BILL AND MELINDA GATES INSTITUTE FOR POPULATION AND REPRODUCTIVE HEALTH

Family Planning Improving the Lives of Women and Their Families Around the World 2011 REPORT

CONTENTS 1

Introduction

2

Message from the Director

4

Family Planning Facts

6 Conferences 10 Family Planning Research 14 Collaborative Research 16 Institutional Development 22 Individual Development 26 Policy/Practice/Advocacy 29 Publications Inside back cover: Executive Committee, Faculty and Staff Cover Credits: Illustration: Joe Cepeda Top: Photo Courtesy of Flickr Creative Commons Middle: Pakistani Family © DFID Courtesy of Flickr Creative Commons Bottom: A child with her mother in Accra, Ghana. © 2008 Erberto Zani, Courtesy of Photoshare This page: Photo Courtesy of Flickr Creative Commons Back Cover: Children in a village near Jodhpur, India, where the Veerni Project works. The girl at right was married at age 10. © 2004 Rose Reis, Courtesy of Photoshare

INTRODUCTION

Sometimes progress can be measured in leaps; other times, it is marked in an incremental crawl forward. During the timeframe of this report, each progressive step taken by the Gates Institute and its partners has fostered better understanding and improved lives around the globe. Mothers were empowered to space the births of their children, fathers became more involved in health and family planning, infants and youth saw their potential for a healthy life increase. Through research, academic programs and partnerships with leaders and leading institutions, from individual choice to community enlightenment to national policy, the Gates Institute is marking and making positive change.

2011 REPORT

1

Message from the Director

As our report goes to press, the seven billionth human (7BH) is joining the world’s population. This baby has a slightly higher chance of being a boy than a girl and an even greater chance of being born in India than any other country. Wherever this baby is born, she/he hopefully will reach his or her 15th birthday with at least a decade of schooling and good nutrition, having been nurtured in a positive family environment. In 2050, when 7BH is 39 years old, she/he will share the planet and its fragile resources with an additional 2.3 billion humans. Undoubtedly, the share of the world’s population that is educated, urban and middle class will have risen substantially by then. The global economy will bend to market demographics, most likely focused on India, China, Nigeria, Ethiopia, Brazil, Pakistan and the U.S., but also on market unions in Europe, Asia and Africa. Family and public investments in 7BH’s start in life will be the most important factors in launching her or him on a path toward a productive and healthy adulthood. In fact, pre-conceptional health and pregnancy health are fundamental aspects of family planning and mark critical periods to nurture and nourish. Some experts liken contraceptive’s importance for maternal health as similar to that of vaccinations for child health. Yet, while immunization coverage of infants is 85 percent or higher in the developing world, there are more than 200 million women who are not benefiting from access to contraception. These women seek to space or limit their births but are not using contraception. The Gates Institute believes that women and men wish to experience parenthood responsibly and desire their experience to be enhanced by reliable and accurate information. Delivering this knowledge and working with likeminded partners to discover new evidence are Institute objectives. Under the Institute, a three-year initiative, Advance Family Planning, was launched in 2009 to conduct evidence-based advocacy. The Institute also co-organized two international conferences on youth development in Abuja, Nigeria, and on family planning in Kampala, Uganda. Four journal supplements have captured some of the research presented there. More than 750 graduate students across six academic partner institutions have gained exposure to reproductive health and population training. Our partners themselves have become independently recognized for their expertise in this area and contribute to national and international policy forums.

2

We are glad to have the privilege to work with many partners on a shared mission to strengthen family planning efforts and improve reproductive health and population well-being with solid evidence. For us, research evidence on family planning is a type of social vaccine. With a social vaccine, individuals, families, communities and societies can enjoy security against such adverse consequences as poverty, premature death, poor health, illiteracy and unemployment. Please join us in helping to develop and deliver the social vaccines that will ensure a better future for the 7 billion human beings—and counting—on the planet we share.

Amy Ong Tsui, PhD Director

Family Planning: Improving the Lives of Women and Their Families Around the World

“We believe that the Institute has contributed in several important ways to the development of increasingly strong academic centers, particularly in Africa, as well as to a significant increase in the attention being paid to population issues, family planning, and reproductive health by those who influence and make policy in the region. This is no small accomplishment.” From “Report of an External Evaluation,” September 2011 Photo Courtesy of Flickr Creative Commons

2011 REPORT

3

Family Planning USE AND UNInTENDED PREGNANCIES IN Sub-Saharan AFRICA The 60% of women who used a traditional method or no method account for 91% of the unintended pregnancies in 2008. 9%

20% 11% 40%

46%

80%

No Method Traditional Method Modern Method Source: Guttmacher Institute, UNFPA, 2010

14%

Women wanting to avoid a pregnancy (78 million)

Unintended Pregnancies (17 million)

A couple and their two children in Nigeria. © 2000 Liz Gilbert, Courtesy of Photoshare

4

Family Planning: Improving the Lives of Women and Their Families Around the World

Family Planning Facts – Global and Africa-specific Statistics

170 million women have no access to safe and effective methods of family planning in developing countries.1 1/3 of population growth is due to unplanned pregnancies.2 year, nearly 80 million are unintended.3

n

n

Of the 210 million pregnancies occurring each

Each year, modern contraceptives help women prevent 215,000

pregnancy-related deaths (including 66,000 from unsafe abortions), 2.7 million infant deaths and the loss of 60 million years of healthy life.4

n

Demand for modern contraception is expected to increase by about 50% to

75% by the year 2020 in countries still reliant on donor assistance for implementing their programs.5 5 married women of childbearing age have an unmet need for contraception in Africa.6 women of reproductive age use a modern contraceptive in Sub-Saharan Africa. Africa are unintended.8 and childbirth in Africa.

n

7

n

n

17% of married

39% of pregnancies in

For every 100,000 births, 640 women die of complications related to pregnancy

n

Unintended pregnancies would drop by 77%

in Africa if women’s family planning needs and maternal and newborn health care needs were met.11 million women 15-19 years old give birth each year.12 Sub-Saharan Africa.

1 in

n 760,000 lives would be saved annually in Africa if women’s family planning needs

9

and maternal and newborn health care needs were met.10

13

n

n

n

n

16

Adolescent women account for 16% of all births in

15% of unmarried adolescent women in Sub-Saharan Africa are sexually active and

want to prevent pregnancy.14 n 21% of married adolescents who want to prevent pregnancy are using a modern contraceptive method in Sub-Saharan Africa.15 Sub-Saharan adolescent females.1

n

n

2.2 million unintended pregnancies occur each year to

21.6 million unsafe abortions occurred worldwide in 2008.17

n

The

reasons why women do not use contraceptives most commonly include concerns about possible health and sideeffects and the belief that they are not at risk of getting pregnant.18

n

Each dollar spent on family planning can

save governments up to $31 in health care, water, education, housing and sewers and other waste disposal.19 Expanding the number of women in the workforce by investing in their education could increase per capita

n

income in some countries by as much as 14% by 2020, and 20% by 2030 in many developing countries.20 1

Smith et al. Family Planning Saves Lives, 4th ed. Population Reference Bureau, 2009, p. 4.

2

http://www.gtz.de/en/presse/23839.htm; facts and figures.

3

WHO, Unsafe Abortion- Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2005, 5th ed. (Geneva: WHO, 2007).

4

Guttmacher Institute, UNFPA. Contraception: An Investment in Lives, Health and Development, 2008 Series.

5

The baseline year is 2005. The lower number is the expected increase in demand based on projected fertility declines (UN median variant). The higher is required to eliminate unmet need for family planning in these countries. Of these projected increases, 33 percent are due to population growth; the rest to expected increases in demand. UNFPA Factsheet: population growth and poverty; http://www.unfpa. org/public/home/factsheets/pid/3856. 6,7,8,9,10,11 12

Alan Guttmacher Institute & IPPF, Facts on Satisfying the Need for Contraception in Developing Countries, November 2010.

WHO, Adolescent Pregnancy. MPS Notes, 1(1): 2008.

13,14,15,16

Guttmacher Institute & IPPF, Facts on adolescent women in the developing world, 2010.

17

World Health Organization (WHO), Unsafe abortion. Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008, Geneva: WHO, 2010. 18

Sedgh G et al., Women with an unmet need for contraception in developing countries and their reasons for not using a method, Occasional Report, New York: Guttmacher Institute, 2007, No. 37. 19

Guttmacher Institute, UNFPA, Contraception: An Investment in Lives, Health and Development, 2008 Series.

20

Goldman Sachs: Women Hold Up Half the Sky, March 2008, accessed April 2009.

2011 REPORT

5

INTERNATIOnaL CONFERenceS

The Gates Institute brings the world together around issues involving youth, family planning and reproductive health. At international conferences, social and political leaders meet scientists, and the exchanges enlighten and inspire. Participants return home revitalized and encouraged, eager to apply their new knowledge to benefit their communities and nations. International Youth Conference 2008 According to Girls Count, young people constitute the fastest growing segment of the world’s population. The Population Reference Bureau has underscored the significance of this by observing that there are 1.77 billion youth in the world, ages 10 to 24—almost one-third of the world’s current population—and 87 percent of them live in low-income settings. To address the issues inherent in these numbers, the Gates Institute and its partners—the Center for Population and Reproductive Health at the University of Ibadan and the Department of Community Health at Obafemi Awolowo University (OAU)—hosted an international conference, “Investing in Young People’s Health and Development: Research that Improves Policies and Programs,” in Abuja, Nigeria, in April 2008. More than 160 experts shared the results of their research and program efforts on population, development, sexual and reproductive health, poverty reduction and gender equity as they affect young people. There were more than 550 conference participants from 36 countries who participated in the oral and poster sessions and expert roundtables that focused on such youth-relevant topics as nutritional challenges, urbanization, networking activists for health, male circumcision, employment and malaria. To enable policymakers to benefit from the wealth of evidence presented at the conference, heads of national adolescent health programs were invited from ministries of health in Egypt, Ethiopia, Ghana, Malawi, Nigeria and Sudan. The policymakers participated in a special session to discuss scaling up effective interventions. Nigerian legislators also engaged in direct dialogue with youth. Well-attended, skill-building workshops were offered before and after the conference by Advocates for Youth, Family Health International, Guttmacher Institute, International Center for Research on Women, Population Council, University of California at Berkeley, and the World Health Organization. To increase public access to significant conference findings, the Institute partnered with the Population Reference Bureau (PRB) to bring journalists from Kenya, Tanzania and Uganda to join Nigerian journalist colleagues to report on the conference.

6

The Call to Action (available at http://www.jhsph.edu/gatesinstitute/ policy_practice/conferences-meetings/adolhealth/calltoaction.html) distilled the meeting’s key findings. It was shared with donors, program developers, policymakers and researchers, urging them to mobilize new resources and scale up efforts to invest in youth. Two journals, the Journal of Adolescence and International Perspectives on Sexual and Reproductive Health, have published research papers from the conference with overview papers by Bloomberg School and OAU faculty, Drs. Michelle Hindin and Adesegun Fatusi, respectively.

