This brief report details the motivation behind, and key findings from, research carried out in Kazakhstan, Kyrgyzstan, Tajikistan and Kosovo to explore reproductive and sexual health and safe motherhood in this region - with an emphasis on gender issues. The Netherlands School of Public and Occupational Health (NSPOH) undertook 2 knowledge, attitudes, and practice (KAP) surveys involving people of reproductive age:

1. Carried out in the framework of the 4-year project "Services to the People, Promotion of Reproductive and Sexual Health and Rights in Rural Areas in Kazakhstan, Kyrgyzstan and Tajikistan", NSPOH worked together with the Netherlands Institute for Health Services (NIVEL) to collect and analyse quantitative data. These data were meant to illuminate how well this project met its goal of enhancing the quality of perinatal care and the empowerment of local communities in terms of their reproductive rights.
2. Conducted in Kosovo in collaboration with the United Nations Population Fund (UNFPA), this project involved educating local Swiss Red Cross volunteers to inform rural populations on reproductive health (hereafter, RH) issues and the use of contraceptives. NSPOH worked with the Kosovo Institute of Public Health to collect and analyse the data.

A key methodological note shared here is that, in both studies, NSPOH ensured that approximately 2/3 of respondents were female and 1/3 were male. This decision reflects the researchers' conviction that, by focusing on women only, research on RH issues can in fact reinforce the false - but common - notion that such issues as the decision to have children or not is a matter for females only. That is, part of the research design involved an effort to effect behavioural change by making male participation a prerequisite.

A background section outlines various issues impacting RH knowledge, communication, and decision making in both of the research areas - highlighting such factors as the role of both the state and religion in shaping women's position in society (a role that is, according to NSPOH, currently being discussed and redefined), as well as the "strong revival" of traditional family relations, which can lead husbands and mothers-in-law to play a dominant role in RH decision making (even while women are expected to bear the burden of preventing pregnancies and dealing with the consequences). This context is complicated by what NSPOH describes as a centralised, state-owned health structure that is "strongly specialized and medicalized", and plagued by "poorly developed public and primary health care, zero level of awareness on client's rights and poor respect for the individual." In short, according to NSPOH, "the level of professionalism, in terms of medical-technical knowledge and skills as well as communication skills, is not meeting international standards."

Results of the KAP surveys are briefly outlined. In short,

• In Tajikistan and Kyrgyzstan, there is a general lack of RH knowledge - both among women and those who make decisions on their behalf - in terms of basics such as recognising danger signs during pregnancy, delivery and the postpartum period. In general, husbands reportedly remain uninvolved in pregnancy, delivery, and childrearing.
  The research found that service providers "have a medical-technical view on their task; they do not consider building a safe environment, trustful relations with their patients and counselling on intimate issues in the personal life of their clients as being parts of their competences. This result[s] in poor quality of care, in terms of lack of information transfer to their clients, necessary for preventive medicine and enabling people to make an informed choice on pregnancy and delivery." Furthermore, service providers were found to lack understanding of evidence-based protocols to monitor their work.
• In Kosovo, large families are the norm in traditional communities. Researchers found that about 80% of respondents indicated that pregnancy-related decision making was undertaken by both spouses together, even as most pregnancies remain unplanned: the main family planning "method" used is withdrawal. In contrast, decisions about abortion were for the main part left up to doctors (the abortion rate in this area is high, and it is a socially unaccepted practice, according to NSPOH). NSPOH found poor infrastructure, low level of professional knowledge and skills, and a low status of medical professionals (resulting in "under-the-table payments" and diminished access to quality services).

In short, this piece shares research on RH communication and decision making in a region of the world that the authors describe as suffering high levels of maternal and neonatal mortality. While not explicitly stated, a focus on strategies that take culture, gender, and traditional practices into account would appear to be appropriate in addressing some of the shortcomings outlined here.

Click here to access a related peer-reviewed summary on the Health e Communication website, and to participate in peer review.

Click here to access the full resource in MS Word format. (Please see the contact information, below, to request complete reports of both KAP surveys.)