshop participants were also informed about the process used in the systematic introduction, adaptation and implementation of the guidelines in countries, along with examples and lessons learnt from the Department’s experience with introduction of the guidelines in Benin and Cameroon.
A global meeting of WHO Regional Reproductive Health and STI Advisers was held in Geneva, Switzerland, in April 2007. This event was used as a platform for promoting synergy within the components of the process from primary research to improved health-care services: i.e. generation of research-based knowledge, synthesis of research findings, development of best practices and normative guidance tools, provision of technical support to countries to effect policy changes, and strengthening of programmes to improve service delivery.

In February and August 2007, two technical meetings were held in Geneva, Switzerland, to formulate prequalification guidelines for the production of CuT380A IUDs and male latex condoms in conformity with the requirements established by the WHO Prequalification of Medicines Programme. These guidelines were reviewed by the WHO Expert Committee on Specifications for Pharmaceutical Preparations in October 2007 and are undergoing further external review.
Two meetings were convened in August and October 2007 to update the specifications for the CuT380A IUD and to inform the work of the Working Group within the International Organization for Standardization that is responsible for setting international standards for IUDs.

Africa and Eastern Mediterranean

The document Turning research into practice: suggested actions from case-studies of sexual and reproductive health research was published by the Department in 2006. In 2007, the framework for turning research into practice contained in it was presented to a subregional meeting of directors of research institutions and sexual and reproductive health programme managers from 10 African countries. The participants also discussed the WHO Global reproductive health strategy and the framework for implementing the Strategy, along with the African Health Ministers Plan of Action for achieving universal access to comprehensive sexual and reproductive health in the region. Following these deliberations, each country team developed an action plan for accelerating progress towards achieving universal access to reproductive health, and submitted its plan to the WHO Regional Office for Africa for support.
An intercountry meeting on the implementation of the WHO Global reproductive health strategy and the Global strategy for the prevention and control of sexually transmitted infections: 2006–2015 in nine countries of the WHO Eastern Mediterranean Region was held in Marrakech, Morocco. The participants recommended that countries should review available information and identify priority areas for research in order to develop action-oriented and cost-effective interventions. They should also raise awareness of sexual and reproductive health issues among the community to reduce stigma and broaden access to services.
Research capacity strengthening grants were awarded to 11 centres in Afghanistan, Ethiopia, Guinea, Kenya, Malawi, Nigeria, South Africa, Sudan, United Republic of Tanzania, Uganda, and Zimbabwe. Grants were also awarded to nine centres to organize research courses, workshops and seminars. Financial and/or technical support was provided for the conduct of five courses dealing with gender and reproductive rights and health systems reform. • Four workshops on ethical issues in sexual and reproductive health research were held in Ouagadougou, Burkina Faso; Khartoum, Sudan; and Tunis and Monastir, Tunisia. The Tunis and Ouagadougou workshops were regional workshops for Frenchspeaking countries. They brought together 120 researchers, clinicians and members of ethical committees from 13 countries.
The Centre de Recherche en Reproduction Humaine et en Démographie (CERRHUD) in Cotonou, Benin, and the London School of Hygiene and Tropical Medicine in London, United Kingdom, conducted a study that compared the incidence of physical and psychiatric ill-health at six and 12 months postpartum among three groups of women, those with a near-miss complication and live birth; a near-miss complication and a stillbirth or perinatal infant death; and a normal childbirth. The study found that for babies of women who had experienced a near-miss complication and who survived until discharge from hospital, the risk of the baby dying was more than 17 times greater compared with that for babies born to women in a normal childbirth.

The Americas

The introduction and implementation of WHO guidelines and tools as well as the development and updating of national norms continued in Honduras, Paraguay and Peru, under SPP. In 2007, Bolivia, Cuba and Guatemala were included in SPP activities.
A regional initiative was launched to assess the feasibility of using the indicators recommended in the Department’s document entitled Implementation framework of the global WHO reproductive health strategy. Collaborating institutions in Argentina, Brazil, Guatemala, Panama and Peru, in collaboration with the respective local and/ or national health authorities, began evaluating to what extent it was possible to obtain data for the indicators included under each of the sexual and reproductive health thematic areas contained in the document, taking into account the level and quality of health statistics and other sources of information available at country level. The findings from these assessments will be available in 2008.
With a grant from the Department, the Centre for Epidemiologic Research in Reproductive Health (CIESAR) in Guatemala City, Guatemala, organized a subregional workshop for Central American countries to help them to develop policies for the prevention of unsafe abortion and postabortion care. Participants included policy-makers, health-care managers and local health professionals from Ministries of Health of all Central American countries. The workshop yielded an extensive list of concrete steps to strengthen postabortion care programmes.
Eleven six-months grants were awarded to individual scientists for training in biomedical (10) and social science aspects (1) of human reproduction research. Four training grants were awarded to sexual and reproductive health programme officers to attend two-week courses in quality of care and in utilization of research findings. Of the four re-entry grant projects submitted for support, three were approved and funded in 2007. A small grant was awarded to the Institute for Nutritional Studies in Lima, Peru, to help the institute disseminate the local research findings of the Global Survey on Maternal and Perinatal Health.