Research Messages from the Youth Conference • Adolescent health and development research is diverse, expansive and intense. • Common concerns include stages of development; factors that influence healthy transitions to adulthood; models for individual, familial and social management of sexuality and initiation of childbearing; and gender security. A substantial number of studies focused on contextual influences, such as interpersonal relationships that mentor positive growth, and risk-protective environments of institutions, such as schools, faith-based organizations, legal codes and regulations, and societal norms. • It is important to embed young persons in a multiplicity of supportive networks. • Education is critical for empowering young people because schools often serve as the gateways for exposure to and absorption of life-protecting information. Educational programs need to be linked to national youth development strategies, and responsibility for their implementation should be inter-ministerial. • Several innovative program models can expand beneficiary coverage, including reaching newlyweds and tapping faith-based organizations. • Most importantly, youth spoke out as researchers and educators and said their future is NOW.

Family Planning: Improving the Lives of Women and Their Families Around the World

“Young people need the right information at the right time and from the right person, so we need to improve communication about sexuality. Adolescents shouldn’t fall victim to things like STIs, pregnancy and HIV because of lack of good information.” Obe Olajide Student of Dentistry Community Dental Health Program University of Lagos, Nigeria

An adolescent couple in Mexico. Mexico is home to one of the largest segments of young people about to enter their reproductive years. In fact, with roughly half the world’s population under the age of 24, some experts are bracing for a “Millennium Baby Boom” in the world’s poorest countries where both education and contraception can be hard to come by. Mexico’s efforts to improve women’s status and to promote family planning services will greatly impact the quality of life for everyone on the planet. © 2000 Rick Maiman, Courtesy of Photoshare

2011 REPORT

7

INTERNATIOnaL CONFERenceS International Conference on Family Planning 2009 “Family planning is to maternal health what immunization is to child health.” These words from Dr. Khama Rogo, then of the World Bank, encouraged more than 1,300 conference participants from 61 countries to take up the challenge to share and apply family planning research discoveries and best practices for family health and family wealth. The conference was organized by the Gates Institute in partnership with Makerere University’s School of Public Health and more than 50 other organizations, including WHO’s Implementing Best Practices Initiative in Reproductive Health, USAID, UNFPA, the World Bank, the Gates and Packard foundations and others. The conference was the first of its kind in more than 20 years. The organizing committee re-affirmed previous calls for action related to family planning, with an appeal to participants to fulfill past promises. The international forum fostered the sharing of findings, identified knowledge gaps and inspired vigorous discussion about using new knowledge to transform development policy. The conference was attended by many dignitaries from African nations and was opened by the First Lady of Uganda, Mrs. Janet Museveni, who observed, “Family planning reduces maternal deaths by avoiding risky pregnancies that are either too early or too late, too many or too close.” The conference included approximately 300 oral and 100 poster presentations, numerous expert roundtables, and capacity-building workshops. It received media coverage from National Public Radio and from print and online journals in China, Ghana, Nigeria and Uganda. Conference events were published through blogs, Twitter updates and real-time conversation through Global Health Live from Kampala, hosted by Family Health International. The ICFP has accelerated interest in family planning, especially in SubSaharan Africa, where families face many challenges. A team in Nigeria replicated in 2010 the international conference at the national level, and other conferences have been held in Kenya, India, Senegal and Burkina Faso. In addition, the 2nd Women Deliver conference explicitly incorporated family planning as the third pillar to maternal health, for which the Institute together with IPPF organized 10 panel sessions to address the link between family planning and maternal health.

International Conference on Family Planning 2011 Family planning remains out of reach for many couples in low-income settings; more than 200 million couples in the developing world are unable to control the number and spacing of births. Among the many technologies available to improve the human condition, family planning is one of the most cost-effective interventions, with enduring health and welfare benefits for women, families and nations.

The coming decades will see a record number of young people entering prime reproductive ages. Ensuring the Millennium Development Goal 5b of universal access to reproductive health requires comprehensive resource planning, which in turn requires a continually refreshed base of strong evidence, best practices and a wide range of contraceptive commodities. To that end, the Gates Institute and the Senegal Ministry of Health—with such partners as the Gates Foundation, USAID, DFID, UNFPA, World Bank, AFD, GIZ and the European community—are co-hosting the November 2011 International Conference on Family Planning in Dakar. The conference program includes around 400 oral and poster presentations, interactive skillbuilding sessions, expert roundtables, and more. National and international journalists will report on the event. With more than 2,000 registrants to date—including researchers, program managers, policymakers, representatives from international donor organizations and foundations, many young people and newly emerging leaders— global discourse to advance family planning continues.

Research Priorities Addressed at the ICFP • Contraceptive use—How can women and men be encouraged and enabled to use contraceptives properly and regularly? • Contraceptive technology—Can we engineer contraceptives that provide dual protection, e.g., vaginal rings combining hormones with microbicides? • Service delivery approaches—What are the best ways to achieve community buy-in, involve community health workers, and integrate family planning with maternal and child health care? • Commodity security\franchising—What are the most cost-effective ways to provide high-quality injectables and implants and integrate family planning into other health care points of entry? • HIV integration—How can we prevent vertical and pediatric transmission cost-effectively? • Cost\financing—Can we capitalize on private and public innovations in service delivery and financing, e.g., social franchising and marketing? • Youth and men—What is the best way to increase outreach to them?

Concluding Themes of the ICFP • We know what to do—we need more action, as scaled-up programs. • Our efforts must be harmonized to reduce duplication.If we work collaboratively, we are a powerful force for change. • African leadership must continue to take ownership of family planning.

8

Family Planning: Improving the Lives of Women and Their Families Around the World

“In Africa, a lot of young persons are being plagued by sexual health challenges like unintended pregnancies and unsafe abortions. In many parts of Nigeria, there are still gender inequities, and sexually transmitted infections are still prevalent among youth. Coming to a conference like this is a lifetime investment because I realize I can conduct my own research on issues that are plaguing youths.” Ayodeji Adeyemo Action Group on Adolescent Health Student, University of Ibadan, Nigeria

A mother with her child attends an awareness rally on safe motherhood and family planning in Kolkata, India. A recent report shows that in India every day, 288 pregnant women, most in the prime of their lives and some still in their teens, die from pregnancy-related complications. In West Bengal alone, a pregnant woman dies every two hours. © 2005 Sudipto Das, Courtesy of Photoshare

2011 REPORT

9

FAMILY PLANNING RESEARCH

Gates Institute researchers glean knowledge from around the globe, and study results are recognized in leading publications in the field of reproductive health. In December 2010, for example, four original research projects, described below, were published in a special issue of the African Journal of Reproductive Health, Vol. 14. In addition, all nine partner institutions are jointly pursuing a Family Health and Wealth Study to understand better family planning’s consequences for household well-being. Knowledge, Perceptions and Ever Use of Modern Contraception among Women in the Ga East District, Ghana R. Aryeetey, A.M. Kotoh and M.J. Hindin In the Ga East district, a 30-minute drive from the business center of Accra, Ghana’s capital, the district health administration commissioned a study to understand why family planning (FP) was suboptimal and adolescent pregnancies were on the rise. Trained field assistants interviewed residents of randomly selected households in 2006, and study results were based on surveys of 332 women, ages 15-49 years. Data was collected on awareness, perception and utilization of family planning methods as well as barriers to accessing family planning services.

10

Assessing the Importance of Gender Roles in Couples’ Home-based Sexual Health Services in Malawi J.D. Gipson, C.J. Muntifering, F.K. Chauwa, F. Taulo, A.O. Tsui and M.J. Hindin Malawi is a landlocked country of 14.2 million people with one of the highest HIV prevalence rates in the world—11.8 percent among adults ages 15-49. Gender-based differences shape HIV/AIDS and family planning knowledge, attitudes and behaviors in the country. Although knowledge of family planning methods is widespread among both men and women, 28 percent of women have never discussed family planning with their husbands, and 27 percent of men think that contraception is a “woman’s business.”

Knowledge of modern FP was almost universal (97 percent) although knowledge of more than three methods was lower, at 56 percent. About 60 percent of all and 65 percent of married respondents reported ever use of a modern method, and the most common methods ever used were the male condom, injectables and the pill. Among ever users, 82 percent thought contraceptives were effective for birth control. However, one-third did not consider modern FP safe, and 65 percent of users reported at least one side effect.

This exploratory, qualitative study examined the feasibility and acceptability of providing couples’ home-based sexual health services in selected communities near Blantyre. Data from six focus group discussions and 10 husband-wife in-depth interviews provided a more thorough understanding of how gender norms differentially impact men and women. Findings reveal that women are expected to defer to their husbands and may avoid conflict through covert contraceptive use and non-disclosure of HIV status. Many men felt that accessing sexual health services was stigmatizing, causing some to avoid services or to rely on informal information sources.

About 20 percent indicated their male partner as a barrier. Being married was significantly associated with ever use of a modern contraceptive method, and most women who had used a modern method reported a joint decision on family planning with their spouse. A majority of women (81 percent) thought that male partners should be involved in the decision to use modern family planning methods. However, health services are not male-friendly. Restructuring services to include men could greatly expand utilization by both men and women.

Couple-focused family planning interventions were shown to be more effective, with respect to contraceptive acceptance and continuation, compared to interventions with women alone. However, it is important to consider potential repercussions of the intervention, as information revealed during intervention could exacerbate existing gender inequalities. These concerns are particularly salient for women, who tend to have less decision-making power and are dependent on their partners or spouses for economic and social well-being.

The study found that health service barriers constitute an important challenge. Although there have been marginal improvements in infrastructure and consumable items for service delivery, barriers to the utilization of family planning remain: contraceptives are frequently out of stock and providers lack skills and understanding of the full range of methods. Interventions are needed to address service- and knowledge-related barriers to use.

Unless sexual health services reach men with more regularity, family planning and VCT will continue to be a “gendered” process. There are considerable benefits to couples being tested simultaneously, and the presence of a trained counselor can help mitigate the risks of unexpected test results or contraceptive use disclosure.

