Historical note: How bringing women’s health advocacy groups to WHO helped change the research agenda

Abstract

Abstract

The politics of population control and its sometimes coercive methods in developing countries documented during the 1960s, 70s and 80s, gave rise to strong opposition by women's groups, and put into question the safety of contraceptive methods that were being developed and introduced into countries. In 1991, the Special Programme on Human Reproduction at the World Health Organization, a research programme focused on development of new methods and safety assessments of existing fertility regulation methods, started a process of “dialogue” meetings between scientists and women's health advocacy groups which lasted for nearly a decade. This paper describes the process of these meetings and what they achieved in terms of bringing new or different research topics into the agenda, and some of the actions taken as a result.

Résumé

Les politiques de régulation de la population et leurs méthodes parfois coercitives dans les pays en développement, documentées dans les années 60, 70 et 80, ont suscité une forte opposition parmi les groupes de femmes et remis en question la sécurité des méthodes contraceptives qui étaient développées et introduites dans les pays. En 1991, le Programme spécial de l’Organisation mondiale de la Santé sur la reproduction humaine, un projet de recherche axé sur la mise au point de nouvelles méthodes et les évaluations de la sécurité des méthodes existantes de régulation de la fécondité, a lancé un processus de réunions de « dialogue » entre les scientifiques et les groupes de plaidoyer pour la santé des femmes qui a duré près d’une décennie. Cet article retrace le cycle des réunions et ce qu’elles ont obtenu pour imposer des thèmes de recherche nouveaux ou différents, et il décrit certaines des mesures prises en conséquence.

Resumen

La política de control de la población y sus métodos a veces coactivos en los países en desarrollo, documentados durante las décadas de los sesenta, setenta y ochenta, suscitaron fuerte oposición por parte de grupos de mujeres, quienes cuestionaron la seguridad de los métodos anticonceptivos que estaban siendo creados e introducidos en los países. En 1991, el Programa Especial sobre Reproducción Humana de la Organización Mundial de la Salud, un programa de investigación enfocado en la creación de nuevos métodos y en la evaluación de la seguridad de los métodos existentes de regulación de la fertilidad, inició un proceso de reuniones de “diálogo” entre científicos y grupos promotores de la salud de las mujeres, el cual duró casi una década. Este artículo describe el proceso de esas reuniones y lo que lograron en cuanto a incluir en la agenda nuevos o diferentes temas de investigación, así como algunas de las acciones tomadas como resultado.

Key Words:

• Research
• contraception
• fertility regulation
• safety
• efficacy
• informed consent
• ethics
• women's health advocates
• human rights
• sexual and reproductive health

Nearly 25 years ago, Mahmoud Fathalla, then Director of the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) based at WHO in Geneva, spearheaded an initiative in which women's health advocates were brought into the process of defining research priorities in contraceptive research. At the time, in 1990, this was a bold and innovative step. HRP had been set up in the early 1970s to conduct research into human reproduction with a large emphasis on the development and long-term safety and efficacy of fertility regulation methods. It worked with a pool of scientists and institutions in both developed and developing countries, aided by a series of technical advisory committees with membership of scientists from around the world. HRP was established in good part as one contribution to address the fears of a “population explosion” in the 1970s and 1980s, perceived by some as likely to lead to mass starvation, a problem that could only be addressed by urgent measures to control population growth.¹ It was thought then that, if more contraceptive methods existed and were available, more women would use them.

While HRP was being established, the international development community was already engaged in providing massive support for population control policies in developing countries, often implemented through programmes euphemistically called “family planning”. The approach, concerned primarily with reaching targets for population reduction, used techniques like incentive schemes which were frequently coercive, pressuring women into accepting long-acting methods such as the IUD, injectables and implants without adequate information or informed consent.

The new wave of feminism in North America and Western Europe was also growing in the early 1970s, with the demand for free contraception and abortion on demand becoming a cornerstone of the political agenda.² The widespread marketing of the first oral contraceptive pill at the end of the 1960s made this demand, in part, seem possible. This had a positive influence on the women's liberation movement, but towards the end of the 1970s, the quality and safety of contraception started to be questioned by women's health advocates. During the same period, and into the decade of the '80s, women in developing countries started to fiercely oppose the coercive nature of the population control policies being implemented in their countries. A statement, for example, made by 16 women's organizations and professional health groups in Cusco, Peru, in June 1989, in response to a USAID document entitled “Strategy for Population USAID/Peru” stated clearly that family planning can be imposed in a discriminatory way, and that it was women in the poorer sectors of society that were the main target of population policies.³ Women in India had concerns about the safety of the injectable contraceptives being introduced: “Feminist groups are concerned about the inconclusive animal studies and undesirable side effects demonstrated by the clinical trials in India and the world over. Therefore a campaign committee against long-acting contraceptives has been formed to try and prevent the introduction of these drugs.”⁴

Responding, in part, to this growing opposition by women's health advocacy groups in different parts of the world, HRP's governing body recommended the Programme consult with women's groups about the research agenda. HRP's Biennial Report for the period 1988-1989 states:

“Women are at the heart of development. They are also the main victims of unregulated fertility and it is imperative, therefore, that any organization concerned with reproductive health issues involves women in all aspects of its operations from policy setting through planning and implementation of activities to disseminating information. In this last respect the Programme has taken an active role during the biennium in seeking to expand its links with women's groups, which are important sources of information to women in many parts of the world.”

