The Bill and Melinda Gates Institute for Population and Reproductive Health, Makerere University's School of Public Health, and other international and national partners are organizing a conference on “Family Planning Research and Best Practices.” The conference program will include an opening plenary, multiple concurrent oral sessions, an exhibit area, poster sessions, lunchtime roundtables, a policymaker forum, and special panel presentations. More information is available at: http://www.fpconference2009.org/

The dates for the conference are November 15 (evening opening) and November 16-17 (full days) with November 18 as an optional day for third-party sponsored meetings.

The PPD ARO will be involved with this conference and is encouraging all PCCs to submit abstracts for oral sessions and poster sessions. The deadline for submission of abstracts is 1 June 2009. Information and guidelines on how to submit an abstract is at: http://www.fpconference2009.org/16701.html

Limited travel support from the conference organizers may be available to participants whose abstracts are selected for oral presentation. The conference organizers will provide you with travel support application forms with notification letters if you are selected for oral presentation.

As the PPD ARO does not currently have funding to support PCC travel to this conference, we are currently seeking funding from donors to help PCCs attend the conference. Thus, the PPD ARO would be willing to write letters of support to donors in your country (UNFPA country office, etc.) if you request. We will be happy to provide you with more information on the conference as the date nears, and would, of course, be happy to assist you with planning your logistics to the best of our abilities.

The PPD ARO contact for this conference is Mr. Abdelylah Lakssir, Programme Officer. You can reach him by email (E-mail:alakssir at ppdsec.org) or by phone (+256-772-779-714) or the general office contact: http://ppdafrica.org/contact.html

Conference website: http://www.fpconference2009.org/
Contact information: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Between 1997 and mid-2008 the World Bank Group's support for health, nutrition, and population (HNP) provided $17 billion for government-run projects in the fields of nutrition, health, and family planning. An additional $873 million was invested in private health and pharmaceutical investments. Although these numbers may seem high, a report issued last week by the bank's Independent Evaluation Group revealed that one third of the 220 projects undertaken by the World Bank HNP had failed to achieve their goals. Furthermore, the emphasis on HIV/AIDS related projects has resulted in unsatisfactory outcomes, and progress in the nutrition and family planning sectors have greatly been inhibited by such unequivocal funding measures.

According to the evaluation, 7 out of 10 AIDS projects financed by the bank had failed to achieve satisfactory outcomes. In Africa, the epicenter of the AIDS pandemic, 8 out of 10 AIDS projects had unsatisfactory outcomes, one of the bank's worst records worldwide. The report insinuated that the failure is not a result of incompetent or ineffective programmes, but rather the inability of inexperienced or weak bureaucracies to carry out such complex projects (ironically, which were encouraged by the donor). Julian Schweitzer, the World Bank’s director of health,nutrition and population, admitted that inexperience and weakness was not just at the country level, but also "sometimes our own".

To improve the effectiveness of such programmes, the report suggested a simplification of projects, a reduction in the number of government ministries involved, and a focus on more modest objectives. Also addressed, was the need to improve programmes in developing nations, with a specific focus on Africa. Middle income countries ranked adequately in their ability to carry out such initiatives, but in Africa, more than three-quarters of the projects were deemed ineffective. The World Bank Group's support for health, nutrition and population needs to make an immediate effort to concentrate resources where they are most crucially needed, and more importantly to ensure that programmes are being carried out appropriately within these regions.

Aside from the issue of programme efficiency, the report detailed another important trend in global health, namely, the disproportionate attention and funding allotted to AIDS programmes in the last decade. Since 1997, foreign assistance for global health has increased, with a specific focus on HIV and AIDS. Although it is incredibly important to deal with such a deadly disease, the focus on family planning has greatly declined as a result of this relatively new emphasis on AIDS funding. In reaction to the report, Professor William Easterly of New York University stated that the evaluation of the World Bank confirmed "a fear that many of us have had for some time: that hugely disproportionate attention to AIDS has had a negative effect on aid efforts for all other health problems."

Since 1997, nearly 60% of World Bank HNP projects have focused on AIDS, while efforts aimed at tuberculosis, malaria and leprosy were granted significantly fewer resources (malaria made up only 3% of the projects, and tuberculosis only 2%). Family planning has also been negatively affected by thedisproportionality of funds, and leaders of the evaluation group have realized the implications of this. Martha Ainsworth, lead author of the report, reaffirmed the groups commitment to increase funding for family planning by stating, "helping women control the number of children they bear is essential to reducing the high rates at which they die in childbirth in the poorest nations, the fact that no one’s been paying attention to reducing high fertility is critical for Africa."