Family Planning: Improving the Lives of Women and Their Families Around the World

Use of HIV-related Services and Modern Contraception among Women of Reproductive Age, Rakai, Uganda F. Makumbi, G. Nakigozi, T. Lutalo, J. Kagayi, J. Sekasanvu, A. Settuba, D. Serwada, M. Wawer and R. Gray

Contraceptive use is still relatively low in Sub-Saharan Africa, where the levels of fertility and unmet need for family planning continue to be high. The lifetime risk of dying due to pregnancy complications is 1 in 22 compared to 1 in 73,000 in the developed world, suggesting a need to prevent unintended and unwanted pregnancies, especially among HIV-infected women who tend to have poorer birth outcomes than those who are uninfected. In Uganda, knowledge of modern contraceptives is almost universal, but current contraceptive use is comparatively low; the contraceptive prevalence rate of married women is only 24 percent. Among unmarried sexually active women, the use of contraceptives is about two times higher, 54 percent. Voluntary counseling and testing (VCT) and HIV care (HIVC) can be an opportunity for reproductive health messages and services integration. This study assessed the association between the use of HIV-related services, the utilization of condoms for family planning and use of modern contraception among reproductive-age women in Rakai District. Data were derived from community cohorts; HIV-positive respondents were referred to the Rakai Health Sciences HIVC clinic. The significantly high use of condoms for family planning among VCT clients and HIV care attendees clearly suggests that HIV programs can increase family planning practice in resource-limited settings. More needs to be done, however, to increase the use of other contraceptive methods. The greater use of condoms-only, relative to other modern methods for family planning among the unmarried, suggests that this group may be opting for a method that can both help them avoid unwanted pregnancies and protect against sexually transmitted diseases. The study findings will be used to help integrate reproductive health messages and services into VCT and HIV care programs.

A community health peer educator in the Kamukunji slums of Eldoret, Kenya, looks on as two adolescents study a book on adolescent sexuality. © 2003 Jones Kilonzo, Courtesy of Photoshare

2011 REPORT

11

FAMILY PLANNING RESEARCH Influence of Independent and Proximate Variables on Condom Use in Selected States in Nigeria A.I. Akinyemi, J.O. Aransiola, O. Banjo, O. Bamiwuye, O. Fadeyibi and A. Adewuyi Family planning and reproductive health indicators in Nigeria are generally poor, and child mortality and maternal mortality rates are among the highest in the world. Sexual risk behaviors have contributed significantly to these high rates. The spacing and timing of pregnancy occur at unintended times for nearly one third of reproductive-age women. Although most women prefer smaller family sizes, the total fertility rate is estimated at 5.7 births per woman, signaling a substantial need for contraception. Coupled with these factors is the risk of HIV and other sexually transmitted infections. The contraceptive prevalence rate (CPR) is low in Nigeria, with less than 15 percent of married females using any family planning method. This study showed that efforts at raising awareness of the benefits of condom use among married couples should be intensified. Condom use is one of the major forms of family planning that also reduces the likelihood of contracting sexually transmitted infections, including HIV/AIDS. The study examined factors associated with condom use, using data from 3,797 sexually active respondents of reproductive age. Levels of condom use were very low in the northern, as compared to other Nigerian states. Younger and better educated respondents were more likely to report condom use. Social values were becoming more tolerant to family planning, and condoms were openly displayed in many health facilities. Awareness of HIV and other sexually transmitted infections, as well as the desire to avoid unwanted pregnancy, appears to motivate youth to use condoms.

Family Health and Wealth Study In 2009, the Gates Partner network embarked on the Family Health and Wealth Study (FHWS), a research project designed to examine the relationship between childbearing patterns and family health and wealth outcomes. Nine Gates Institute partner institutions in China, Egypt, Ethiopia, Ghana, India, Malawi, Nigeria and Uganda are participating. As of July 2011, nearly 5,000 families had been recruited to the study by the partner institutions. Currently, investigating sites are preparing for the second round of data collection. One of the first analyses was completed by Carie Muntifering, Michelle Hindin and Easmon Otupiri to examine how marital relationship quality may influence contraceptive decision-making in Kumasi, Ghana. This study assessed psychometric properties of four relationship quality scales and calculated mean ratings of different dimensions of relationship quality for 799 cohabitating/married couples of reproductive age. The analysis showed that on average, men and women rated the quality of their relationship high, and several dimensions of relationship quality were positively associated with contraceptive use. The study concluded that relationship quality scales validated in high-income countries provide a framework for constructing similar measures in Ghana and that relationship quality is itself an important aspect of contraceptive decision-making.

While there are national policies and programs aimed at promoting family planning services, the study suggests that more efforts can be focused on the marginalized—those uneducated and living in rural and northern areas. In the same vein, religious leaders need to be encouraged to participate in family planning programs. The paper concludes that understanding factors influencing condom use is critical to improving family planning and reproductive health in Nigeria.

12

Family Planning: Improving the Lives of Women and Their Families Around the World

Although knowledge of family planning methods is widespread among both men and women, 28 percent of women have never discussed family planning with their husbands, and 27 percent of men think that contraception is a “woman’s business.”

Above: Adolescents at a high school in Bamako, Mali perform a skit about unintended pregnancy and then discuss the relevance to their own lives. © 2000 Elizabeth Robinson, Courtesy of Photoshare Left: A condom demonstration for adolescents in Hanoi, Vietnam. © 2002 Nguyen Thien Bac, Courtesy of Photoshare

2011 REPORT

13

COLLABORATIVE RESEARCH

The Gates Institute supports collaborative research between Johns Hopkins University faculty and faculty/scientists in partner institutions and other developing countries. The research relates to the key areas of adolescent health, family planning, HIV and sexual health, maternal health, men’s reproductive health, post-abortion care and population/demographic techniques. The findings are published in highly regarded journals, influencing programs and policies around the world. Adolescent Health

Abortion and Contraception

In this reporting period, the Gates Institute has funded three initiatives on adolescent health. One was a three-Asian city study; one was a small grants initiative for participants in the Gates Institute Summer Institute, and the last was a small grants program for young researchers in Pakistan. To enable interaction among researchers, the Institute planned that its 2008 leadership forum would focus on adolescent health and development at the Abuja Youth Conference. Formal submissions were solicited from researchers, and after review of the abstracts, six papers from the three-city study, five from the small grants initiative, and four from the Pakistan small grants program were accepted for presentation at the conference. A post-conference publication skills workshop was held, and the best papers were submitted for a scientific journal supplement.

In 2006, case studies of how pregnancy termination relates to contraceptive use were completed in five countries—Pakistan, Mexico, Peru, Nigeria and the United States. The studies were conducted by researchers at the Population Council (Pakistan), El Colegio de Mexico, Cayetano University in Peru, Obafemi Awolowo University in Nigeria, and the Guttmacher Institute for the U.S. The qualitative studies, based on in-depth interviews conducted with females and males, are now published in a 2011 supplement of the Global Public Health Journal. In addition to the five case studies, two overview papers were prepared which found that:

One study has had more recent observations. In 2005, the Gates Institute awarded a grant to Dr. Laurie Schwab Zabin. In collaboration with researchers in Shanghai, Taipei and Hanoi, Dr. Zabin assessed the determinants of sexual behaviors and reproductive health of adolescents and young adults in three Asian cities with Confucian-based cultures. In March 2009, the team published “Levels of change in adolescent sexual behavior in three Asian cities” in Studies in Family Planning. The study explores the dimensions and context of this change in three sites at different stages in the process of modernization: Hanoi (early), Shanghai (intermediate), and Taipei (later stage). A survey was conducted of 17,016 males and females ages 15–24 in urban and rural settings. Survival analysis and Cox regressions were performed to explore ages of respondents at key transitions and the significance of differences between two age cohorts: 15–19 and 20–24.

• Reproductive planning is largely non-existent. Accidental pregnancies are common, not necessarily because of contraceptive failure but because of careless unprotected sex. • Opting between contraception or induced abortion is not really a matter of choice. • Contraceptive methods are negatively viewed by those terminating pregnancies. • Male partners are engaged with pregnancy management but their roles are poorly understood. • Abortion stigma is strongly felt but not frequently experienced, largely because disclosure is rare. • Abortion experience affects subsequent reproductive behaviors, with most females and males voicing intentions to use contraception postabortion.

The study concluded that considerable change in the romantic and sexual behaviors of Asian young people may be occurring as traditionally Confucian societies modernize and increase outside contacts. Significant differences were found, even within the narrow time span reflected by the age cohorts. The findings highlight the impact of modernization on adolescent sexual behavior as traditional societies undergo social change, and they underline the importance of context in exploring youthful transitions.

14

Family Planning: Improving the Lives of Women and Their Families Around the World

The study concluded that considerable change in the romantic and sexual behaviors of Asian young people may be occurring as traditionally Confucian societies modernize and increase outside contacts. Photo credit: Creative Commons

Maternal and Child Health

HIV and Family Planning Integration

In conflict-riddled eastern Burma (Myanmar), and particularly among internally displaced communities along the border, obstetric care was traditionally delivered by untrained birth attendants, resulting in rates of infant and maternal mortality many times higher than rates in neighboring Thailand. In 2005, four ethnic health organizations, the Center for Public Health and Human Rights at Johns Hopkins, and the Global Health Access Program collaborated to launch the Mobile Obstetric Medics (MOM) Project, dramatically improving access to skilled care.

In 2005, the Gates Institute launched a study in Ethiopia in collaboration with Pathfinder International/Ethiopia, the Miz-Hasab Research Center and Jhpiego, and with support from the David and Lucile Packard and the William and Flora Hewlett foundations. The study evaluated whether adding a family planning component to voluntary counseling and testing (VCT) programs fulfills an existing demand for contraception among VCT attendees, including both HIV-positive and HIV-negative individuals. The study was completed in fall 2009, and the results have been published in the World Health Organization Bulletin, AIDS Care and in the November 2009 AIDS Supplement on HIV and Family Planning. Among the major findings are:

In a November 2010 talk at JHSPH, “Renewal Out of Ruin: Saving Lives and Building Capacity in Fragile and Failed States,” Assistant Secretary of State Eric P. Schwartz highlighted the MOM Project as an effective strategy. Also in 2010, project results were published in PLoS Medicine. Lead author Luke Mullany observed, “Our collaboration and the work of our implementing partners produced a three-tiered network of community-based providers who were able to provide elements of basic emergency obstetric care.” From 2005 to 2008, births attended by trained health providers increased almost ten-fold, and the effort was viewed as a model for settings with similar constraints.

• VCT clients in Voluntary HIV Counseling and Testing Integrated with Contraceptives Study (VICS) facilities are young, well-educated and urban. Many are sexually inactive. • VCT clients demonstrated more contraceptive use and lower unmet contraceptive need at endline compared to baseline. • The quality of VCT counseling improved markedly post-intervention. Clients received more family planning and HIV counseling at endline than at baseline. • Despite major improvements in counseling, contraceptive uptake was relatively low. HIV-positive clients and those with more sexual risk were more likely to receive both contraceptive counseling and contraceptive methods in VCT sessions. Many of the VICS clients were at low risk for unintended pregnancy and HIV, either because they were not having sex or already using contraception. This may explain the relatively low contraceptive uptake among study participants. Significantly, clients with more sexual risk were more likely to accept both contraceptive counseling and methods, suggesting that the benefits from integrating family planning and VCT services may be more pronounced among higher risk populations. The quality of both HIV and family planning counseling improved dramatically, indicating, at the very least, that service integration is possible in the Ethiopian context. Offering services that do not reflect the needs of the program’s catchment population is a persistent concern for health programs. The most salient finding from the VICS study is that policy-makers and program managers should know and understand their client populations before deciding whether service integration is likely to be efficacious or cost-effective. This study suggests that higher risk clients are interested in receiving family planning methods as part of VCT, and HIV and reproductive health programs should consider targeting clients who are most in need of sexual health services.

