Addressing unmet needs for family
planning in Central Asia and Eastern
Europe
Prof Johannes Bitzer
Former President of the European Society of Contraception
and Reproductive Health
Editor in Chief of the European Journal of Contraception
and Reproductive Health Care
Member of the Executive Board of EBCOG
Key Factors Influencing Contraceptive Use in Eastern
Europe and Central Asia -Findings from a Qualitative Study
Conducted in Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria,
Kazakhstan, the Republic of Macedonia and Serbia
Recommendations for Improving
Access to Modern Contraception in the Region
Key Factors Influencing Contraceptive Use in Eastern Europe and Central Asia -Findings
from a Qualitative Study
Conducted in Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria,
Kazakhstan, the Republic of Macedonia and Serbia
Recommendations for Improving
Access to Modern Contraception in the Region
• INADEQUATE KNOWLEDGE, ATTITUDES AND
AVAILABILITY OF SERVICE PROVIDERS
– Gynaecologists are the only ones allowed to provide
contraceptive services
– Gynaecologists are misinformed and not well trained in
contraception
– Expensive unecessary tets and wrong contraindications limit
access for women to modern contraceptives
– There is a considerable lack of interest and motivation to inform
women properly and a lack of counseling skills leading to non
information and non adherence
Key Factors Influencing Contraceptive Use in Eastern Europe and Central Asia -Findings
from a Qualitative Study
Conducted in Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria,
Kazakhstan, the Republic of Macedonia and Serbia
Recommendations for Improving
Access to Modern Contraception in the Region
• A LACK OF GOVERNMENT COMMITMENT TO
CONTRACEPTIVE SECURITY
– No policies and programmes regarding family
planning
– Even in countries where policies and programs are
present there is no or very little committment
Key Factors Influencing Contraceptive Use in Eastern Europe and Central Asia -Findings
from a Qualitative Study
Conducted in Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria,
Kazakhstan, the Republic of Macedonia and Serbia
Recommendations for Improving
Access to Modern Contraception in the Region
• SOCIAL NORMS AND EXPECTATIONS
REGARDING SEX AND SEXUALITY
– Strict norms and patterns of sexual and
reproductive behavior
– Taboos around sexuality preventing women from
getting the necessary information to make
reproductive decisions in their interest
– Gender based violence
– Discrimination towards those women and men
who do not comply with the norms (minorities)
Key Factors Influencing Contraceptive Use in Eastern Europe and Central Asia -Findings
from a Qualitative Study
Conducted in Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria,
Kazakhstan, the Republic of Macedonia and Serbia
Recommendations for Improving
Access to Modern Contraception in the Region
• PERCEPTION OF MODERN CONTRACEPTION AS
HARMFUL
– Safety concerns based on myths and misinformation
keep women away from the use of modern
contraceptives
– The evidence based approach of modern medicine
acts in favour of non science based traditional
methods
– Withdrawal is regarded as the safest natural method
without taking into account the lack of efficacy
Key Factors Influencing Contraceptive Use in Eastern Europe and Central Asia -Findings
from a Qualitative Study
Conducted in Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria,
Kazakhstan, the Republic of Macedonia and Serbia
Recommendations for Improving
Access to Modern Contraception in the Region
• COST
– One factor but not a determining factor
– Lack of accesability for the poorest, adolescents,
housewifes depending on the money of the
husband
– Rural women must add the cost of travel
Key Factors Influencing Contraceptive Use in Eastern Europe and Central Asia -Findings