Mr. Schweitzer, of the World Bank, strongly agreed with the evaluators call for greater efforts in family planning and nutrition, and reaffirmed the necessity of donors and recipient countries working together to coordinate projects and achieve targeted results. In recent years, PPD has advocated against global decrease in population and family planning funding, and it is our hope that such an internal evaluation will be a call to action for the World Bank Group's support for health, nutrition, and population to change their efforts. And as PPD has long recognized, an emphasis on the African region and family planning efforts are crucial to achieving progress worldwide.

To view an executive summary of the report, visit: http://siteresources.worldbank.org/EXTWBASSHEANUTPOP/Resources/exec_summary.pdf

Or you can access the entire evaluation at:http://go.worldbank.org/EI6ARNQKX0

Interested in reading more about specific countries project performance assessment reports? Then check out:http://go.worldbank.org/3764K5QNI0

In March this year, 83 Governments issued a joint statement to the United Nations Human Rights Council. Expressing concern over the unacceptably high number of women who die each year due to pregnancy related complications, the delegation urged the Human Rights Council to declare maternal mortality a human rights violation.

Each year more than 500,000 women die from pregnancy or childbirth. Most of these deaths could be prevented, and by not doing so, such inaction clearly constitutes a human rights violation. A women's right to health, life, education, dignity, access to information and appropriate healthcare are violated each and every time a preventable death occurs, and this is completely unacceptable. Reaffirming the importance of The Convention on the Elimination of All Forms of Discrimination Against Women, The International Covenant on Economic, Social and Cultural Rights, Millennium Development Goal 5, The Beijing Declaration and The International Conference on Population and Development, the delegation demanded a recommitment to such global obligations.

MDG 5 aims to reduce the maternal mortality ratio by three quarters, however, between 1990 and 2005 the global rate decreased by less than 1%. Governments and international organizations must recommit themselves to decreasing maternal mortality by 5.5% annually in order to meet set targets. Maternal mortality is an issue that affects women worldwide, and must not be looked at as a concentrated regional problem, but rather a sector of health in which continuous improvement is required.

The delegation laid out 4 keys actions that the Human Rights Council should undertake to contribute to existing efforts. Identifying the human rights dimensions of preventable maternal mortality and morbidity, reviewing and considering information on discrimination in the provision of and access to healthcare for women and discrimination against women in respect of their right to decide freely and responsibly on the number and spacing of their children, talking about the human rights implications of maternal mortality and morbidity in the universal periodic review and in treaty body dialogues, including the exchange of programmes and policies that have successfully reversed the trend of maternal deaths and injuries, and finally, requesting states to include women in decision-making about maternal health, including decisions on the design of local health care mechanisms, and to recognize women’s right to skilled professional care before, during and after pregnancy and childbirth. Goal 3 highlights the importance of South-South cooperation and sharing of good practices as an excellent tool of progression.

The Council will meet next in June of this year and it is PPD's hope that the suggestions provided by one of the largest joint-intergovernmental statements delivered to the Council will have taken effect, and that maternal mortality will be declared a human rights violation. Urgent action is needed in order to meet Millennium Development Goal 5 and to prevent thousands of unnecessary deaths, and the Human Rights Council has the ability to spur such action.

You can view the entire joint statement issued to the Human Rights Council at: http://www.womendeliver.org/news/pdf/NewZealand.pdf

The Eastern Africa Reproductive health Network was founded in 1996 to support population issues through enhanced south -south cooperation. The network has already started  galvanizing regional efforts to create and strengthen networks with in member countries sharing of experiences and expertise, transfer of skills and technologies and holding each other accountable in the areas of Reproductive Health, Population and Development. We have succeeded together in revamping this network and putting it back on track.

A four year strategic plan has been re developed and it was indeed important in providing the general framework and refocus on the merging and complex issues that need to be given priority in order to achieve the ICPD goals and the MDGs .The main focus during the coming four years will be on repositioning Reproductive Health as a central component in ensuring sustainable development through the South – South Cooperation as a modality of change.