A health provider demonstrates the use of the moon bead method for family planning at a health fair in Uganda. © 2008 Daniel Kasansula, Courtesy of Photoshare

2011 REPORT

15

INSTITUTIONAL DEVELOPMENT

Strengthening the reproductive health training and research capacity of institutions in developing countries is a primary focus of Gates Institute efforts. Through MPH degree training and strong, sustainable academic programs, we are producing wellinformed reproductive health specialists—future generations of practitioners who will work at the community level to improve reproductive health. Global Institute Network

Measuring Performance

In this reporting period, the Institute had multi-year partnerships with eight academic institutions in seven countries: Assiut University (Egypt); Addis Ababa University (Ethiopia); Kwame Nkrumah University of Science and Technology (Ghana); University of Malawi (Malawi); University of Ibadan (Nigeria), Obafemi Awolowo University (Nigeria), Makerere University (Uganda) and the Health Services Academy (Pakistan).

The Institute monitors a set of performance measures that address the areas above for capacity strengthening of six partnerships and regularly shares the collective findings. The three newest partnerships (in Egypt, Pakistan and Uganda) have significantly smaller programs and are monitored with other criteria. Institute staff visit all partnerships annually to observe programs and review progress. These partnerships have all built training capacity from a base of zero: none of these institutions had a graduate training program in reproductive health prior to the commencement of the partnership.

The first five years of each institutional partnership focused on strengthening an educational infrastructure for reproductive health training and research, such as updating a Population and Reproductive Health (PRH) curriculum, launching the PRH graduate degree programs, providing grants to students and faculty for PRH research, enhancing the teaching skills of faculty through visits to Johns Hopkins Bloomberg School of Public Health, and upgrading computer laboratory equipment and Internet connectivity. In some cases, it was necessary to acquire electricity generators to secure a regular supply of power.

The table on the next page shows the status of five programs that have been in the partnership for at least six years (2003-2009). The subagreement for a sixth program, at the University of Ghana, was not immediately renewed upon expiration in late October 2008. The “return on investment” was significant—that is, over this period, the amount generated in external RH funding has ranged from $0.45 to $7.51, with an average of $2.28.

Work continues now in the second five years with the addition of steps toward sustainability. In this phase, partners are encouraged to achieve sustainability by: • Establishing a National Advisory Group to advise on priority research areas, facilitate linkages to local funding agencies and translate results into national activities; • Mentoring another university to extend PRH training and research opportunities and to integrate that increased capacity into national PRH advocacy; • Strengthening research and analytical skills to build a strong scientific base in country through peer-reviewed journal publications, externally funded research and dissemination activities; and • Establishing new professional RH associations (where none exist) to enhance the exchange of findings between research and program practice at annual meetings and through the regular publication of a journal that includes peer-reviewed research articles.

16

Family Planning: Improving the Lives of Women and Their Families Around the World

“Institutional development will be the key to ensuring that the efforts of the Gates Institute will have a lasting impact on population and reproductive health in Africa. All the evidence shows that the partner institutions have been significantly strengthened through the work of the Institute.” From “Report of an External Evaluation,” September 2011

Program component

KNUST Ghana

Addis Ababa University Ethiopia

Obafemi Awolowo University Nigeria

University of Ibadan Nigeria

University of Malawi

Total

Master’s concentrating in PRH

114

256

161

89

115

772

Master’s completing RH program

93

60

8

72

17

268

Curriculum development workshops

7

10

4

4

3

43

PRH courses taught

17

36

11

14

6

93

Faculty visits to JHU

7

7

8

17

4

48

Photo © Eric Bruce Salsbery

2011 REPORT

17

INSTITUTIONAL DEVELOPMENT

Partnership Site Reports Egypt: Assiut University, Faculty of Medicine, Department of Public Health and Community Medicine

Ethiopia: Addis Ababa University, School of Public Health

The project, Building Reproductive Health Capacity to Serve the People of Upper Egypt, is a collaboration with JHSPH and is funded by the Gates Institute. The overall goal of the project is to reach the grassroots level in communities and improve reproductive health services. Manpower development is at the heart of the project, with both short- and long-term strategies aimed to provide the provincial Ministry of Health and Population with well-trained physician leaders in the area of RH.

The number of MPH students specializing in Reproductive Health (RH Specialty Track) continued to be one of the highest in the School of Public Health in 2009 and 2010, representing about one-third of the total enrollment. A similar proportion of doctoral candidates who joined the school in the years 2009 and 2010 chose the RH Specialty Track.

In 2008 and 2009, faculty conducted 12 workshops for audiences such as physicians and nurses. The workshops included a curriculum development series on such topics as “Making Evidence-based Decisions in Reproductive Health” and “Communicating Research Results on Population and Reproductive Health Issues to Policy Audiences.” In April 2009, Assiut University organized and held the First Regional Conference on the Population Problem in Upper Egypt. Her Excellency, Dr. Moushira Khattab, who was newly appointed Minister of Population and Governor of Assiut Nabeel El-Ezabee, launched the conference. The conference was held to define the universities’ role in the Strategic National Population Plan (2007-2017), to agree on plans for setting a research strategy for population and reproductive health for Upper Egypt, and to update achievements and obstacles in Upper Egypt Governorates. As a result, a population control conference for north and middle Upper Egypt was held in Fayoum in December 2009, followed by the Second Population Conference for Assiut Governorate in April 2010. The Supreme Council of the Egyptian Universities is now proposing to introduce teaching of the Population Problem in Egypt to students in all Egyptian universities as an important topic in their curricula. The Assiut partnership has been approved to establish a new MPH degree program with a population and reproductive health concentration.

18

Since 2006 Addis Ababa University (AAU), with the support of Bloomberg School faculty—and for the past three years, specifically Dr. Henry Mosley—has conducted two-week training on family planning in RH for health managers, RH and development officers in government and non-government organizations, representatives of professional associations, and faculty from other universities. In December 2009, the partnership also established a national advisory group composed of representatives of the Federal Ministry of Health, schools and departments from AAU, international and national organizations working on RH and population, and other universities. The group has met twice, providing these important outputs: • Identifying two research priorities, one on maternal health and the other family planning; • Establishing a steering committee for advocacy on population and RH; • Identifying activities for mentoring Mekelle and Hawassa universities; and • Identifying ways to sustain the gains of Institute-AAU collaboration beyond the project life and using this project as a platform for a larger area of work to promote RH and related issues.

Family Planning: Improving the Lives of Women and Their Families Around the World

Population Council field worker (L) interviews men in the Sindh Province of Pakistan while conducting research on reproductive health and population. © 2000 Abdul Rashid Memon, Courtesy of Photoshare

Ghana: Kwame Nkrumah University of Science and Technology, School of Medical Sciences (KNUST-SMS) A number of events have taken place as a result of the Institute’s collaboration with Kwame Nkrumah University of Science and Technology (KNUST), including admission of 34 MPH population and RH graduate students. With support from the Institute, KNUST’s School of Medical Sciences enhanced the teaching environment in lecture halls with ceiling-mounted LCD projectors and mobile projector screens. KNUST also began a mentoring relationship with the University of Development Studies public health program in northern Ghana. In addition, prompted by KNUST-conducted research, the Kumasi Metropolitan Health Directorate designated family planning for the vulnerable female head-porter population as a top health priority.

Malawi: University of Malawi, College of Medicine, Center for Reproductive Health The Center for Reproductive Health (CRH) had significant accomplishments in 2008-2010, including convening the second national reproductive health conference in collaboration with the Ministry of Health and other stakeholders in Lilongwe in August 2009. Vice President Joyce Banda attended the conference, the main objective of which was to share research findings to help design interventions and improve reproductive health practice. The CRH also conducted a number of research projects, including an obstetric fistula follow-up study to examine social recovery of women whose obstetric fistulas were surgically repaired; a study to assess the feasibility and acceptability of home-based family planning and HIV counseling and testing for couples; and the launch of the Family Health and Wealth Study. The CRH also conducted a number of studies with funding from other partners and donors (e.g., Columbia University, WHO, and the Family Federation of Finland), highlighting the Center’s significant leveraging of the Gates investment. Training continued as a strong focus of the CRH grant. CRH faculty participated in teaching two MPH modules: family planning and gender and health. In addition, in collaboration with other partners, the CRH staff received training in qualitative, statistical and spatial analysis software.

Nigeria: Obafemi Awolowo University, Department of Community Health and Department of Demography and Social Statistics Obafemi Awolowo University (OAU) began 2008 by co-hosting the “Investing in Young People’s Health and Development Conference” in Abuja. Along with the University of Ibadan, OAU played a critical role in coordinating the National Steering Committee and bringing together key policymakers. The conference convened more than 500 participants from over 30 countries. As a follow-on to the conference, OAU conducted a series of activities addressing the needs of youth. Activities included a five-day training workshop on adolescent-friendly health services for 12 doctors, nurses and community health workers, and a one-day orientation for school counselors and health teachers on school-based adolescent health programs. In July 2008, OAU held a Strategic Leadership workshop for 23 participants. Also, 12 faculty and five students attended the National Conference on Public Health in Ibadan and made 10 presentations. OAU continued to expand access to public and reproductive health education for those already working in the field through its Executive MPH Program, the only one of its kind in the country. The program targets people working in such critical government agencies as the federal and state Ministry of Health, as well as international development organizations. A mentoring relationship was launched with the University of Abuja’s public and reproductive health program. OAU collaborated with a number of different groups. An important collaboration between OAU and Ibadan was the formation of the National Association of Public Health and the planning of a new research journal. OAU also partnered with UNICEF to develop a national manual on school health, counseling and adolescent health development, and on strategic leadership management with the University of North Carolina-based MEASURE Project and the Gates Foundation-funded Nigerian Urban Reproductive Health Initiative. Finally, many faculty partnered with the Ministry of Health by taking lead roles in developing or revising the national policies on RH and HIV for 2010–2015.

Finally, the CRH has become involved in advocacy, including taking journalists on a media tour of reproductive and maternal health project sites; disseminating research work to the Ministry of Health; conducting “science and health” cafes at sports bars; and participating in radio talk shows and press conferences about reproductive health issues.

