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Seminar on "Reproductive Health Issues in Central and Eastern Europe, and Countries of the Former Soviet Union" Bucharest, Crowne Plaza Hotel, 17 - 20 October 2004

The IUSSP Committee on Reproductive Health sponsored a seminar on Reproductive Health Issues in Eastern Europe and the Former Soviet Union, in Bucharest, Romania, from 17-20 October 2004. The local host institution, collaborating with IUSSP, was the Eastern European Institute of Reproductive Health (EEIRH). The EEIRH, located in Targu Mures, Romania, conducts projects of research, training, information-education-communication and behaviour change and provides services in the different areas of sexual and reproductive health as well as topics related to demographic change. Their international partners and donors include WHO, UNFPA, UNICEF and USAID.

The scientific panel included three members of the committee, Gigi Santow (Chair), Leo Morris and Susheela Singh. Non-IUSSP institutions providing funding for the seminar included UNFPA, WHO, and the Swiss Red Cross.

The goal of the seminar was to examine the state of reproductive health in the former socialist countries of Eastern Europe and the Former Soviet Union, now undergoing transition to a market economy, to assess the impact this transition has had on reproductive health care and demographic change. Papers evaluated the state of knowledge and data on reproductive health in the region with the objective of highlighting populations most at risk and in need of reproductive health care interventions. Topics included HIV/AIDS and STIs, induced abortion trends and the role of modern contraception in reducing abortion rates, maternal health, fertility and infant mortality issues, and the state of service provision.

The seminar was attended by 28 participants, 10 observers from donor agencies and the Ministry of Health, and 4 administrative staff. The 28 participants came from 12 countries with the following regional breakdown: 15 from Eastern Europe, 5 from Western Europe, 4 from the United States, 3 from the Former Soviet Union and 1 from Asia. Twenty (71%) of the 28 participants were female and 16 (57%) could be considered to be at a junior career stage.

There were 25 presentations divided into 10 sessions. In addition, in an opening overview presentation, Dr. Florina Serbanescu, from Romania, spoke about “Reproductive Health in Transition Countries in the European Context”. This overview presentation provided excellent background for the papers to follow in the 10 sessions. The 10 session themes were as follows:

1. Contraception and Abortion: Romania
2. Contraception and Abortion: Russia and the Baltics
3. Cervical Cancer
4. Reproductive Health Issues: Romania
5. Contraception and Abortion: Caucasus Region
6. Pregnancy Outcome/ Unintended Pregnancy
7. Reproductive Health Issues: Russia, Poland and Serbia
8. Special (at risk) Populations
9. Young Adults
10. Qualitative Studies

Discussants for the sessions included Howard Goldberg, Henry David, Merce Gasco, Florina Serbanescu, Mihai Horga, Gigi Santow, Leo Morris, Noreen Walsh, Irina Dinca and Adriana Baban.

The first session on abortion and contraception in Romania highlighted the history of abortion legislation in Romania, including the Ceausescu years when contraception and abortion were not legal, and the decline in maternal mortality since the overthrow of Ceausescu and the legalisation of contraception and abortion. Between 1993 and 1999, modern contraceptive use among married women increased from 14% to 30% and condom use among unmarried women doubled. The maternal mortality ratio declined from 160 per 100,000 live births to 40 per 100,000 in this same period.

The second session included three papers on trends in contraceptive use and abortion in Russia and Estonia. One of the papers also touched on the problem of increasing HIV/AIDS and sexually transmitted infections in Russia. There was a change in themes in the third session, which covered cervical cancer issues in Bulgaria and Romania. The percentage of women who have had cervical cancer screening in this region is much lower than in Western Europe.

Session 4 included papers on reproductive health issues in Romania, including the problem of domestic violence. Session 5 returned to the issue of contraception and abortion, this time in the three countries of the Caucasus region. The total abortion rate in these three countries, Georgia, Armenia and Azerbaijan, are the highest in the former Soviet Union ranging from 2.6 to 3.7 per woman. Among the 12 countries in this region with a recent Reproductive Health Survey (RHS) or Demographic Health Survey (DHS), modern contraceptive use is lowest in these three countries ranging from 12 to 22 percent.

The next session on pregnancy outcome and unintended pregnancy was highlighted by Henry David’s presentation on the 35 year Prague study, which followed the children of denied abortions and a control group of children following wanted pregnancies in that time period. The session also included two papers describing studies in Russia. Session 7 returned to reproductive issues, this time in Russia, Poland and Serbia.

The session on special (high risk) populations included studies on the Roma population in Romania, refugee populations in Serbia and military conscripts in Russia. The next to last session on young adults included presentations on the patterns of marriage, sexual debut, premarital sex and unprotected sex in Bulgaria and Central Asian countries. The last session was devoted to qualitative studies that included papers on studies from Estonia and Romania.

At this seminar, common reproductive health issues were identified as well as important differences and gaps in knowledge, as well as behaviour, in the region. Study results based on research data were linked to the necessity of improving policy formulation and service programmes, and recommendations were made on methodological issues that warrant further study. The discussions following each paper and the final session devoted to the discussion “What do we know? What don’t we know? : Implications for intervention and further research” highlighted the following issues:

1. Under-reporting of infant mortality: There is a general consensus among demographers that governmental official infant mortality rates for many countries in this region are underestimated and a number of studies, including the RHS and DHS surveys, have provided mortality estimates that exceed government reported rates. Surveys in eight countries with a RHS or DHS estimate the infant mortality rate to be from 1.5 to 4.3 times higher than the official rate. Clearly, the official reporting of infant mortality in many countries of the region needs to be evaluated and improved.

2. Underreporting of abortion: There is also a problem of official reporting of legal abortions in these countries. In most countries, survey based estimates of abortion were higher than government estimates for the same period of time – several times higher in the case of Armenia, Azerbaijan and Georgia Also, across surveyed countries, there was a clear positive relationship between the abortion level and reliance on traditional methods of contraception (withdrawal and calendar methods) .The greater the traditional component of method use, the higher the level of abortion.

3. Lack of reliable data on the level and of HIV/AIDS and other sexually transmitted infections.

4. Policy issues related to declining fertility rates: The total fertility rate (TFR) in eastern Europe and the Caucasus region range from 1.1 to 2.1 and has been declining in the 1990’s. How do you resolve the policy maker’s concern regarding declining fertility and the right of couples to have the number of children they want within a good system of providing reproductive health services?

5. Excellent discussions touched on the use of qualitative data to complement quantitative data.

6. Premarital sexual experience is increasing in the region. How do you improve/introduce age-appropriate health/sexuality education both in schools and outside of schools?

7. Other reproductive health issues needing better studies included smoking during pregnancy and second hand smoke, trafficking of women, and how to reach at-risk populations such as the Roma and refugee populations.

8. An overriding issue for both improving services and reporting systems, and high quality demographic and reproductive health research, is the shortage of funds. Related to this is the challenge of changing the emphasis on curative medicine, as seen in the socialist years following 1945, to quality preventive services, and how to involve the private sector and civil societies to complement the public sector.

A unique aspect of this seminar was the interchange between demographers and medical professionals working on reproductive health issues. The nationally representative survey data on key demographic and health indicators produced by both the RHS and DHS has introduced the advantage of population-based surveys to this region. The results of these surveys can be used to design or modify health interventions, identify high-risk behaviours amenable to change and highlight demographic and reproductive health issues that need greater attention.

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