We welcome Burundi, Rwanda and Ethiopia on board and we wish that other countries in the continent join hands together to address burning Reproductive Health issues specific to the continent.

We are confident that with the blessing of all our stakeholders, we will remain the forerunner in the pursuance of our mission.
 
Mr. Charles Zirarema
The Chairperson, EARHN

Access to information crucial in HIV fight...

One-year-old Maria sits listlessly on her mother’s lap, her frail right hand tugging at one of her mother’s breasts, while she hungrily sucks at the other.

Realising that there is nothing coming from the breast, she gives up and, laying her head on her mother’s chest, gazes into the distance.

Around her, deep inside Nalweyo sub-county, Kibaale district, children play with the neighbour’s four-month old twins. Maria’s mother, 40-year- old Federesi Kaahwa watches them. Sighing heavily, as if wondering whether her own little one will one day engage
in such antics, she turns her attention back to us.

Thin, pale and sickly, Maria has no idea what is going on in her life, or why. Her appearance strikes a chord in my heart, and my eyes quickly well with tears. Fighting them back, I think of my own one-year-old daughter back at home, and imagine that it could have been her.

Young and innocent as she is, Maria is HIV-positive. Hers is a situation many other children have known. Some have succumbed  to the disease very early on in life, while others
are still fighting, given hope by the increasing access to anti- retroviral treatment.

Maria’s fate is entwined in that of her mother, who is HIV- positive. A widow, Kaahwa’s husband died eight years ago, leaving her with four children– aged ten, eight, seven and five. Unknown to her, her businessman  husband had another wife with whom he also had four children.

Kaahwa did not consider herself to be at risk for infection until she heard messages on voluntary counseling and testing disseminated  by a project run by the Orthodox Church, supported  by the Population Secretariat. She then decided to take the HIV test.

The first test came out negative, as did the second, but the third time she was not so lucky. The test showed that she was HIV- positive. “I was advised to go to the hospital for help after this.
I am now on anti-retroviral treatment,”  she says.

After her husband’s death, Kaahwa began a relationship with a casual labourer, which resulted into Maria. The man, a target worker who had just come to the area to make some little money, later returned to his home, leaving Kaahwa pregnant.

Asked why she decided to engage in unprotected sex after finding out that she was HIV- positive, Kaahwa says “it was due to lack of information about the probable consequences.” She neither knew the partner’s HIV status nor did she think she could just been pregnant.

Even at the hospital where Kaahwa delivered from, was unaware of her HIV status, which could have contributed to baby Maria contracting the disease as available drugs to prevent mother-to-child transmission were not given to Maria upon birth. The same reason explains why Kaahwa has been breastfeeding  Maria, and is just in the process of weaning her after being advised to do so by medical personell.

Today, many people in urban areas know how children contract HIV from their mothers, and are able to seek the right avenues to prevent it. However, in the rural areas, information on HIV transmission is not widely disseminated.

In Nalweyo sub-county, where Kaahwa stays, it is not easy to access health information and services. Many women resort to Traditional Birth Attendants (TBAs) to help them give birth, because the hospital is over 20 kilometres away and they would rather spend the Ug. Sh3,500 bicycle fare on buying food for their children. What guarantee do they have, therefore, that the TBA will take into consideration the fact that the mother is on when delivering the baby to ensure it is not infected with the virus if it was not infected before? Lack of information is therefore a foe in the struggle to stem HIV infections in rural areas. Many of the public information programmes on HIV are targeted  at and concentrated in the urban areas, yet according to the Food and Agriculture Organisation (FAO), AIDS is becoming a greater threat in rural areas than in cities. In absolute numbers, more people living with HIV reside in rural areas. The epidemic is spreading with alarming speed into the remotest villages, cutting food production and threatening the very life of rural communities. Every day in the world, about
1,200 children under the age of 15 become infected with HIV, and in 2007, UNAIDS estimated there were 2.1 million children living with HIV, approximately 90 per cent of whom live in Africa. The majority of these children either acquire HIV before they are born, during pregnancy or during delivery or when they are being breastfed (if their mother is HIV-positive).

Kaahwa has been breastfeeding Maria, one avenue through which the baby could have gotten the disease. Maria is not on medication because, as her mother says, treatment is only available at the main hospital, which is difficult to reach, yet it is known that without HIV treatment and care, HIV multiplies and destroys children’s defense to infection, leaving them less able to resist pneumonia and other common childhood infections.