2011 REPORT

19

INSTITUTIONAL DEVELOPMENT Nigeria: University of Ibadan, College of Medicine, Center for Population and Reproductive Health The University of Ibadan (UI) also began 2008 by co-hosting the “Investing in Young People’s Health and Development Conference” in Abuja. UI, along with OAU, played a critical role in coordinating the National Steering Committee and bringing together key policymakers. One of the outcomes of the conference was the recognition of the need to educate traditional leaders about reproductive health issues and to utilize them to lead change in their communities. To this end, UI held a seminar for traditional leaders in August 2008. With support from Bloomberg School’s Dr. Henry Mosley, Nigerian parliamentarian Saudatu Sani, and Mairo Mandara, Senior Country Advisor of the Packard Foundation, the seminar demonstrated to five selected northern emirs how they could use their leadership role as advocates for improved RH services. The emirs carried this message to the Sultan of Sokoto, and it is expected that these emirs will share their commitment to grassroots advocacy of birth spacing and child health investments with other northern traditional rulers. Also in 2008, UI organized a workshop on “Health Promotion and Education” targeted at health educators and another on “Proposal & Report Writing.” The public health faculty, in collaboration with two Nigerian partners, hosted a national conference in July 2008 called “Public Health in Nigeria and the Challenges of Achieving the Millennium Development Goals (MDGs): Science, Policy and Programmes.” The Association of Public Health Practitioners of Nigeria was inaugurated. UI also began a mentoring relationship with Bayero University, a relatively new university with a growing public health program. Despite school closures because of strikes, the program graduated 67 students in November 2009 and began two collaborative research studies: the Family Health and Wealth Study and a study on husbands’ support during childbirth. The husbands’ support study is aimed at evaluating the effect of husbands’ presence during labor on subsequent intention to use modern contraceptive after delivery. The key findings indicate that more women in the experimental than control group use modern contraceptives at six weeks and three months and that husbands in the experimental group are more likely to initiate the use of modern contraceptives with their wives than those in the control group.

Uganda: Makerere University School of Public Health The Makerere University School of Public Health (MUSPH) assumed a major role as co-sponsor of the 2009 International Family Planning Conference. The School’s Dean and a large number of faculty were actively involved in conference arrangements, including hosting the National Steering Committee meetings. MUSPH faculty presented their family planning research at the conference, participated in plenaries, chaired sessions, and facilitated the participation of Ugandan government officials. It also helped sponsor the International Medical Student Conference in November 2010, which focused on reproductive health in Sub-Saharan Africa. MUSPH received Gates Institute funding to launch a Family Health Research and Development Center that will focus on family planning and other priority population and RH research; develop faculty and student research skills; strengthen RH education and training; build the capacity of lower-level health facilities and develop them as satellite sites for research, training and advocacy; and conduct research translation to advocate for improved RH policies. The Center model has already attracted interest from the University of Sydney as a future partner.

Pakistan: Health Services Academy A pilot partnership with the Health Services Academy (HSA) in Pakistan commenced in January 2007. Despite efforts to recruit faculty with RH expertise, the Academy was only able to make instructor-level appointments. The absence of qualified faculty, leadership turnover and the political situation in the country led to a decision in mid-2009 to suspend partnership activities. Three HSA faculty, however, were sponsored to the 2010 Summer Institute, but only one was able to obtain a visa to attend. JHSPH faculty continue to advise HSA students on research protocols by distance.

Three brands of combined oral contraceptives (L-R): Lo-Femenal, Confidence (Duofem), and Microgynon. Confidence pills are marketed in Nigeria by Population Services International (PSI). All three of these oral contraceptives can also be used as emergency contraceptives. © 2003 David Alexander, Courtesy of Photoshare

20

Family Planning: Improving the Lives of Women and Their Families Around the World

Munawar is 25 years old and has been married for four years. She and her husband, Rashid, have two daughters and a son and live in Pakistan. Behind them is a mobile health clinic where more than 50 women and children gather around a female nurse for treatments of all kinds. © 2010 DFID, Courtesy of Flickr Creative Commons

Partner Network Meetings The Gates Institute holds one to two meetings annually with its partners. The goal of these meetings is to enable the partners to share the progress and experiences of their training and collaborative research activities. Since April 2008, there have been six partners meetings: 1) April 2008 in Abuja subsequent to the youth conference, 2) October 2008 in Nanjing, China, in collaboration with the Nanjing International Training Center and Nanjing College for Population Program Management, 3) March 2009 in Baltimore, Maryland USA, in conjunction with an investigators meeting for the Family Health and Wealth Study, 4) November 2009 in Kampala, Uganda, subsequent to the family planning conference, 5) August 2010 in New Delhi, India, in conjunction with the Global Maternal Health Conference, and 6) March 2011 in Baltimore in conjunction with the Population Association of America Conference. The meetings have exposed the attending faculty to a broad range and depth of population and reproductive health research. In addition, the Gates partners have come to identify with the network, draw on each other for consultations, and plan to continue it beyond the Institute’s support period.

“The Gates Institute is uniquely positioned to continue the stream of scientifically sound research on family planning and reproductive health. According to one U.S. affiliate, ‘The Gates Institute has established itself as a global leader on family planning and should keep that role and run with it.’” From “Report of an External Evaluation,” September 2011

2011 REPORT

21

INDIVIDUAL DEVELOPMENT

The potential impact of one skilled reproductive health researcher or practitioner is incalculable. By supporting the efforts of individuals in our field—who ultimately form a powerful global community—we leverage the health of hundreds and thousands who benefit from their expertise. Summer Institutes in Reproductive Health and Development (RHD) The Gates Institute has held annual Summer Institutes since 2002, with an average of 30 participants from more than 20 countries. The courses have attracted key reproductive health researchers, programmers and policymakers who work in NGOs, academia, research centers and governments. The course co-instructors, Drs. Michelle Hindin, Henry Mosley, Amy Tsui and Saifuddin Ahmed, are assisted by other Hopkins faculty and Gates Scholars as teaching assistants. Evaluations indicate that satisfaction is consistently high. The Institute also makes an effort to increase the workshop’s financial self-sufficiency annually, measured by the proportion of participants who self-finance. In 2005, 94 percent of the participants received Gates support; in 2011, only 20 percent were supported by the Institute.

Gates Scholars In this period one Gates doctoral scholar graduated, with two others remaining to complete their degrees. Chizoba Wonodi (MBBS-Ibadan, Nigeria) successfully defended her dissertation on “Patterns and Correlates of HIV Risk among Married and Single Men in Rakai, Uganda from 1997-2006” and graduated in May 2009. Chizoba is currently working as an Assistant Scientist with the Gates Foundation- and GAVI-funded International Vaccine Access Center in the Department of International Health at JHSPH to increase child immunization coverage in Nigeria. Maria Perez-Patron (Mexico) is near completion of her thesis on “A Life-Course Approach to International Migration: The Importance of Family,” while Dr. Ye Mon Myint (MBBS, Myanmar) is examining “Husband-Wife Differences in Reporting Pregnancies and Outcomes among Married Couples in Rural Bangladesh.” Ye Mon Myint took a leave of absence to work on an evaluation of the Global Fund in Myanmar under the Swiss Tropical Medicine Institute. Alain Koffi (MD/PhD, Cote d’Ivoire) was appointed a Gates Post-Doctoral Fellow for 2010-2011. He strengthened his research skills in complex data analysis, using linked couple data from the Demographic and Health Surveys to study couple-level concordance on reporting of recent protected sexual activity. Now a Research Associate in the International Health Department, Dr. Koffi continues to be involved in the Institute, assisting partners with their Family Health and Wealth Study activities.

22

Dissertation Research Grants The Gates Institute enables Johns Hopkins doctoral students from developing countries who are pursuing research on population, family planning and reproductive health to apply for dissertation support. The funds can be applied toward fieldwork, data analysis, writing and dissemination expenses. In early 2010, Adel Takruri (Jordan), a PFRH doctoral student, received a dissertation award to study “The Role of Men in Contraceptive Use and Family Planning Decisions in Upper Egypt,” using the Egypt Demographic and Health Survey data. Terri Ann Thompson (Jamaica) received a dissertation award to pursue her study on the “Influence of Parental Messages on Adolescent Contraceptive and Sexual Behavior” in Jamaica and graduated in May 2011. Ozge Tungcalp (Turkey) received a dissertation grant to explore the concept of “maternal near misses” at a maternity clinic in a tertiary-level hospital in Accra, Ghana. Esther Kaggwa (Uganda), who received a dissertation award to study the psychological well-being of Ugandan HIV orphans, successfully defended her dissertation in 2009. She presented her findings at the Abuja Youth Conference, and her papers have since been published in Social Science and Medicine and International Perspectives on Sexual and Reproductive Health. Esther is now with Makerere University’s Department of Population Studies and is pursuing a prospective study of sexual behaviors and reproductive health among HIV-positive youth recruited through an antiretroviral therapy clinic in Kampala, with support from the Institute.

Gates Interns The Gates Institute offers three- to six-month internship awards to continuing MHS and doctoral students at JHSPH. Students are encouraged to perform their internship at Gates partner institutions, where they are supervised by collaborating faculty. The arrangement allows for reciprocal enrichment of substantive knowledge, analytic skills and cultural understanding. The internships provide their hosts, Gates Institute partners, with assistance in research and teaching. Since the Gates Institute began its internship program, more than 40 internships have been awarded to Hopkins students to conduct work in developing countries on population and reproductive health issues. Twenty were awarded for 2009 and 2010; most of the interns worked with Gates Institute partners.

Family Planning: Improving the Lives of Women and Their Families Around the World

A group of Ethiopian women practice implant insertion on an arm model. © 2009 Mengistu Asnake, Courtesy of Photoshare

Country

2009 (9)

2010 (11)

Ghana

3 (Kwame Nkrumah University of Science and Technology)

3 (Kwame Nkrumah University of Science and Technology)

Malawi

3 (University of Malawi)

1 (University of Malawi)

Ethiopia

1 (Addis Ababa University)

1 (CARE-Ethiopia)

Jamaica

1 (University of West Indies)

Philippines

1 (University of San Carlos)

Indonesia

1 (JHU Center for Communication Programs)

Guatemala

1 (Alianzas)

Cameroon

1 (Bandjoun Hospital)

Nepal

1 (Center for Research on Environment, Health and Population Activities)

China

1 (Shanghai Institute for Planned Parenthood Research)

Visiting Scholars The Institute has increased its emphasis on strengthening the teaching and research capacity of faculty at partner institutions by hosting Visiting Scholars at the Bloomberg School of Public Health. Gates Visiting Scholars spend one or more academic terms at the JHSPH to audit (in some cases take for credit) Hopkins courses in areas that they are, or will be, teaching in their own institutions. Most scholars take three or four Hopkins courses during their stay and come with research topics or data on which they work in collaboration with Hopkins faculty to strengthen their analytic skills. The result has been new means and methods of delivering course content to students at their home institutions. The faculty also are sought out as reproductive health experts and consultants, raising the national visibility and appeal of their programs. In this period, the following visiting scholars were hosted at the Gates Institute:

Addis Continental Institute of Public Health, Ethiopia Nega Assefa Telake Azale Melake Demena Abebaw Gebeyehu Abebe Haile Gebremariam Yohannes Wado Assiut University, Egypt Ghada Salah Eldeen Al-Attar Mirette Aziz Manal Darwish Dalia Galal Mahran Mohammad