Asia and Western Pacific

China, Indonesia, Mongolia, Myanmar, Nepal, Solomon Islands, Tonga, Vanuatu and Viet Nam were selected as countries of intensified focus to recieve support from the WHO-UNFPA SPP for the implementation of guidelines on family planning, maternal and neonatal health and RTIs/STIs. The Medical eligibility criteria wheel for contraceptive use was translated into Chinese and Mongolian and the Global handbook for family planning providers was also translated into Chinese. The WHO Reproductive health library No.9 was translated into Chinese and Vietnamese. Lao People’s Democratic Republic, Maldives and Thailand translated into local languages the Decision-making tool for family planning clients and providers.
A workshop to identify regional and national sexual and reproductive health research priorities was held in Yangon, Myanmar. The participants – representatives from 11 countries of the two regions and the International Medical Centre of Japan, staff from WHO Country and Regional Offices and UNFPA Country Technical Services Team and members of the Asia and Western Pacific Regional Advisory Panel – placed emphasis on research to improve quality of care and access to services and to develop linkages between sexual and reproductive health and RTIs/STIs and HIV.
Mongolia, Myanmar and Sri Lanka conducted national workshops to identify research priorities in sexual and reproductive health. Myanmar chose to focus on reducing maternal mortality and morbidity.
Fifteen research capacity strengthening grants – either resource maintenance grants or small grants – were awarded to institutions in the two regions. Research training grants for Master’s degree courses in epidemiology or population and reproductive health were awarded to researchers from Cambodia, Lao People’s Democratic Republic and Myanmar. Support for short-term training in advanced epidemiology was provided to three researchers from Sri Lanka. Two investigators from Indonesia and Viet Nam attended the training course in reproductive health/ sexual health research organized by the Geneva Foundation for Medical Education and Research and the Programme, in Geneva, Switzerland.
An inter-regional workshop on operations research in sexual and reproductive health was held in Bangkok, Thailand. National workshops on ethics in sexual and reproductive health research were conducted in Indonesia and Mongolia, and a workshop on ethical issues in assisted reproduction technology was organized for the ethics committees of medical faculties in Sri Lanka. A scientific writing workshop for mid-level researchers was held in Viet Nam, and a training-of-trainers workshop in scientific writing was conducted in China. Workshops on research methodology were organized in Indonesia, Mongolia and Myanmar.

Eastern Europe and Central Asian Republics

Under the WHO-UNFPA SPP, a series of introductory workshops was conducted in Uzbekistan to introduce various healthcare providers to newly adapted national guidelines on integration of reproductive health, family planning and STI services. In Turkmenistan, activities focused on the wider adoption of national family planning and STI guidelines developed and piloted in one region in 2006. The guidelines Medical eligibility criteria wheel for contraceptive use, Decision-making tool for family planning clients and providers, and Sexually transmitted and other reproductive tract infections: a guide to essential practice were translated into Russian.

Implementing best practices (IBP) in reproductive health

To disseminate widely the publication Family planning: a global handbook for providers, a series of monthly online virtual discussion forums was launched focusing on each section of the handbook.
To reposition family planning in Africa, the IBP Partnership prepared, in collaboration with the WHO Regional Office for Africa, a “Family Planning Advocacy Kit” which provides advocacy material on family planning for different audiences. This kit was introduced to policy-makers and programme managers at a workshop in Benin.
In support of the new Convention on the Rights of Persons with Disabilities, the IBP Secretariat, working with UNFPA, held a virtual global discussion forum on the challenges faced by individuals with disabilities in accessing sexual and reproductive health services. The outcome of this discussion will inform the development of a manual for use by international organizations and agencies.
The IBP Knowledge Gateway is a unique system designed by the IBP Partnership for use in technically challenged countries to support collaborative learning and knowledge- sharing through virtual “communities of practice”. The Gateway now supports over 10 000 members from 193 countries with over 400 virtual, topic-specific communities of practice. The Gateway has been used to organize and manage seven virtual global discussion forums on topics such as “Client–provider interaction in family planning and HIV integration” and “Strategic communication for behaviour change globally: the power of the media” .
A conference entitled “Scaling-up high impact family planning and maternal, newborn and child health best practices: achieving the Millennium Development Goals in Asia and the Near East - technical meeting,” held in Bangkok, Thailand, hosted 490 participants from Afghanistan, Bangladesh, Cambodia, East Timor, Egypt, India, Indonesia, Iraq, Jordan, Lao People’s Democratic Republic, Nepal, Pakistan, Philippines, Thailand, Viet Nam, West Bank and Gaza Strip and Yemen. At this conference, the IBP Secretariat organized 150 technical mini-university sessions, a technology café, management skill-building sessions, and working group sessions to prepare country plans. Each country/ territory identified the best practices they wanted to scale up and formulated initial plans.