It is generally understood  that about 50 per cent of children who acquire HIV from their mothers die before their second birthday.

Like any other mother, losing a child, or knowing that something is wrong with them, is very heartbreaking. This is why Kaahwa has not taken any of her older children for HIV testing.
She says that at the moment they are healthy, and she is contented with that. If only things could stay that way.

By: Sylvia Nabanoba
Uganda

Through the use of a poverty tool, voucher distributors recruited by the project screen clients for eligibility before they purchase a safe motherhood (SMH) or a family planning (FP) voucher at a subsidized price of Kshs 200 and Kshs 100 respectively. With the safe motherhood  voucher, a client is entitled to access the following services from an accredited service provider: four antenatal care visits, birth by either normal delivery or caesarean section, and a postnatal care visit within 6 weeks after delivery.

The FP voucher entitles a client to access any of the following contraceptives from an accredited health facility; Implants, IUCDs, vasectomy, and tubal ligation. In addition to the services provided under the two vouchers, the project also caters for clients who require gender based violence (GBV) recovery services. Under this arrangement,  survivors of GBV are provided clinical examination, treatment, and counseling.

A client with a voucher is required to present the voucher to an accredited service provider in exchange for services. At the end of each month, the accredited service providers submit claims forthe services rendered. These claims are submitted to the Voucher Management Agency (PricewaterhouseCoopers) and the population council for processing and payment. The maximum reimbursement levels for SMH and FP services are Kshs 21,000 and Kshs 3,000 respectively. Government, private, NGO, and FBO service providers are eligible to participate in this project if they can meet the required standards for providing the targeted  services.

The basic principle of the RH- OBA project is that financing inputs does not always result in the desired health outcomes. As a change of paradigm, the project’s approach is to finance pre-defined outputs which are closely tied.

Since the inception of the RH- OBA Project in June 2006, a total of 38,945 poor SMH clients and 4,288 poor FP clients from five sites had benefited from the project as at the end of December 2007. The results of the safe motherhood  are an increase of about 20% over the number of similar clients in the accredited facilities before the commencement of the project. The distribution of these SMH and FP voucher clients is shown in the charts , Kiambu and Kisumu had the highest uptake of long-term FP methods among the poor people, though the figures are generally low. Kitui district had the lowest uptake of FP methods. In all the sites, implants were the most preferred method.

The mid term evaluation of the project was undertaken in December 2007. Findings of this evaluation show that the project’s approach has been successful in targeting the neediest clients. It also points out that this kind of approach works well in urban and peri-urban areas.
 
In the rural areas challenges related to communication hamper the uptake of services and this largely explains the low figures for Kitui district which is expansive and has comperatively poor communication infrastructure.

Other challenges experienced by the project include the low uptake of Gender Based Violence (GBV) recovery services. By the end of December 2007, 250 clients had been served in all the sites.

The sensitive nature of GBV has been ascribed as the cause and efforts to create awareness on the matter at the community level and encourage reporting and seeking of GBV services have been implemented. However, that this kind of service may not be suitable for a voucher scheme.

In addition cases of fraud by some distributors and service providers have been detected especially during the initial months of the project.The Voucher Management Agency responded by cancelling some vouchers and disqualifying errant distributors and service providers.

by Charles N. Oisebe
Kenya

Caesarean delivery rates are rising among mothers in many developing countries, and likely exceed the 15 percent limit recommended by the World Health Organization in 2005.

Caesarean deliveries are especially common in some Asian and Latin American countries, accounting for many as 40 percent of babies delivered—but not in Africa, where they account for just 2 percent of deliveries in some countries.

Within countries, caesarean deliveries tend to increase sharply with wealth. Less than 1 percent of women in the poorest households had caesareans in many countries—below the minimum rate required to cover fatal complications. Rates are much higher among wealthy women—nearing 80 percent in some countries. Indications have shown that caesareans can provide maternal health solutions in case of complications and can also reduce high maternal mortality rates. However, caesareans are prone to abuse (more so in developed countries) and are sometime utilized in non- emergency situations.

Below, health experts answer some critical questions on the importance of caesareans, linkages to MTCTs (Mother to Child Transmissions), availability of these services as life saving options and policy options as well.
 
