Towards Better Reproductive Health in Eastern Europe: Concern, Commitment, and Change

Towards Better Reproductive Health in Eastern Europe

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Towards Better Reproductive Health in Eastern Europe Concern, Commitment,and Change

Edited by

G. LINDMARK, M. HORGA, A. CAMPANA, and J. KASONDE WHO Scientific Working Group on Reproductive Health Research

- CEU 4 ' )

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PRESS

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Central European University Press

World Health Organization

Published by Central European University Press Okt6ber 6. utca 12 H- 1051 Budapest Hungary 400 West 5gfh Street New York, NY 10019 USA

0 1999 by WHO, Geneva Distributed by Plymbridge Distributors Ltd., Estover Road, Plymouth PL6 7P2, United Kingdom All rights reserved. No partof this publication may be reproduced, stored in a retrieval system, or transmitted,in any form or byany means, without the permission of the Publisher. ISBN 963-91 16-30-0 Graphic artwork on cover by Tamhs Karksonyand Tamas Maros Library of Congress Catalogingin Publication Data A CIF catalog record for this book is available upon request Printed in Hungary by Akadimiai Nyomda Kft.

Contents

List of tables . . . . . . . . . . . . . . . . . . . . . . . . .

vii

List of figures . . . . . . . . . . . . . . . . . . . . . . . .

ix

List of contributors . . . . . . . . . . . . . . . . . . . . .

xi

Foreword by J. E. Asvall

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Reproductive health in Eastern Europe: an overview and the challenges ahead HELENAHONKANEN and GIUSEPPE BENAGIANO. . . . . . . . . . . .

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Can a process of quality assurance improve pregnancy outcome? GUNILLA LINDMARK. . . . . . . . . . . . . . . . . . . . . . . . . . .

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The challenge of rising trends in the incidence of sexually transmitted diseases in Eastern Europe A. GROMYKO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Obstacles and opportunities in the development of adolescent reproductive health care GUNTALAZDANEand ILONA AUZINA . . . . . . . . . . . . . . . . . .

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V

Contraception: current use and future perspectives LASZLOKovAcs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

85

How can the rates of induced abortion be reduced? ..................

99

MIHAIHORGAand FRANKLUDICKE.

Infertility in Eastern Europe: a survey of the current status in nine countries FRANKLUDICKE,ASSIA BRANDRUP-LUKANOW, MIHAI and HORGA ALDOCAMPANA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Towards better reproductive health in Eastern Europe ....................

ASSIA BRANDRUP-LUKANOW ..

vi

143

List of tables

2.1 American College of Obstetricians and Gynecologists Obstetric Clinical Indicators - p. 35 2.2 KeycommonEuropean quality development indicators in perinatal care (OBSQUID project) - p. 36 2.3 Perinatal mortality in the year 1995, Tallinn, Tartu, and Estonia, using different birthweight cutoff points - p. 37 2.4 Common Nordic-Baltic perinatal death classification - p. 37 2.5 Perinatal deaths by categories of the Nordic-Baltic perinatal death classification in Lithuania 1993-94 and Denmark and Sweden 1991 -p. 38 5.1 Contraceptive use in several countries - p. 94 5.2 Survey on human sterilization in Eastern Europe - p. 95 5.3 Contraceptive prevalence and reproductive healthindicators -p. 95 6. l Fertility, birth, abortion, and contraception prevalence rates in countries of Eastern Europe - p. 126 7.1 Existence of referral centers and national organizations dealing with infertility; specific legislation on donor insemination or adoption in selected countries of EE/NIS - p, 140 7.2 Investigation of infertility as performed by the centers in nine countries of EE/NIS - p. 140. vii

7.3 Possible treatments offered by the centers in nine countries of EE/NIS - p . 141 7.4 Age distribution and type of infertility - p. 141 7.5 Self-reported history, female partner - p. 141 7.6 General categories of infertility - p. 142 7.7 Distribution of specific diagnoses of infertility - p. 142

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List offigures

1.1 Contraceptive prevalence rate (effective methods) for 100 married women - p. 13 1.2 Abortion rate per l000 women aged 15-49 years - p. 14 1.3 Abortion to birth ratio per 100 births - p. 15 1.4 Maternal mortality rate per 100 000 live births - p. 16 1.5 Infant mortality rate per 1000 live births - p. 17 2.1 Maternal mortality rate per 100 000 live births - p. 39 2.2 Infant mortality rate per 1000 live births - p. 40 2.3 Health care system: process of quality assurance and improvement - p. 41 2.4 Eclampsia prevalence per 100 000 deliveries (national data) - p. 42 2.5 Blood transfusion national averages and local data, percent of deliveries - p. 43 2.6 Intrapartum deaths per 1000 deliveries - p. 44 2.7 Cesarean sections (national data), percent ofdeliveries - p. 45 3.1 Incidence of syphilis cases in the Baltic states during the last l 5 years - p. 56 3.2 Annual incidence of syphilis in the Russian Federation, Belarus, Republic of Moldova, and Ukraine - p. 57 3.3 Annual incidence of syphilis in Kyrgyzstan, 1986-95 - p. 58 ix