Addis Ababa University, Ethiopia

International Institute of Population Sciences, India

Hibret Alemu

Abhishek Singh

Fikre Enquosellassie

Kwame Nkrumah University of Science and Technology, Ghana

Dereje Habte

Emmanuel Nakua

Jemal Ali Haidar

Easmon Otupiri

Wubegzier Mekonnen Assefa Seme Solomon Shiferaw Melesse Tamiru

University of Ibadan, Nigeria Imran Oludare Morhason-Bello University of Montreal Visseho Adjiwanou (PhD student, Togo)

2011 REPORT

23

INDIVIDUAL DEVELOPMENT Training Evaluation To assess the impact of its efforts in training, the Gates Institute recently conducted an evaluation and examined four Hopkins-based training activities—Gates Scholars, postdoctoral fellowships, Visiting Scholars and the Summer-Winter Institute programs. The evaluation assessed the extent to which participants’ training expectations were met and how the graduates of the programs were utilizing the acquired knowledge and skills in their post-training jobs and other activities. Respondents were also asked how to improve the training programs. Data were collected from the participants using both key informant interviews (19) and a Web-based questionnaire. The interviews were largely conducted by telephone. All 764 “graduates” of the various programs were contacted by email, but only 510 had current addresses. Of those, 176 (34.5%) completed the survey. The responses strongly affirmed the value of the Institute’s various training programs: • Participants expressed a high level of satisfaction with the quality of the training received and thought the knowledge and skills acquired were relevant to their jobs and enhanced their work performance. • The level of met expectations of their Hopkins training was an average score of 8.3 out of 10. The contributions of the Gates Institute to their training were positively rated at 8.7 out of 10. • More than 40% were able to secure grants and/or publish on their PRH work post-training. • About 70% had presented their work publicly at meetings and conferences. • More than 80% were serving in PRH committees at their own organizations, 54% were serving on national PRH committees, and 31% were serving on international or global PRH committees. • Most graduates of the programs (70%) now see themselves as PRH leaders and hope to be even more active in the future. Two gaps were identified: 1) an insufficient opportunity to develop program skills and 2) an absence of public health practice opportunity, both while in the U.S. for training.

24

Family Planning: Improving the Lives of Women and Their Families Around the World

Above, left: Plan B ® (levonorgestrel) emergency contraception. © 2006 David Alexander, Courtesy of Photoshare

“Individual development is regarded by those we interviewed as the most successful of the three parts of the Gates Institute mission. On a scale of 1 to 10, Insert: A teacher explains reproductive anatomy and the menstrual cycle at Urdu High School in Rakhial, Ahmedabad, India with the help of a model of a uterus and diagrams. The recent census shows that India has the highest number of adolescents in the world. Health education efforts involving youth and teachers, such as the Adolescent Health and Nutrition Education project seen here, promotes the concept of “catch them young and teach them right.” © 2003 Rajal Thaker, Courtesy of Photoshare Village families in Nigeria wait in line for HIV/AIDS voluntary counseling and testing (VCT). © 2003 Shehu Danlami Salihu, Courtesy of Photoshare

it received an average score of 8, and all but one of the people who responded ranked it first in terms of importance. It is especially valued by the partner institutions.” From “Report of an External Evaluation,” September 2011

2011 REPORT

25

POLICY, PRACTICE AND ADVOCACY

The Millennium Development Goals have become a catalyst for increased funding for reproductive health, an improved policy environment and greater visibility for family planning. Gates Institute activities have also gained momentum through the recognition of family planning as a sound investment, with dividends in health, women’s empowerment and socioeconomic development. Making the Case

Advance Family Planning

In 2008, the Gates Institute convened a group of five former directors of the Population and Reproductive Health Program of the U.S. Agency for International Development (USAID) to prepare the report, “Making the Case for U.S. International Family Planning Assistance.” The report called for renewed U.S. political and financial commitment to international family planning programs, recommending that funding for USAID’s international family planning assistance be increased to $1.2 billion in FY 2010 (from $457 million in 2008) and raised to $1.5 billion by 2014.

In 2009, the Gates Institute received a grant to revitalize the family planning and reproductive health global agenda. The goal of the three-year project is to empower developing countries to advocate for universal access to reproductive health as a critical component in achieving the MDGs.

Increased funding would support training, equip health care providers, expand successful programs, extend programs into more underserved countries, secure USAID’s technical expertise, and renew U.S. leadership and funding for global organizations. It would represent an appropriate American contribution to international efforts to achieve the global consensus Millennium Development Goal (MDG) target of universal access to reproductive health services, including family planning, by 2015. The report was widely disseminated in the United States and in Europe, and the directors held briefings with members of Congress, their staff and senior executive branch staff. “Making the Case” was just one of several advocacy efforts to increase funding for international family planning.

Led by Duff Gillespie and supported by both the Bill & Melinda Gates and the David and Lucile Packard foundations, with combined grants totaling $12 million, the project emphasizes the urgent need to reach the 200 million women who wish to delay or end childbearing but have no access to family planning services. Advance family planning (AFP) has three interrelated objectives:

Mobilize and strengthen sustainable family planning/reproductive health advocacy through catalytic invest•

ments in Tanzania, Uganda and Indonesia—countries with potential to foster wider replication of the AFP approach in other developing countries;

Strengthen existing family planning/reproductive • health advocacy investments in India, Pakistan, Ethiopia, Kenya, Nigeria and Senegal by providing cutting edge and highly specialized technical assistance;

Leverage the voices of global South champions in • demanding revitalization of the family planning/reproductive health agenda and to enable greater South-to-South cooperation. The project has been implemented in nine countries in Sub-Saharan Africa and South Asia by a consortium of core partners that collaborates with other donors, organizations and the private sector to advocate for increased political commitment and resources. Additionally, the project works with USAID to draw on lessons learned and to scale up successful initiatives. In Indonesia, for example, AFP and USAID cost-shared an organizational analysis of the National Family Planning Coordinating Board (BKKBN), which in turn co-sponsored with Futures Group International advocacy training for BKKBN officials. The project also helped establish a sustainable African Women for Reproductive Health Network to harness the energy, talents and needs of women at the community level.

26

Family Planning: Improving the Lives of Women and Their Families Around the World

Nigeria National Assembly Delegation TIn 2005, the Gates Institute hosted a Leadership Forum with parliamentarians, which resulted in an enduring relationship with the Honorable Saudatu Sani of Nigeria. In December 2008, Hon. Sani and a delegation of 25 National Assembly members and staff representing the House Committee on the Millennium Development Goals (MDGs) visited the Bloomberg School. Their interest was in learning more about the areas needing investment and the evidence-based strategies for achieving the MDGs. Bloomberg School experts Amy Tsui, Robert Blum, Thomas Quinn and Duff Gillespie made presentations on maternal and child health, needs of adolescents, family planning and HIV. Visitors learned about strategic approaches being implemented by Johns Hopkins, including behavior change strategies, service delivery and health systems. The delegation also met with a group of Nigerian students attending the School to learn about their concerns regarding returning to Nigeria and the availability of jobs in public health.

Governor and First Lady of Zamfara State, Nigeria In September 2009, the Governor and First Lady of Zamfara State visited the Institute. Zamfara, in northwest Nigeria, has the worst health and development indicators in the country. It established a Sharial legal system, which weighed heavily on women and discouraged female empowerment. First Lady Hajiya Aisha Mahmud Aliyu Shinkafi is the daughter of Ibrahim and Maryam Babangida, the former President and First Lady of Nigeria. Maryam Babangida was a participant in the Gates Institute Summer Institute in June 2006 and is considered to be one of the greatest women in Africa for her work in rural women’s development. The Governor and First Lady came with a two-fold purpose: to meet with faculty in the Department of International Health to discuss activities in Nigeria around World Pneumonia Day and to learn about Johns Hopkins’ reproductive health programs in Nigeria. The First Lady also inquired about the technical resources necessary to invest in cancer treatment. The Governor and First Lady visited Jhpiego and the Center for Communication Programs to learn about their respective programs in Nigeria. They returned to the Bloomberg School to learn about the Gates Institute’s Nigeria activities, including the youth conference, partnerships with OAU and University of Ibadan, AdvocacyNigeria, work with traditional rulers, and obstetric fistula research.

A young father relaxes with his son in Funyula, Kenya. This young man is one of the youths in his village who has taken on the responsibility of parenthood at an early age, without a job. Such young male parents do odd jobs in the village in order to survive, sometimes being hired as grave diggers when a wealthy person dies, or doing manual jobs at funerals. © 2005 Felix Masi, Courtesy of Photoshare

“I am a strong advocate of women having access to family planning. …We have been able to draw the traditional institutions into discussing maternal health, which had never happened before. I saw myself as an agent of change.” The Hon. Saudatu Sani, formerly a Nigerian Parliament member

2011 REPORT

27

The documentary film, “The Edge of Joy,” follows Nigerian doctors, midwives and families to the frontlines of maternal care as it explores the complexities of bringing emerging health technologies to the developing world. One of the two obstetricians featured in the film, Dr. Oladosu Ojengbede, heads the Institute’s partnership with the University of Ibadan. Global Health Magazine called the film “a timely rallying cry against women accepting the perilous status quo.”

28

This teenage girl, having never received any family planning information or services, is hospitalized for pregnancy-related complications. The maternal mortality rate in Nigeria is among the highest in the world. A Nigerian woman faces a 1 in 13 lifetime risk of maternal mortality. For women in the United States, the risk is 1 in 3,500. Nigeria is Africa’s most populous country with an estimated population of nearly 123 million people. At the average annual population growth rate of 2.9 percent, Nigeria’s population is expected to surpass 200 million by the year 2025.

Family Planning: Improving the Lives of Women and Their Families Around the World

Gates Institute Journal Publications 2007 Ahmed, S., R. Genadry, C. Stanton, and A. Lalonde. “Dead Women Walking: Neglected Millions with Obstetric Fistula.” International Journal of Gynecology and Obstetrics 99, Supplement 1 (2007): S1–S3. Ahmed, S., and S.A. Holtz. “Social and Economic Consequences of Obstetric Fistula: Life Changed Forever?” International Journal of Gynecology and Obstetrics 99, Supplement 1 (2007): S10–S15. Bradley, H., A. Bedada, H. Brahmbhatt, A. Kidanu, D. Gillespie, and A. Tsui. “Educational Attainment and HIV Status among Ethiopian Voluntary Counseling and Testing Clients.” AIDS and Behavior 11, no. 5 (September 11, 2007):731–742. Bradley, S., N. Prata, N. Young-Lin, and D. Bishai. “CostEffectiveness of Misoprostol to Treat Postpartum Hemorrhage in Low-Resource Settings.” International Journal of Obstetrics and Gynecology 97 (2007):52–56. Creanga, A., R. Acharya, S. Ahmed, and A. Tsui. “Contraceptive Discontinuation, Failure and Subsequent Abortions in Romania: 1994–1999.” Studies in Family Planning 38, no. 1 (2007): 23–34. Creanga, A., S. Ahmed, R. Genadry, and C. Stanton. “Prevention and Treatment of Obstetric Fistula: Identifying Research Needs and Public Health Priorities.” International Journal of Gynecology and Obstetrics 99, Supplement 1 (2007): S151.