Policy and programmatic issues in sexual and reproductive health

The Paris Declaration, endorsed by over 100 governments and United Nations and other organizations on 2 March 2005, is an international agreement to harmonize and manage aid in line with a set of monitorable actions and indicators. UNFPA and the Department developed a comprehensive work plan for 2008–2010 to increase the capacity of UNFPA and WHO Country Offices to work in the new aid environment following the Paris Declaration and to strengthen their respective linkages with civil soci- Highlights 2007 ety organizations. Under this work plan, a joint UNFPA and WHO capacity building workshop on the new aid environment in Africa was held in December 2007 in Addis Ababa, Ethiopia.
Strengthening management capacity at the subnational level to implement public– private partnerships in sexual and reproductive health care is a pressing challenge in most countries. A report summarizing three case-studies of how district-level officials in India have managed contracting out of reproductive and child health-care services was published in 2007.
A study in Egypt investigated the effect of a performance-based payment scheme on the performance of reproductive healthcare service providers. The study found statistically significant improvements in the quality of care provided related to family planning, antenatal care and child care. The Ministry of Health in Egypt is using these findings as evidence for the need to scale up the implementation of the performance-based payment scheme in the country.
The Programme led an external evaluation of a 10-year health project conducted in 97 rural counties in China with funding support from the World Bank and the United Kingdom Department for International Development (DFID). The evaluation concluded that the project had helped to improve the performance of the health system which helped to accelerate improvements in maternal health outcomes at a faster pace compared with non-project sites.
Using the Strategic Approach, a strategic assessment addressing the prevention of unsafe abortion was conducted in Macedonia, while a strategic assessment on the prevention and treatment of reproductive tract and sexually transmitted infections was conducted in Viet Nam. In Peru, Reprolatina (a Brazil-based nongovernmental organization) helped the School of Public Health of the Cayetano Heredia Peruvian University in Lima to develop and implement a course on the Strategic Approach.
A Stage II operations research study was conducted in Yunnan, China, to develop and evaluate interventions to increase access to better quality family planning and related sexual and reproductive health services for urban migrants in both the public and private sectors. The study was completed in 2007 and the final report was disseminated at a meeting sponsored by the Yunnan provincial government. Subsequently, the Secretariat together with ExpandNet colleagues, worked with the Yunnan team to develop a strategy for scaling up the project.
In Zambia, the Department, in collaboration with the United States Agency for International Development (USAID) and the Population Council, is assisting the Copperbelt Provincial Health District in scaling-up of interventions to improve the method mix available at family planning clinics, train health-care workers, and link district communities with the health sector. Following a national dissemination workshop in 2007, scaling up activities in other provinces were started, with health-care staff from the Copperbelt province providing technical support to other provinces.
The Programme, together with the network ExpandNet, published a book presenting a literature review, theoretical framework and seven country case studies analysing experience with scaling up. In addition, guidance documents and a process intended to assist policy-makers and programme managers to develop successful strategies for scaling up of pilot and demonstration projects were developed and successfully field-tested in Kyrgyzstan, Peru, Sierra Leone and Yunnan, China.

