RESEARCH NEEDS

Women's health advocates were of the view that research on fertility regulation is not neutral, but is influenced by political factors such as the policies of population funding agencies, the search for markets by pharmaceutical companies, and political restrictions on the development of safer abortifacients. Priority has been given to: laboratory and clinical research to generate information about pharmacology and to satisfy requirements for registration of methods by drug regulation agencies; development of new fertility control methods (especially provider-controlled methods); and demographic research (especially fertility trends, marriage patterns and contraceptive prevalence). Only recently, has attention been paid to health service delivery systems or to users' needs.

" I don't know of a time that the development of a new contraceptive was started by saying what women need is this, so let's try to study a method that responds to this need. What really happens is that there is an opportunity of developing a new contraceptive method because of a new discovery in the biological sciences. And it has been very difficult to reconcile the women's needs or the clients' needs with the opportunities of developing a method. I think the only example that I have is the new studies directed to the needs of women who are breast feeding, which is not led by demographic interests but by women's interests". - Anibal Faundes

It was agreed that new discoveries in the biological sciences, rather than women's needs, have most often stimulated the development of new contraceptive methods. However, two recent examples were given of fertility regulation methods which have been developed to reduce side effects that the women are worried about: the low-dose once-a-month injectable which was developed because bleeding problems frequently occurred with two- or three-monthly injectables; and hormone-releasing IUDs developed with a view to reducing menstrual blood loss associated with ordinary IUDs. While acknowledging the importance of such efforts, women's health advocates pointed out that responding to women's criticisms of existing methods was not sufficient. They suggested that research should begin by studying the needs of a particular population and the existing delivery system, as the basis for selecting a mix of methods, both old and new, for introduction.

Clients' needs and preferences

Currently, research on sexual activity, reproductive health, and fertility desires is inadequate. Many more studies are needed to find out what women think about various methods, how they understand them to work, what are their fears, why they discontinue methods, what they find acceptable (both in terms of methods and services received), and what are their views on the financial and social costs of methods. Much more also needs to be learned about women's sexual experiences, their experiences with and attitudes towards reproductive morbidity such as reproductive tract infections, and indigenous fertility control practices and preferences.

The Special Programme supports research on the dynamics of contraceptive use which aims to determine what happens to a woman once she starts practicing contraception, how she chooses among the options available, and how she manages the complexities of contraceptive use, pregnancy, delivery, and post-partum family planning.

"When we talk about selection and introduction of methods, not only biomedical research...is important, but along with it...study of women's attitudes and relationships, their way of life, their religion...". - Ninuk Widyantoro

Health and family planning delivery systems

The extent to which clients' needs can be met depends fundamentally on health and family planning infrastructure, including, among others, supply and logistics systems, service delivery points, staff skills, regulations and management capacity. Participants gave particular emphasis to the need to assess the skills, knowledge, attitudes, and practices of providers, including not simply medical skill and provision of technologies to clients, but also their ability to provide information and counseling. Several participants pointed out that service providers often have very little information about new methods and that provider bias can certainly affect method

It was suggested that KAP (knowledge, attitudes and practice) surveys which are normally carried out on the general public, should also be carried out among scientists, programme managers and providers in order to determine the extent to which they are likely to enable clients to make fully informed choices and provide technically competent services. The participants recognized that such research may be particularly challenging as health systems and personnel are medically oriented and may find it difficult to think and work in terms of broader social needs. In addition, most health and family planning systems give priority to services and will need to be persuaded of the importance of research and their participation in it.


Fertility regulation methods

The objective of methods research should be to develop a range of methods to suit a wide variety of clients. Women's health advocates pointed out that very little research has been done on withdrawal as a method and that barrier methods are given far less priority than hormonal or provider dependent methods. Scientists suggested that because of AIDS there is a renewed interest, including in the Special Programme, in barrier methods, especially condoms. Some interest also exists in traditional methods such as withdrawal, although this work focuses on why couples choose these methods rather than on their use effectiveness. Participants urged that more emphasis be placed on research into male methods.

Women's health advocates felt that research is needed on the interaction of fertility regulation methods with common disease conditions such as recurrent diarrhea, parasitic infestation, anemia and recurrent reproductive tract infections. Staff from the Special Programme reported that considerable research on such issues is being supported by the Special Programme.

Who should do the research and how

Most researchers - laboratory and clinical scientists, demographers, and social scientists tend to be men. Service managers and physicians who are or should be involved in introduction research also tend to be men, while non-physician providers such as midwives and village health workers are generally women and are lower in the programme hierarchy. This results in a severe gender imbalance in research that influences both the questions that are asked and the interpretation of the findings.

"there can be different interpretations of the same results of scientific studies, and different conclusions drawn from different interpretations. Findings ways of discussing those differences is really important...". - Anita Hardon

Two ways were suggested to broaden and balance current research activities: first, to add women to the research team; and second, to draw on the expertise of groups who work closely with women and are likely to represent clients' and women's perspectives. It was agreed that it is vital to include women's perspectives at the very earliest stages of research and throughout the process including the final interpretation of results.

The scientists in the meeting pointed out that laboratory and clinical research must be carried out according to certain scientific norms and standards and expressed some doubt whether nonscientists could be fruitfully involved in these processes. In this regard, the women's health advocates felt that scientific expertise needed to be broadened and in formed by the skills and experience of other professionals who work closely with women.

Participants agreed that many different approaches can be used in research on health systems and on clients. In recent years, for example, several techniques have been used - participatory research, focus groups, and "action-oriented" research- to learn about clients' perspectives while assessing delivery systems. A women's health advocacy group in Brazil, for instance, involved women from the barrios in designing and carrying out research on women's attitudes to sterilization, contraception, and local health services. The women then used the results to educate other women and to take action where needed. Research of this kind can empower women as well as generate important and reliable information.

Participants agreed that women and women's health advocates must be included on ethical committees and should participate in the elaboration and revision of research guidelines, both nationally and internationally. Research and trial protocols could include an instruction to scientists to consult with women's groups and guidelines for protocols could include information about how to encourage the participation of women, especially at local levels.

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