from a Qualitative Study
Conducted in Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria,
Kazakhstan, the Republic of Macedonia and Serbia
Recommendations for Improving
Access to Modern Contraception in the Region
• LIMITED RANGE OF CONTRACEPTIVE
METHODS RESTRICTING CLIENT CHOICE
– Limited availability on the market
– Lack of good supply chaines (out of stock
situation) especially in small pharmacies in the
countries
Bachelor Programme for EBCOG-UNFPA Joint Initiative
Day 1 - 09h00
Part 1: Knowledge
09h00 - Setting out the objectives of the course
Knowledge
09h05 - Societal factors and barriers to contraception
09h15 - Targeted history taking for the Sexual and Reproductive health care-Protocol based
approach
09h30 - Basic reproductive physiology and contraception
09h50 - Medical Eligibility Criteria
10h00 - Contraceptive Methods- 1
The big five: Most effective methods
Action, Efficacy, Safety, Side Effects, Benefits of each method
Methods applied by Health Care Professionals
IUD
Implant Injections
Methods used by the client
10h30 – COC and Progestogen pill
11h00 - Coffee/Tea break
11h30 - Contraceptive Methods- 2
Medium effective methods
Action, Efficacy, Safety, Side Effects, Benefits of each method
Barrier Methods Natural Family Planning
11h50 - Contraceptive Methods- 3
Permanent Methods of contraception (Female Sterilisation and Vasectomy)
Emergency Contraception
12h10 - Women with medical conditions
Women with cardiovascular risks
Women with cancer risks
Women with metabolic risks
Women with STI risk
Physiology
SRH History
taking
Methods
Women
with
medical
conditions
Bachelor Programme for EBCOG-UNFPA Joint Initiative
13h00-13h45 LUNCH
13h45 Sexually transmitted infections
An overview of the diagnosis, and treatment of common STIs
The epidemiology of STI in the local population and its relationship to
contraceptive needs
Teaching supported with videos and discussion
Knowledge
STI
14h30 - Sexual health issues
Coital difficulties
Sexual Violence
Teaching supported with videos and discussion
Sexual Health
15h15-15h30 - Refreshments
15h30 - Women with special needs
Adolescents (Younger women)
Women after birth
Women after abortion
Peri-menopausal women (Older women)
Migrants/Asylum seekers/Minorities
Those with disabilities
Vulnerable adults/drugs misuses/prisoners
16h45 - Discussion
17h00 - END OF DAY 1
Women with
special needs
(Life Course
approach)
Bachelor Programme for EBCOG-UNFPA Joint Initiative
DAY 2 - 09h00
09h00 - Recap of Day 1
09h15 - Unplanned Pregnancy and Abortion care
Attitudes to unplanned Pregnancy (societal, legal,
religious and local support services)
Societal options for unplanned Pregnancy (Access to
Abortion, Antenatal care, Adoption etc)
Knowledge
Abortion Care
Standards of
Care in SRH
Medical and Surgical methods of termination
10h45- 11h00 Refreshments
11h00 Delivering the Care
Setting up Local Audit to improve the standards of
Care
Leadership Skills- working as a service lead (Needs
assessment, option appraisal for the correct
Implementation
Leadership
Bachelor Programme for EBCOG-UNFPA Joint Initiative
12h00 - Part 2: Skills
Counselling skills (Pre –recorded Videos of Counselling and evaluation by a
check list) (Group Work)
13h00-13h45 - LUNCH
13h45 - Helping the woman to find the right method for her (lecture):
Decision making
14h00 - Small Group Work 1:
Four cases will be given to delegates with a check list to make a
recommendation for the women - work for 30 min feedback- 30 min
Template:
Helping the woman to find a method
Structure of the protocol:
What are the needs of the woman?
What is her profile (medical, psychosocial)
Does she already have a method in mind?
Has she already used a contraceptive method? What does she know, what are
her concerns
Are there methods she does not want?
What are her risks?
Which methods should be excluded for medical reasons?