Question:
Women who undergo a Caesarean Section (CS) are regarded as failures in Nigeria. This makes even the wealthy ones who can afford this very expensive procedure not to willingly accept it, except as a last resort to save the mother’s life. This procedure is very expensive and it seems many doctors do not want to prescribe it to their patients because of these beliefs. How can CS be made more attractive to both experts and women in Nigeria where the mortality rate is as high as 1000 deaths (per 100,000 life births?)

Answer:
Community education is needed so that women and families recognize that cesarean can
truly be a life-saving procedure.
 
Qualitative research from West Africa has shown that women needing cesareans  sometimes face severe reactions when they return home from the hospital for having “failed” at childbirth, for subjecting their families to the expense required for the procedure, and for not returning with an infant on their backs (when the child does not survive).

Question:
Do you see a role for HIV programs in developing countries to support local health systems in providing safe caesarean-sections? There is good evidence that elective caesarean-sections can lower MTCT around two-fold and funding in many countries for HIV related programs are often far greater than for maternal health programs. How can the two be linked?

Answer:
I do not know of anyone in the maternal health community who is a proponent of routine caesarean for HIV positive women. It is important to try and achieve safe and appropriate caesarean via the traditional routes of pre and in-service training, clinical audit, insurance schemes to address financial barriers and an increased role for NGOs to address transport for emergency referral.

Question:
Although more than 80 % of women from high income group go for caesarean,  less than 1%
of women of low income group have caesarean. Does this mean the services are not available or unaffordable by the latter group? Can you suggest some ways to cope this problem?

Answer:
When one sees rates above about 20%, I think most would agree that this must include some non-medically indicated caesareans. The issue of caesarean  on maternal request is controversial; some consider it a woman’s right, some argue caesarean delivery
can be safer than vaginal delivery, some argue it is less safe and some argue it is not a good use of health care resources. A fair amount of experimentation is on- going regarding provision
of caesarean for all women and for for poor women. Governments have found
it difficult to assure on- going, timely and adequate reimbursement  of funds
to hospitals to cover these costs.

Question:
Caesarian deliveries are a quick but efficient solution to a complex maternal health issue. How do nations, especially developing nations, implement national and local level policies
to ensure that caesarean deliveries are available to all those who need it?

Answer:
Extensive efforts have been made to document why caesareans are being done across many developing countries. Although information is recorded whenever a caesarean is being done, it was rarely that this information included indication for caesarean among the indicators that they collect in their routine health information systems.

Question:
What have caeserean deliveries got to do with health systems status? How can these deliveries be addressed in regards to the practitioners  and the public, especially the wealthy part of the population?

Answer:
The caesarean rate will be affected by the distribution of comprehensive versus basic emergency obstetric care facilities. And, some countries require families to purchase a caesarean kit before the caesarean can be performed.

Question:
Do you think that the Caesarean deliveries cases are on the increase as doctors have discovered a new way of making more money?

Answer:
I’m sure that in some places there are financial incentives for providers to perform caesarean,  but it would be unfair to pin all the blame on that. In some countries, the cost of a caesarean is the same as the cost of a vaginal birth to discourage performing caesarean for financial benefit. Caesarian for life-saving purpose should be widely welcomed.

Question:
In Zambia, caesarean births are only considered as a last option to save the mother and child. People believe that for a woman to have a caesarean-section that the husband was having
extra marital affairs and this caused the to woman fail to have a normal vaginal delivery.

Answer:
Your question makes me realize that we really do have a serious problem in how we talk about this issue.

Question:
Some developing countries, I am thinking of Mali, have put in place a policy that provides free caeserean for women to overcome the cost barrier. There has been some discussion that this policy has led to increase demand for c-section since normal assisted delivery is still fee based. Do you know of examples of other policies/ strategies that have been put in place which address the cost barrier to accessing caesarean in developing countries?

Answer:
Several West African countries are trying innovative approaches to improving access to emergency obstetric care, and I really hope these efforts are being documented in a rigorous manner because we have so much to learn from them. However, clearly, more work is to be done as in the case of Ghana. The policy was put into place, but was very difficult to sustain,
for example facilities were not reimbursed in a timely manner, putting facility staff in a very difficult position.
 
Question:
You have mentioned more than once in your responses that people in Asia and Africa do not want to talk about c sections and the issues. What do you think are the reasons why no one wants to discuss the issue?