Gillespie, D. Review of J.F. Kantner and A. Kantner’s “The Struggle for International Consensus on Population and Development.” Studies in Family Planning 38, no. 3 (2007): 222–223. Gillespie, D. “Contraceptive Use and the Poor: A Matter of Choice?” PLoS Medicine 4, no. 2 (February 2007): e49. Gillespie, D., S. Ahmed, A. Tsui, and S. Radloff. “Unwanted Fertility among the Poor: An Inequity?” Bulletin of the World Health Organization 85, no. 2 (2007): 100–107. Howard, C.T., U.S. McKakpo, I.A. Quakyi, K.M. Bosompem, E.A. Addison, D. Sullivan, and R.D. Semba. “Relationship of Hepcidin with Parasitemia and Anemia among Patients with Uncomplicated Plasmodium Falciparum Malaria in Ghana.” American Journal of Tropical Medicine and Hygiene 77, no. 4 (2007): 623–626. Jaya, Jaya, and M.J. Hindin. “Nonconsensual Sexual Experiences of Adolescents in Urban India.” Journal of Adolescent Health 40, no. 6 (2007): 573.e7–14. Jaya, Jaya, M.J. Hindin, and S. Ahmed. “Differences in Young People’s Reports of Sexual Behaviors According to Interview Method: A Randomized Trial in India.” American Journal of Public Health 98, no. 1 (2007): 169–174. Mullany, B.C., M.J. Hindin, and S. Becker. “The Impact of Including Husbands in Antenatal Health Education Services on Maternal Health Practices in Urban Nepal.” Health Education Research 222, no. 2 (2007): 166–176.

Creanga, A., H. Bradley, A. Kidanu, Y. Melkamu, and A. Tsui. “Does the Delivery of Integrated Family Planning and HIV/AIDS Services Influence Community-Based Workers’ Client Loads in Ethiopia?” Health Policy and Planning 22 (2007): 404–414.

Stanton, C., S.A. Holtz, and S. Ahmed. “Challenges in Measuring Obstetric Fistula.” International Journal of Gynecology and Obstetrics 99, Supplement 1 (2007): S4-–S9.

Creanga, A., and R. Genadry. “Obstetric Fistulas: A Clinical Review.” International Journal of Gynecology and Obstetrics 99, Supplement 1 (2007): S40–46.

Tsui, A., A. Creanga, and S. Ahmed. “The Role of Delayed Childbearing in the Prevention of Obstetric Fistulas.” International Journal of Gynecology and Obstetrics 99, Supplement 1 (2007): S98–S107.

Do, M., and M. Koenig. “Effect of Family Planning Services on Modern Contraceptive Continuation in Vietnam.” Journal of Biosocial Science 39 (2007):201–220. Genadry, R., A. Creanga, M. Roenneburg, and C. Wheeless. “Complex Obstetric Fistulas.” International Journal of Gynecology and Obstetrics 99, Supplement 1 (2007): S51–S56.

2008 Barden O’Fallon, J., and A. Tsui. “Infertility.” Encyclopedia of Public Health. The Netherlands: Springer-Verlag (2008): 780–783. Bradley, H., A. Bedada, A. Tsui, H. Brahmbhatt, A. Kidanu, and D. Gillespie. “HIV and Family Planning Service Integration and Voluntary HIV Counseling and Testing Client Composition in Ethiopia.” AIDS Care 20, no. 1 (2008): 61–71.

2011 REPORT

29

Creanga, A., P. Roy, and A. Tsui. “Characteristics of Abortion Service Providers in Two Northern Indian States.” Contraception 78, no.6 (2008): 500–6. Epub September 4, 2008. Creanga, A., and A. Tsui. “Fertility.” Encyclopedia of Public Health. The Netherlands: Springer-Verlag (2008): 449–453. Fatusi, A.O., and R.W. Blum. “Predictors of Early Sexual Initiation among a Nationally Representative Sample of Nigerian Adolescents.” BMC Public Health 8 (2008): 136, doi:10.1186/1471-2458-8-136. Hoffman, I., F.E. Martinson, K.A. Powers, D.A. Chilongozi, E.D. Msiska, E.I. Kachipapa, C.D. Mphande, M.C. Hosseinipour, H.C. Chanza, R. Stephenson, and A. Tsui. “The Year-Long Effect of HIV-Positive Test Results on Pregnancy Intentions, Contraceptive Use and Pregnancy Incidence among Malawian Women.” JAIDS 47 (2008):477–483. Kassie, G.M., D.H. Mariam, and A.O. Tsui. “Patterns of Knowledge and Condom Use among Population Groups: Results from the 2005 Ethiopian Behavioral Surveillance Surveys on HIV.” BMC Public Health 8 (December 31, 2008): 429. Kumwenda, N.I., J. Kumwenda, G. Kafulafula, B. Makanani, F. Taulo, C. Nkhoma, Q. Li, and T. Taha. “HIV-1 Incidence among Women of Reproductive Age in Malawi.” International Journal of STD and AIDS 19, no. 5 (May 2008): 339–41. Liu, L., S. Becker, S. Ahmed, and A. Tsui, “Simple Approaches to Estimating Births Averted Due to Contraception at the National Level.” Population Studies 62, no. 2 (2008): 191–210. Mullany, L.C., C.I. Lee, P. Paw, Oo E.K. Shew, C. Maung, H.K. Kulper, N. Masenior, C. Beyrer, and T.J. Lee. “The MOM Project: Efforts to Increase Access to Reproductive Services among Internally Displaced Populations in Burma.” Reproductive Health Matters 16, no. 31 (May 2008): 44–56. Mullany, L.C., C.I. Lee, L. Yone, P. Paw, Oo E.K. Shew, C. Maung, T.J. Lee, and C. Beyrer. “Access to Essential Maternal Health Interventions and Human Rights Violations among Vulnerable Communities in Eastern Burma.” PLoS Medicine 5, no. 12 (December 23, 2008): 1689–98. Peterson, H., A. Creanga, and A. Tsui. “Family Planning.” Maxcy-Rosenau-Last Public Health & Preventive Medicine, edited by Robert Wallace and Douglas Scutchfield. McGraw-Hill Publishers (2008): 1303–1316.

Rahman, M.H., W.H. Mosley, S. Ahmed, and H. Akhter. “Does Service Accessibility Reduce Socioeconomic Differentials in Maternity Care Seeking? Evidence from Rural Bangladesh.” Journal of Biosocial Science 40 (2008): 19–33. Roy, T.K., R.K. Sinha, M. Koenig, S.K. Mohanty, and S.K. Patel. “Consistency and Predictive Ability of Fertility Preference Indicators: Longitudinal Evidence from Rural India.” International Family Planning Perspectives 34, no. 30 (2008): 138–145. 2009 Bazant, E., and M.E. Koenig. “Women’s Satisfaction with Delivery Care in Nairobi’s Informal Settlements.” International Journal for Quality in Health Care 21, no. 2 (April 2009): 79–86. Epub 2009 Feb 9. Bazant, E.S., M.A. Koenig , J.C. Fotso, and S. Mills. “Women’s Use of Private and Government Health Facilities for Childbirth in Nairobi’s Informal Settlements.” Studies in Family Planning 40, no. 1 (March 2009): 39–50. Becker, S., R. Mlay, H. Schwandt, and E. Lyamuya. “Comparing Couples’ and Individual Voluntary Counseling and Testing for HIV at Antenatal Clinics in Tanzania: A Randomized Trial.” AIDS Behavior (September 10, 2009). Epub ahead of print. Blanc, A.K., A.O. Tsui, T.N. Croft, and J.L. Trevitt. “Patterns and Trends in Adolescents’ Contraceptive Use and Discontinuation in Developing Countries and Comparisons with Adult Women.” International Perspectives on Sexual and Reproductive Health 35, no. 2 (June 2009): 63–71. Bradley, H., D. Gillespie, A. Kidanu, Y.T. Bonnenfant, and S. Karklins. “Providing Family Planning in Ethiopian Voluntary HIV Counseling and Testing Facilities: Client, Counselor and Facility-Level Considerations.” AIDS 23, suppl 1 (2009): S105–S114. Fatusi, A.O., and R.W. Blum. “Adolescent Health in an International Context: The Challenge of Sexual and Reproductive Health in Sub-Saharan Africa.” Adolescent Medicine State of the Art Rev 20, no. 3 (2009): 874–86, viii. Gillespie, D., E. Maguire, M. Neuse, S. Sinding, and J. Speidel. “International Family Planning Budgets in the New ‘US-Era.’” The Lancet 373 (May 2, 2009): 1505–1057. Gillespie, D., H. Bradley, W. Woldegiorgis, A. Kidanu, and S. Karklins. “Integrating Family Planning into Ethiopian Voluntary Testing and Counselling Programmes.” Bulletin of the WHO 87, no. 11(November 2009): 866–70. Hindin, M., and A.O. Fatusi. “Adolescent Sexual and Reproductive Health in Developing Countries: An Overview of Trends and Interventions.” International Perspectives on Sexual and Reproductive Health 35, no. 2 (2009): 58–62.

30

Family Planning: Improving the Lives of Women and Their Families Around the World

Jaya, Jaya, and M. Hindin. “Premarital Romantic Partnerships: Attitudes and Sexual Experiences of Youth in Delhi, India.” International Perspectives on Sexual and Reproductive Health 35, no. 2 (2009): 97–104.

Danso, K., H. Schwandt, C. Turpin, J. Seffah, A. Samba, and M. Hindin. “Preferences of Ghanaian Women for Vaginal or Cesarean Delivery PostPartum.” Ghana Medical Journal 43, no. 1 (2010): 29–33.

Mohanty, S.K., R.K. Sinha, T.K. Roy, and M. Koenig. “Programmatic Implications of Meeting the Unmet Need for Contraception.” Asian Population Studies 5, no. 1 (2009): 21–39.

Gipson, J., C. Muntifering, F. Chauwa, F. Taulo, A. Tsui, and M. Hindin. “Assessing the Importance of Gender Roles in Couples’ Home-Based Sexual Services in Malawi.” African Journal of Reproductive Health 14, no. 4 (2010): 63–74.

Taulo, F., M. Berry, A. Tsui, B. Makanani, G. Kafulafula, Q. Li, C. Nkhoma, J.J. Kumwenda, N. Kumwenda, and T.E. Taha. “Fertility Intentions of HIV-1 Infected and Uninfected Women in Malawi: A Longitudinal Study.” AIDS and Behavior 13, Suppl 1 (June 2009): 20–7. Epub 2009 Mar 24.