Which methods are suitable for her (no contraindications)
Which of these methods best fits her needs and gives her additional benefits
15h00-15h15 - Coffee Break
15h15 Helping the women to use the method correctly – empowerment
Lecture: Information and Education
16h00 - Small Group Work 2
Small group work 30 min and feedback 30 min
The woman has chosen the combined pill, the progestogens only pill, the IUD:
Discussion
17h30 - END OF DAY 2
Skills
Introductory lectures
and group work
Counselling Skills
Models of Counselling
Information, Education,
Empowerment
Shared Decison making
Bachelor Programme for EBCOG-UNFPA Joint Initiative
DAY 3 – 09h00
09h00 - Recap of Day 2
09h15 - Follow up and care
09h30 - How to follow up, enhance compliance, and manage side effects09h45 - Small Group Work 3
The woman has chosen an oral combined hormonal contraceptive The woman
has chosen a progestogen only pill
The woman has chosen a progestogen injection
The woman has chosen an Implant
The woman has chosen a Copper IUD
The woman has chosen a LNG IUS
The woman has chosen the condom
The woman has chosen the diaphragm
The woman has chosen natural method of contraception
10h45 -11h00 Coffee Break
11h00 - Small Group Work 4
The adolescent
The perimenopausal women
The postpartum, post-abortion woman
11:45 Small Group Work - 5
Medical conditions: The patient with a cardiovascular, metabolic, or cancer
risk
12h30 - Discussion
Skills
Introductory lectures
and group work
Follow up Care
Enhancing adherence
Managing side effects
Managing women with
medical conditions
Bachelor Programme for EBCOG-UNFPA Joint Initiative
Skills/Attitudes
13h00-13h45 LUNCH
13h45-Practical Training in insertion and removal of LARC:
(Videos and Models)
IUDs
Subdermal implants
15h00 -15h15 Coffee break
15h15 - Small Group work: 6
Leadership project:
We will develop two scenarios and they will work out the
local strategy as discussed on day 1
Possible scenarios:
1-High teenage pregnancy rates-poor compliance with the
contraceptive methods
2- Clinic based close to the university campus- strategy to
look after young adults with active sex lives
3 - High rates of repeat Termination of Pregnancies in a
given population- socially deprived area
4- A dramatic increase in gonorrhoea in a given population
16h30- Discussion and Feedback
17h00- END OF THE COURSE
Introductory lectures
and group work
Practical Training with
LARCs
Developing a strategic
plan
Basic of
implementation,
monitoring auditing
EBCOG - UNFPA Masters Programme in Sexual And Reproductive
Health
0900-0930
Breaking the Ice: Introductions and expectations
Lectures:
0930-0950
1-What is Sexual Reproductive Health?
0950-1010
2-Mapping the factors affecting SRH of the population
1010-1030
Global challenges of SRH and its long term health
economic impact
1030-1050
Defining indicators of unmet needs for SRH Services
1050-1120
Discussion
Module 1:
Setting the
Scene
SRH Definitions
Challenges
Indicators
EBCOG - UNFPA Masters Programme in Sexual And Reproductive
Health
Module 2:
Strategy Overview
Lectures:
11h35-11h55 - National Expert:
Overview of National Strategy
11h55-12h15 - UNFPA Expert:
Regional UNFPA Strategy
12h15-12h35 - Global Experience
in delivering SRH Strategy
12h35-12h50 - Discussion
12h50-13h45 - Lunch
13h45-15h00 Introduction to
Group Work
Strategies
National and
International
Examples
Targets
EBCOG - UNFPA Masters Programme in Sexual And Reproductive
Health
Module 1 and 2
Group Work
Participants should access different data sources to find data for
their country.
Delegates will work in groups of 4 - 6 and will have on line access to
various types of data (national data base locally, WHO, World
Bank, UNFPA etc) to identify what type of data is available as
regards SRH data indicators in their own country.
Then they will apply that information against indicators identified
in the lectures as listed down below. The participants will be
expected to triangulate these data as has been described to them
in the morning lectures to set out national strategy for the future.
EBCOG - UNFPA Masters Programme in Sexual And Reproductive
Health
Module 3: Assessment of Current
Service Provision / Health
Lectures
Economics – Value for Money
15h45-16h05 - How to undertake a
helicopter view of your national SRH
service?
Providers - what do they provide?
Profiling of service providers and of
current workforce
16h05-16h25 - Contraception, STI
screening and School Sex Education
16h25-16h45 – Mother and Child Care
16h45-17h05 - Integrated SRH Healthcare
and Societal Benefit
17h05-17h30 - Discussion
Strength and
weaknesses of systems
regarding SRH/MCH
Contributing Factors
Providers
EBCOG - UNFPA Masters Programme in Sexual And Reproductive Health
Module 3
Group Work
Delegates will work in groups of 4 - 6 and will undertake a helicopter view
of the provision of their national SRH service provision. For this
exercise they will build upon the information already gathered in group exercise
1.
They will then map their service provision against the best models of care.
This will help them to undertake gap analysis of unmet needs against national
strategy.
For this exercise, unmet needs would be measured against the national strategy
and agreed outcome indicators.
They will then apply international indicators identified in the lectures to
identify gaps in the current service provision.
Finally they would postulate how added societal and economic benefits
can be achieved by proposing a more comprehensive integrated
SRH strategy and service provision.