Answer:
The issue seems to make people very uncomfortable. I had the same experience (talking about free access to caesarean for women in need) with a group of surgeons dedicated to the repair of fistula. You would think that of any group, this group would jump on board. But, actually, there was hesitation. This just tells me there is a great deal we don’t understand. I think this whole area is very fertile ground for qualitative research - again, on both the supply and the demand side.

Adopted from Population Reference Bureau An Interview with Dr. Cindy Stanton
www.prb.org

Although abortion is legal in the United States, pro-life activists and the religious right interfere with its provision: they stage demonstrations outside abortion clinics in attempt  to dissuade women from procuring legal abortions and they lobby for more restrictive abortion laws. Therefore, despite its legality, abortion is becoming increasingly difficult for women to obtain and for health care providers to perform. In 2005, 87% of counties in the United States did not have an abortion provider, further compromising access to this essential service. Despite the United States’ prolific biomedical research and relatively high standard of living, the majority of the developed world has better access to abortion, and consequently better reproductive health indicators.

In Uganda, access to abortion is even worse than in the United States.  In order to obtain a legal abortion, the pregnancy must pose a threat to the woman’s life or, to obtain an illegal abortion, the woman must have sufficient funds to pay for it. Women can receive abortions only under the most severe circumstances or if they have the resources to pay health care providers who will provide them illegally. Because of this, women seeking to end their pregnancies are forced to resort to illegal and potentially harmful practices:  ingesting large quantities of quinine or aspirin, drinking gasoline, or inserting sharp instruments into their uteruses.  As a result, women suffer drug overdoses, hemorrhages, infections, permanent damage to their reproductive tracts and even death.

Gynecology wards in Uganda are filled with women experiencing incomplete abortions or the suffering from post-abortion complications:  up to one half of beds on these wards are occupied by these women.  A large proportion of health care expenditures go to providing post-abortion  care, and women who die from post-abortion complications account for some 20% of maternal mortality.

Women are so desperate  to end their pregnancies that they will risk their lives. Some estimates  state that roughly half of all Ugandan women will require medical care for induced abortions at some point during their lifetime, and 15 out of 1000 women of reproductive age (15-49) are treated for post-abortion complications annually.

During my first few weeks in Uganda, I heard part of an abortion debate on the radio. Several men called in with the opinion that abortion is the result of loose morals and irresponsible sexual behavior, that abortion is only necessary for those who are having extra-marital sex or who do not trust in God’s divine plan for them and their families. They do not believe that Ugandans need abortion services. However, this attitude does not take into account the numerous and varied situations that can result in unintended pregnancies. First, this assumes that all sex is consensual sex, although we know that women can become pregnant following rape or coerced sex. Second, this implies that women can refuse sex or use contraception if they do not wish to become pregnant.  However, this attitude fails to recognize that a woman may receive undue pressure from her husband or family to procreate, or may be the victim of physical or verbal abuse if she refuses sex or suggests the use of family planning.  Finally, this implies that family planning methods and the women who use them never fail. Indeed, we know that this is not the case. Therefore, even if a woman only has sex when she wants to, with whomever she desires and uses contraception, she may still become unintentionally pregnant

I believe that in the United States as well as Uganda, abortion services should be expanded to improve reproductive health. There will always be a need for abortion services, as women will always encounter situations in which they do not wish to be pregnant, but become pregnant nonetheless.  Currently, large amounts of scarce resources go into providing health care services for women suffering from post- abortion complications.  The provision of safe, legal abortions would drive down health care costs and improve maternal and child health.  I believe that the work that Population Secretariat is doing is essential to improving reproductive health, and efforts to minimize unintended pregnancies should be continued. 

However, we cannot continue to deny that abortion is a service that women need: providing it will reduce pregnancy-related  morbidity and mortality and promote health among the world’s women and girls.

By Bonnie Smith, Masters’ Public
Health Student at UCLA
While interning Uganda Population Secretariat

As an American masters student in public health who has only studied reproductive health in Uganda and sub- Saharan Africa from afar, having the opportunity to live in Kampala and work at the Population Secretariat for the summer has been a truly rewarding experience. I am constantly impressed by the efforts of so many organizations and community members that I have had the chance to meet and observe during various conferences, meetings, and public debates.  Witnessing the passion and concern that Ugandan citizens have for the health of their women, children and families is deeply inspiring.