Monitoring and evaluating sexual and reproductive health

In collaboration with the United Nations Children’s Fund (UNICEF), UNFPA and The World Bank, the Department developed global, regional and country estimates for maternal mortality in 2005 as well as global and regional trends between 1990 and 2005. The findings show that, in 2005, 536 000 women died of maternal causes, compared to 576 000 in 1990. Ninety-nine per cent of these deaths occurred in developing countries, mostly (86%) in sub- Saharan Africa and South Asia. The decline in global maternal mortality ratio was estimated at less than 1% per year between 1990 and 2005. No region achieved the 5.5% annual decline required to achieve Millennium Development Goal (MDG) 5, although East Asia came closest to the target with a 4.2% annual decline. Northern Africa, South-east Asia and Latin America and the Caribbean experienced relatively faster declines than sub-Saharan Africa, where the annual decline was only 0.1%.
The 2007 updates of the proportion of births attended by a skilled health worker were developed and disseminated widely. Worldwide, 63% of births were attended by a skilled health-care worker. Although virtually all births were attended by skilled health-care personnel in the more developed countries, the corresponding figure was 59% in developing countries and only 34% in the least developed countries.
In response to the addition of antenatal care coverage as a new MDG indicator, a database for antenatal care coverage (at least four visits) was developed in collaboration with UNICEF.
The Department continued to participate in the Interagency and Expert Group (IAEG) on MDG indicators. In 2007, the IAEG reviewed the operational implications of the modifications made to the MDG monitoring framework on the basis of the World Summit 2005. The IAEG decided to base the MDG reporting and all related products on the new framework which was presented to the UN General Assembly in October 2007. In addition to other modifications, the monitoring framework now includes a new target under MDG 5: “to achieve, by 2015, universal access to reproductive health” and four new indicators: contraceptive prevalence, adolescent birth rate, antenatal care coverage, and unmet need for family planning.
In collaboration with UNFPA, a technical consultation was convened in Geneva, Switzerland, on 13–15 March 2007 to elaborate the concept of universal access to sexual and reproductive health and provide guidance in measuring various aspects of universal access at the country level. The report of the consultation will be published in early 2008.
A workshop to increase awareness about the methods of measuring maternal mortality and findings and limitations of the 2005 global maternal mortality estimates was held for 11 English-speaking and 12 French-speaking countries in Africa in collaboration with The World Bank and UNFPA in Dakar, Senegal.
Technical assistance was provided in monitoring and evaluation as part of the ongoing project of the Family and Community Health Cluster to support the Kenyan Ministry of Health in strengthening its sexual and reproductive health programme. Technical assistance was provided also to the development of a project to test the feasibility of data collection for a range of sexual and reproductive health indicators in Latin American countries.

Mapping and implementing best practices in reproductive health

The WHO Reproductive Health Library (RHL) No. 10 was updated with 21 new Cochrane reviews and a video on “Active management of the third stage of labour.” RHL was issued in Vietnamese, in addition to the other four language versions (Chinese, English, French and Spanish).
An international scientific meeting was held in Khon Kaen, Thailand, to mark the 10th anniversary of RHL. Apart from discussing new developments in sexual and reproductive health and evidence-based medicine, the participants focused on ways of improving RHL in its second decade. In a survey conducted during the meeting, the participants agreed that: the current focus on predominantly maternal and perinatal health and fertility regulation topics was acceptable; the contents should be expanded to include guidelines; and the current practice of publishing RHL on the Internet and on CD-ROM should continue.
New systematic reviews on high-priority topics in maternal/perinatal health and fertility regulation were published (10) and existing reviews were updated (2) by the Department and its collaborating institutions.
An e-learning curriculum developed by the European Union Leonardo da Vinci programme for teaching evidence-based clinical decision-making in reproductive health was adapted by incorporating RHL content as the primary source of evidence-based sexual and reproductive health information. As a second step, a research project was launched in collaboration with Birmingham University, Birmingham, United Kingdom, and the Geneva Foundation for Medical Education and Research, Geneva, Switzerland, to test the effectiveness of the adapted curriculum.
A training workshop on evidence-based decision-making in sexual and reproductive health was conducted in the United Republic of Tanzania. Six dissemination workshops on RHL/evidence-based medicine were conducted in China (3) and Viet Nam (3).

Communication, advocacy and information

A total of 82 information materials were produced and distributed widely in 2007. Of these, nearly half were in languages other than English, illustrating the Department’s commitment to ensuring that its important publications are accessible to as wide an audience as possible.
During the period 1 January to 1 December 2007, the Internet site of the Department had an estimated 2.7 million visitors (number of sessions) who made approximately 1.4 million document downloads. Significant progress was made in making the site more multilingual – the site now hosts 127 documents in languages other than English. Also, the entire contents of the web site were published twice on CDROM, allowing those without good Internet access to obtain materials from the Department in searchable electronic form.
In 2007, four scientific writing workshops for biomedical researchers were conducted in China, Nigeria, South Africa and Viet Nam. The workshop in China was a training- of-trainers workshop in which seven researchers were trained as facilitators for scientific writing workshops. In addition, in collaboration with FRONTIERS/Population Council, a scientific writing workshop for social science researchers was held in Bangladesh.

Statistics and informatics support

Data management was decentralized or outsourced for an increasing number of projects, with the Programme providing general oversight of the work.

(1) The three other cornerstones are: Medical eligibility criteria for contraceptive use, third edition; Selected practice recommendations for contraceptive use, second edition; and The decision-making tool for family planning clients and providers.

(2) The Strategic Approach is a three-stage process to assist countries to assess sexual and reproductive health needs and priorities, test interventions to increase access to and the quality of sexual and reproductive health services, and then scale up successful models for wider implementation.

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