Kaggwa, E., and M. Hindin. “The Psychological Effect of Orphanhood in a Matured HIV Epidemic: An Analysis of Young People in Mukono, Uganda.” Social Science and Medicine (2010). doi: 10.1016/j.socscimed.2009.12.002.

Teela, K.C., L.C. Mullany, C.I. Lee, E. Poh, P. Paw, N. Masenior, C. Maung, C. Beyrer, and T. J. Lee. “CommunityBased Delivery of Maternal Care in Conflict-Affected Areas of Eastern Burma: Perspectives from Lay Maternal Health Workers.” Social Science and Medicine 68, no. 7 (April 2009): 1332–40. Epub 2009 Feb 18. Yeakey, M.P., E. Chipeta, F. Taulo, and A.O. Tsui. “The Lived Experience of Malawian Women with Obstetric Fistula.” Culture, Health and Sexuality 11, no. 5 (June 2009): 499–513. Yeakey, M.P., C.J. Muntifering, D.V. Ramachandran, Y.M. Myint, A.A. Creanga, and A.O. Tsui. “How Contraceptive Use Affects Birth Intervals: Results of a Literature Review.” Studies in Family Planning 40, no. 3 (2009): 205–214. Zabin, L.S., M.R. Emerson, L. Nan, C.H. Lou, E.S. Gao, N.H. Minh, Y.L. Chuang, S.H. Baai, D. Bishai, and R.W. Blum. “Levels of Change in Adolescent Sexual Behavior in Three Asian Cities.” Studies in Family Planning 40, no. 1 (2009): 1–12. 2010 Ahmed, S., A. Creanga, D. Gillespie, and A. Tsui. “Economic Status, Education and Empowerment: Implications for Maternal Health Service Utilization in Developing Countries.” PloS ONE 5, no. 6 (June 23, 2010):e11190. Aryeetey, R., A.M. Kotoh, and M. Hindin. “Knowledge, Perceptions and Ever Use of Modern Contraception among Women in the Ga East District, Ghana. African Journal of Reproductive Health 14, no. 4 (2010): 27–32. Bradley H., A. Tsui, A. Kidanu, and D. Gillespie. “HIV Infection and Contraceptive Need among Female Ethiopian Voluntary HIV Counseling and Testing Clients.” AIDS Care 22, no. 10 (2010): 1295–1304.

Lutalo, T., G. Kigozi, E. Kimera, D. Serwadda, M. Wawer, L. S. Zabin, and R. Gray. “A Randomized Community Trial of Enhanced Family Planning Outreach in Rakai, Uganda.” Studies in Family Planning 41, no. 1(2010): 55–60. Makanani, B., J. Kumwenda, N. Kumwenda, S. Chen, A. Tsui, and T. Taha. “Resumption of Sexual Activity and Regular Menses after Childbirth among Women Infected with HIV in Malawi.” International Journal of Obstetrics and Gynecology 108, no. 1 (2010): 26–30. Makumbi, F., G. Nakigozi, T. Lutalo, J. Kagaayi, J. Sekasanvu, A. Settuba, D. Serwada, M. Wawer, and R. Gray. “Use of HIV-Related Services and Modern Contraception among Women of Reproductive Age, Rakai, Uganda.” African Journal of Reproductive Health 14, no. 4 (2010): 91–102. Midhet, F., and S. Becker. “Impact of Community-Interventions on Maternal and Neonatal Health Indicators: Results from a Community Randomized Trial in Rural Balochistan, Pakistan.” Reproductive Health Journal 7 (2010): 30. Mmari, K., O. Oseni, and A.O. Fatusi. “STI TreatmentSeeking Behaviors among Youth in Nigeria: Are There Gender Differences?” International Perspectives on Sexual and Reproductive Health 36, no. 2 (2010): 72–79. Mote, C., E. Otupiri, and M. Hindin. “Factors Associated with Induced Abortion among Women in Hohoe, Ghana.” African Journal of Reproductive Health 14, no. 4 (2010): 115–122. Mullany, L.C., T.J. Lee, L. Yone, C.I. Lee, K.C. Teela, et al. “Impact of Community-Based Maternal Health Workers on Coverage of Essential Maternal Health Interventions among Internally Displaced Communities in Eastern Burma: The MOM Project.” PLoS Medicine 7(8)(2010): e1000317. OlaOlorun, F., and A. Tsui. “Advancing Family Planning Research in Africa.” African Journal of Reproductive Health 14(4)(2010): 9–12.

2011 REPORT

31

Olayemi, O., D. Strobino, C. Aimakhu, K. Adedapo, A. Kehinde, A.T. Odukogbe, and B. Salako. “Influence of Duration of Sexual Cohabitation on the Risk of Hypertension in Nulliparous Parturients in Ibadan: A Cohort Study.” Australian and New Zealand Journal of Obstetrics and Gynecology 50 (2010): 40–44. Olayemi, O., D. Strobino, K. Adedapo, C. Aimakhu, A.T. Odukogbe, and B. Salako. “Influence of Previous Abortions and New Paternity on the Risk of Hypertension in Nulliparous Parturients in Ibadan: A Cohort Study.” The Journal of Obstetrics and Gynecology Research (Japan). doi: 10.1111/j.1447-0756.2010.01268.x. Oni, G., A. Fatusi, A. Tsui, F. Enquselassie, O. Ojengbede, T. Agbenyega, E. Ojofeitimi, F. Taulo, and I. Quakyi. “Strengthening Public-Health Education in Population and Reproductive Health through an Innovative Academic Partnership in Africa: The Gates Partners’ Experience.” Global Public Health Journal (2010). doi: 10.1080/17441692.2010.491485. Tsui, A., R. McDonald-Mosley, and A. Burke. “Family Planning and the Burden of Unintended Pregnancies.” Epidemiologic Reviews. doi: 10.1093/epirev/mxq012.

Shah, N., W. Wang, and D. Bishai. “Comparing Private Sector Family Planning Services to Government and NGO Services in Ethiopia and Pakistan: How Do Social Franchises Compare Across Quality, Equity and Cost?” Health Policy and Planning 26 (2011): i63–i71. Shellenberg, K., A. Moore, A. Bankole, J. Casterline, F. Juarez, A. Omideyi, N. Palomino, Z. Sathar, S. Singh, and A. Tsui. “Social Stigma, Decision-Making, and Disclosure about Induced Abortion: Results from a Multi-Country Qualitative Study.” Global Journal of Public Health Supplement (in press). Tsui, A., J. Casterline, S. Singh, A. Bankole, A. Moore, A. Omideyi, N. Palomino, Z. Sathar, F. Juarez, and K. Shellenberg. “Managing Unplanned Pregnancies in Five Countries: Perspectives on Contraception and Abortion Decisions.” Global Journal of Public Health Supplement (in press). Wilson, A.L., E. Chipeta, L. Kalilani-Phiri, F. Taulo, and A. Tsui. “Fertility and Pregnancy Outcomes among Women with Obstetric Fistula in Rural Malawi.” International Journal of Gynecology and Obstetrics 113, no. 3 (June 2011): 196–198.

Yeakey ,M., E. Chipeta, Y. Rijken, F. Taulo, and A. Tsui. “Experiences with Fistula Repair Surgery among Women and Families in Malawi.” Global Public Health Journal (July 6, 2010): 1–15. 2011 Bradley, H., A. Tsui, M. Hindin, A. Kidanu, and D. Gillespie. “Developing Scales to Measure Perceived HIV Risk and Vulnerability among Ethiopian Women Testing for HIV.” AIDS Care 23, no. 8 (August 2011): 1043-1052. Bradley, H., A. Tsui, A. Kidanu, and D. Gillespie. “Client Characteristics and HIV Risk Associated with Repeat Testing Among Women in Ethiopia.” AIDS Behavior 15, no. 4 (May 2011): 725-33. Creanga, A., D. Gillespie, S. Karklins, and A. Tsui. “Low Use of Contraception among Poor Women in Africa: An Equity Issue.” Bulletin of the World Health Organization 89 (2011): 258–266. Creanga, A., H. Schwandt, K. Danso, and A. Tsui. “Knowledge about Emergency Contraception among Family Planning Providers in Urban Ghana.” International Journal of Gynecology and Obstetrics 114, no. 1(2011): 64–68. Schwandt, H., A. Creanga, K. Danso, R. Adanu, T. Agbenyega, and M. Hindin. “A Comparison of Women with Induced Abortion, Spontaneous Abortion and Ectopic Pregnancy in Ghana.” Contraception 84, no. 1 (2011): 87–93.

32

Family Planning: Improving the Lives of Women and Their Families Around the World

Executive Committee, Affiliated Faculty

Gates Institute Staff

Johns Hopkins Bloomberg School of Public Health Department of Population, Family and Reproductive Health

Amy Tsui, PhD Professor and Director

Saifuddin Ahmed, MBBS, PhD* Associate Professor

Natalie Culbertson Senior Program Coordinator

Stan Becker, PhD* Professor

Monnie Heminthavong, MPH Training Program Officer

David Bishai, MD, PhD, MPH* Professor

Ken Creeger, MBA Financial Manager

Robert Blum, MD, PhD, MPH* William H. Gates Sr. Chair Professor

Carrileen Edwards Budget Analyst

Vladimir Canudas-Romo, PhD Assistant Professor Duff Gillespie, PhD* Professor Ronald Gray, MBBS, MSc* William G. Robertson Jr. Professor In Population and Family Planning Bernard Guyer, MD, MPH* Zanvyl Krieger Professor of Children’s Health Michelle Hindin, PhD* Associate Professor W. Henry Mosley, MD* Professor Laurie Schwab Zabin, PhD* Founding Director, Gates Institute Professor

Other FACULTY Affiliations Jane Bertrand, PhD, MBA* Director, Center for Communication Programs Professor, Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health Anne Burke, MD Assistant Professor, Obstetrics and Gynecology, Johns Hopkins School of Medicine Andrew Cherlin, PhD* Benjamin H. Griswold III Professor of Public Policy Department of Sociology, Zanvyl Krieger School of Arts and Sciences, Johns Hopkins University William K. Pan, PhD Assistant Professor, Department of International Health, Johns Hopkins Bloomberg School of Public Health Taha E. Taha, PhD Professor, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health *Executive Committee

Gate Institute Advance Family Planning Project Duff Gillespie, PhD Professor and Director Beth Fredrick Deputy Director Sabrina Karklins, MPA Senior Research Program Coordinator Jennifer Carlin, MA Program Administrator Naomi Johnson Senior Research Service Analyst

Girls from a village near Jodhpur, India, © 2006 Rose Reis, Courtesy of Photoshare Graphic design by Marti Betz Design

Bill and Melinda Gates Institute for Population and Reproductive Health Johns Hopkins Bloomberg School of Public Health 615 N. Wolfe Street, Suite 4041 Baltimore, MD 21205-2179 USA 410-955-2232 (T) 410-955-0792 (F) [email protected] www.jhsph.edu/gatesinstitute