What I have been most impressed by thus far is the community participation at these reproductive health public meetings (such as the Safe Motherhood Conference in Arua and the Sexual and Reproductive Health Meeting for Policy Makers in Kampala). I strongly believe that allowing community members to not only attend these debates  but to also give them a venue to express their concerns and personal challenges results in a true sense of empowerment. It is through this active participation in such processes that communities can continue to grow, evolve and become further empowered to create positive changes within their own lives.

One aspect of reproductive health in Uganda that has been particularly disconcerting to me is adolescent sexual health.  Although I have studied this topic in graduate school and have worked in this field in the United States, being able to observe programs in action and hear community members and professionals discuss the challenges faced by these adolescents has been illuminating.

I have attended numerous conferences and parliamentary meetings in which the topic of the ABC approach (abstinence, be faithful, use condoms) is emphasized as the primary means to prevent the spread of HIV/AIDS among youth in Uganda. However, it seems as if the C part of this approach is often de-emphasized and sometimes  completely neglected.

Focusing on abstinence education can be useful for teenagers who are not yet sexually active as a way to delay their sexual debut; however, studies have demonstrated that emphasizing abstinence without discussing contraception or communication and assertiveness skills is ineffective in deterring risky behavior among sexually active youth.

According to the Guttmacher Institute, focusing on abstinence has shown to be unsuccessful in sustaining any long-term beneficial impact on youths’ attitudes or behaviors. Furthermore, this research indicates that in comparison to comprehensive sex education programs, recipients of abstinence-only programs are not any more likely to delay their sexual initiation than recipients of comprehensive sex education programs.  Advocates for Youth has also found that abstinence- only education programs in the U.S. have failed to produce any statistically significant changes in the sexual behavior of youth who were exposed to such programs. This is primarily because abstinence programs do not provide any information about how to protect oneself against pregnancy, sexually transmitted infections or HIV. Furthermore, if these programs do discuss condoms and contraception, they emphasize their failure rates rather than provide information about the positive consequences of their usage.  This method of education has resulted in feelings of confusion and ambivalence among youth regarding the usage of condoms and contraception.

Considering that 26% of women age 15-19 in Uganda are mothers and that the adolescent pregnancy rate is currently 43%, it seems that focusing mainly on abstinence and being faithful is irrelevant for the many youth who are already sexually active. Furthermore, not educating teenagers about condoms and access to contraception and reproductive health services can be seen as punitive against youth who are sexually active.

Additional studies have demonstrated that giving youth information about contraception and how they can access reproductive health services does not encourage them to have sex. In fact, providing comprehensive sex education to teenagers often results in a delay of first sexual intercourse, fewer sexual partners and better contraceptive use.  Withholding information about condoms or health services from youth has not been proven to discourage youth from having sexual intercourse, especially when youth’s sexual curiosity and propensity for experimentation are taken into consideration.

In addition, emphasizing being faithful to one’s sexual partner, the B part of the ABC message, generates a false sense of security among those who are faithful to their partner but whose partner may be engaging in other sexual relationships. By providing to youth the A and B messages as the sole way to prevent the transmission of HIV, many youth who comply with these messages will find that their compliance fails them.

Research states  that along with correcting myths and misinformation about condom use, programs should aim to teach young women and girls’ assertiveness and communication skills that will give them the confidence they need to avoid unsafe sex. Programs such as Girls Power in Nigeria that do such activities to educate females about safe sex have proven effective in empowering young women to make responsible decisions regarding their sexuality. Further, reducing idleness among both boys and girls via opportunities of extra- curricular activities such as skill-development and sports has also been shown to reduce the prevalence of casual sex among youth.  These types of youth interventions have proven to serve as protective factors against adolescent risk behaviors. Although the ABC strategy has been effective in helping to curb HIV prevalence rates within Uganda from 15% in 1991 to 6.5% currently, sexually active youth would benefit greatly from the provision of comprehensive information regarding responsible sexual decision- making. In addition to offering information to youth about their risks of contracting HIV, skill-based information regarding condom and contraception use must be included in these discussions: simply increasing youth’s awareness of their risks of HIV does not lead to behavior change unless this education is coupled with skill-building lessons regarding condoms and contraception.

If Uganda can commit itself to improving the health of its adolescents in this manner, not only will HIV prevalence rates among young people decline, but the health of a generation will be improved.

By Caroline Elson
Masters’ Public Health Student at UCLA while interning with Uganda Population Secretariat Office (July – September, 2008)