3.4 Annual incidence of syphilis in the Republic of Kazakhstan, 1986-95 -p. 59 3.5 Incidence of syphilis cases in the Russian Federation, 199096 - p. 60 in Ukraine, 1991-95 - p. 61 3.6 Annual incidence of syphilis cases 3.7 Annual incidence of syphilis cases in the Republic of Moldova, 1980-95 - p. 62 3.8 Imported cases of gonorrhea in Helsinki - p. 63 3.9 Annual incidence of syphilis cases in Finland, 1980-95 -p. 64 4.1 Prisoners-juveniles in Latvia - p. 77 4.2 Children who have acquired a basic education in Latvia - p. 78 4.3 Births in Latvia outside marriage - p. 79 4.4 Induced abortions in Latvia in the age group 4 9 years - p. 80 4.5 Deliveries by mothers 19 years and younger in Latvia- p. 8 1 4.6 Incidence of syphilis among adolescents in Latvia - p. 82 4.7 Incidence of gonorrhea among adolescents in Latvia - p. 83 5.1 Contraceptive prevalence rate (effective methods) 1992-94 -p. 96 5.2 Oral contraceptive use - p. 97 5.3 Intrauterine device use - p. 98 6.1 Flowchart of the process resulting in a woman having an unwanted pregnancy - p. 127 6.2 Strategies to reduce abortion rates by breaking the cycle of unwanted pregnancy - p. 128

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List ofcontributors

I. Auzina, Medical Academy of Latvia, Riga, Latvia G. Benagiano, WHO, Geneva, Switzerland A. Brandrup-Lukanow, WHO Regional Office for Europe, Sexual and Family Health Unit, Copenhagen, Denmark A. Campana, University Hospital, Geneva, Switzerland A. Gromyko, WHO Regional Office for Europe, Copenhagen, Denmark H. Honkanen, WHO, Geneva, Switzerland M. Horga, Center of Public Health, Targu-Mures, Romania L. Kovacs, Albert Szent-Gyorgyi Medical University, Szeged, Hungary G. Lazdane, Medical Academy of Latvia, Riga, Latvia G. Lindmark, University Hospital, Uppsala, Sweden F. Ludicke, University Hospital, Geneva, Switzerland

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Foreword

In the field of international health the twentieth century will go down in history as the period of the greatest advances in health technology and health care; and in these achievements Europe will be known to have played a leading role. But the discrepancies in health and health care status between the market economies of the West and the transitional economies of theEast have shown a glaring gap, especially in the last decade of the century. This gap has been particularly prominent in the area of reproductive health. The scientific community in both the East and the West has fortunately risen to the challenge. The development of technologies and the generation of knowledge have proceeded faster than ever, providing policymakers with the tools they need to respond to the challenge. Programs and services that had degenerated in difficult economic circumstances have begun to improve tremendously, justifjring the hope that the status of health and health care in the whole region will attain even higher levels in coming years. The WHO Region of Europe has shown leadership in the movement to improve health in general and reproductive health in particular. Policymakers and program managers in the member

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states of the Region now have an added tool in the information provided in these pages. Let them use this knowledge to achieve better reproductive health in Eastern Europe. I urge them to take up the challenge. J. E. Asvall Regional Director WHO Regional Office for Europe

xiv

Reproductive health in Eastern Europe: an overview and the challenges ahead HELENA HONKANENand GTUSEPPE BENAGIANO UNDP/UNFPA/WHO/World Bank Special Programmeof Research, Development and Research Training in Human Reproduction, Geneva, Switzerland

Abstract The countries of Eastern Europe are in transition not only economically but also culturally. Reproductive health indicators show that the prevalence of contraceptive use is low, abortion rates are high, maternal and infant mortality are rising, and the incidence of sexually transmitted diseases shows an upward trend. As the political climate changed in Eastern Europe, more opportunities arose to promote cooperation between research centers in Eastern and Western Europe. To facilitate this cooperation, the Special Programme of Research, Development and Research Training in Human Reproduction recently established a Scientific Working Group on Reproductive Health Research in Eastern Europe to coordinate research and research training activities in the region. To improve reproductive health in Eastern Europe, health care delivery also needs to be improved; to achieve this, training of health care personnel is required to allow them to obtain updated information; education, especially for adolescents, on sexual and contraceptive matters is at the center of the new agenda; and more research is needed on reproductive health in general.

1

Introduction For the purpose of WHO activities in this region, Eastern Europe covers the Baltic states, the countries of Central and Eastern Europe, the Commonwealth of Independent States, the former Soviet Central Asian Republics and Kazakhstan, and the countries of former Yugoslavia, A list of these countries is provided as an Appendix. This huge area is by no means uniform. A woman in Turkmenistan has a life expectancy of 62 years, a man 69 years. A Russian woman can expect to live 72 years, a man only 59 years. As a comparison, in Western Europe life expectancy varies between 70 years for a man and 78 years for a woman in Portugal, and 75 years for a man and 8 1 years for a woman in Switzerland (Monnier, and De Guibert-Lantoine, 1995). In Russia the mean number of livebirths per woman is 1.4, close to that of most Western European countries, where the birthrate is usually under 2. In the Central Asian Republics, on the other hand, the total fertility rate is much higher: in Tajikistan it is 5.0 and in Turkmenistan 4.1 (Monnier, and De Guibert-Lantoine, 1995).

Characteristics of reproductive health in Eastern Europe Contraceptive prevalence is low The overall utilization of modern methods of contraception in the region is usually low. Prevalence varies from 7% in Azerbaijan to 60% in Hungary (fig. 1.1). Intrauterine devices are the most widely used methods in Russia, the Central Asian Republics, and the Baltic states (80% of users of modem methods), whereas in Hun2