EBCOG - UNFPA Masters Programme in Sexual And Reproductive
Health
Module 4:
Developing an Action Plan
Lectures
11h45-12h15 - Key Factors influencing
National Planning
(Human Rights Based, Gender Responsive and
Culturally Sensitive, Effective and affordable,
Technical and Organisationally Feasible, What
contribution all stakeholders will provide to
deliver the above action plan and recapping
what works best)
12h15-12h45 - Standards of Care and
Indicators
12h45-13h00 - Discussion
13h00-13h45 - Lunch
13h45-14h15 - Lecture Best Service Delivery
Model
14h15-15h15
Key factors contributing
to national level of SRH
and MCH
Targets for action plan
Content of action plan
Quality of services
Model of best Quality
EBCOG - UNFPA Masters Programme in Sexual And Reproductive
Health
Module 4
Group Work
The delegates will work in a group of 4-6. The
challenge will be to develop a national
strategy plan based on local economic and
situational analysis.
The group will analyse the existing national
strategy against the newly proposed action
plan and describe how gap analysis has been
addressed.
EBCOG - UNFPA Masters Programme in Sexual And Reproductive
Health
Module 5:
Capacity Building
16h00-16h20 - Principles of Adult
Learning
16h20-16h40 - Role of Different Levels of
Care Providers
16h40-17h00 - Implementing Training
Strategies:
Nurse practitioners (Diploma Course);
General Practitioners/Community
Gynaecologists (Bachelor Programme);
Specialists (Masters Programme)
17h00-17h20 - Continuing Professional
Development
17h 20- Discussion
Traing tools for
different HCP in
the field of SRH
and MCH
International
Networking
Exams and
Accreditation
EBCOG - UNFPA Masters Programme in Sexual And Reproductive
Health
Module 5
Group Work
The delegates will work in a group of 4-6 and apply
the key skills acquired in the previous two modules
to define national capacity building plans for the
future. They will take account of current
workforce, institutional facilities, Operational,
Infrastructure, Supply Chain and Continuing
Development Strategy in order to define the
future.
10h45-11h15 - Group Work Feedback
EBCOG - UNFPA Masters Programme in Sexual And Reproductive
Health
11h30-11h50- Special focus on Mother and
Child healthcare
Models of best care
Indicators on different levels
Identify key audiences and their position
towards MCH
Also Define governmental communication
policy, social media/internal and external
media relationship, community based
information, school education, behaviour
change communication, engaging through
opinion leaders and champions (film stars,
sports personalities etc.), engaging with
opposition to family planning and advocacy
policy.
Module 6:
Mother and Child Health
care
Model of best
care
Indicators
Audiences to
address
EBCOG - UNFPA Masters Programme in Sexual And Reproductive
Health
11h50-12h10 - Lecture Audience Analysis
Identify key audiences and their position
towards family planning, governmental policy
as regards reproductive rights, and gender
based rights.
Engaging through opinion leaders and champions
(film stars, sports personalities etc.), engaging with
opposition to family planning and advocacy policy.
12h10-12h30 Lecture Monitoring Framework
What needs to be collected? How to collect
and what tools to use? How to analyse and
How to interpret for service change?
12h30-12h45 - Discussion
12h45-13h45 - Lunch
13h45-14h15 - Lecture - Continuous
Improvement Process - Setting up Audit
Module 7:
Communication Strategy and
Monitoring
Whom to address
promoting SRH
Where are the barriers
Which data to collect
and how to evaluate
Continous improvement
EBCOG - UNFPA Masters Programme in Sexual And Reproductive
Health
Module 5
Group Work
A recent report about SRH services in your region has
demonstrated a high abortion rate among teenagers, an increased
admission rate with complications after unsafe abortions and six
maternal deaths among women under the age of twenty. The
delegates will work in a group of 4 - 6 and your task will be to
explore the underlying causes of such adverse outcomes by using
a supply chain algorithm which was discussed on Day 1. Your will
group will be asked to develop a protocol for audit and service
improvement.
Add back slides
Key Factors Influencing Contraceptive Use in Eastern
Europe and Central Asia -Findings from a Qualitative Study
Conducted in Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria,
Kazakhstan, the Republic of Macedonia and Serbia
Recommendations for Improving
Access to Modern Contraception in the Region