The major expansion of these “links with women's groups” was realized in 1991 when HRP, in partnership with the International Women's Health Coalition (IWHC),^* held the first of what was to become a series of “dialogue” meetings between scientists and women's health advocacy groups. These meetings came to be known as Creating Common Ground, and took place from 1991 to 1997.

As the rapporteur for that first meeting and coordinator of another six such meetings at both international and regional level, I feel that this current issue of RHM presents an opportunity to reflect on what these meetings achieved and how they contributed to modifying, if not radically changing, the research agenda of HRP and to some extent that of its collaborators. The meetings highlighted the kinds of questions that representatives of contraceptive users found important in a way that most scientists (until then) had simply not thought about. I offer it as an informal review from a personal perspective rather than a full evaluation of the events and their impact. I do, however, ground my reflections in documented references.

The first Creating Common Ground dialogue

The first Creating Common Ground meeting took place in Geneva in February 1991. It aimed to establish a dialogue between the scientists and scientific collaborators of HRP on the one hand, and people involved in women's health advocacy on the other, and to identify means by which women can influence and be involved in both the choice and introduction of methods of fertility regulation. It was an attempt to “narrow the distance between institutions that formulate policy and the consumers affected by policy”.⁵ The participants included sixteen scientists from different regions of the world, collaborating with the Programme, selected for their expertise on contraceptive safety and efficacy, sexually transmitted diseases, provider-dependent methods such as injectables and intrauterine devices (IUDs) and the introduction of new methods, but also for their ability to listen to different points of view. To match them, sixteen women's health advocates from international, regional and national organizations around the world (Bangladesh, Brazil, Chile, India, Indonesia, Netherlands, Nigeria, Peru, Sudan, USA) were invited to participate. All were from organizations working with IWHC and were selected on the basis of their long experience in working with women’s sexual and reproductive issues, and their known ability to represent a broad range of women's views. Care was taken to ensure that all regions of the world were represented. Because of the weight that science carries, especially within an international organization such as WHO, IWHC insisted that there be the same number of women's health advocates as scientists.

The discussion was broad-ranging and often complex, but highlighted here are just some of the key issues raised, as they are by no means irrelevant today. They are all drawn from the report of the meeting.⁵

Concept of safety

The first meeting immediately brought to the fore the use of terminology, definitions and meanings. The concept of safety, for example, was hotly debated. The scientists' concern was to establish safety of methods according to specific, measurable parameters such as toxicity (first tested in animals) and whether a method might be carcinogenic or have severe effects on physiological functions such as those of the heart, the kidneys or the reproductive organs. The women's health advocates, however, described how women were also concerned about how methods might affect their overall health, and that this included their sexual interest, physical stamina or emotional well-being – aspects of health that had generally been given lower priority by researchers and service providers. Side effects such as menstrual bleeding disturbances, which scientists considered medically less important, could be of great concern to women and affect how they perceived the safety of any method. Indeed, in cultures where women are prohibited from praying or preparing food when menstruating, disturbances that take the form of prolonged, heavy or irregular bleeding, may have consequences for women's ability to manage the house or to find work, with sometimes even severer consequences such as violence from their husbands and/or loss of earnings. The women's health advocates also highlighted the fact that little appeared to be known about the effects of using a hormonal contraceptive by, for instance, women who have parasitic infestations or who are suffering from severe anaemia, and questioned whether IUDs were appropriate in communities with endemic reproductive tract infections (especially where they are undiagnosed and untreated). Scientists agreed that further research was needed on these topics, but also urged that what was known medically about safety should be more adequately conveyed to women.

Considerations for efficacy

For scientists developing new contraceptives, the health risks of any method should be measured against the risks of a clandestine abortion or of a full-term pregnancy. Their approach was to develop the most effective contraceptive method to reduce the likelihood that women would resort to dangerous abortions or go through a high-risk pregnancy. Inevitably, this led to a bias towards systemic or provider-dependent methods that have less likelihood of user failure, often to the detriment of user acceptability or satisfaction.

Women's health advocates, on the other hand, made the argument that women often see the risks of some methods, whether inherent or caused by poor services, to be too high. Many might prefer having a method with minimal side effects, particularly barrier methods, with safe abortion as a back-up. They might also prefer to accept a pregnancy even if not ideally timed, rather than undergo some of the side-effects of contraceptives, sometimes experienced as severe, an aspect that scientists found difficult to understand.

Acceptability and ethical service delivery

Acceptability was – and still is – usually measured through rates of acceptance and rates of continuation. The women's health advocates pointed out that services using questionable incentives or frankly coercive approaches had been widely documented, including in contraceptive trials. National ethical guidelines for both research and service delivery were either non-existent or not adhered to, and often there were no minimum standards for the quality of care in contraceptive services. They therefore argued for indicators of acceptability that also measure dimensions of user satisfaction and whether the services pay attention to fundamental rights such as privacy, confidentiality and informed decision-making.

From the systems point of view, the advocates argued that adding fertility regulation methods, especially those that require sophisticated delivery and follow-up, would likely only compound existing service weaknesses, and not serve women's interests and health.

Ethical questions on the introduction of contraceptive methods

Among the broader questions raised were whether it is morally acceptable to restrict access to safe abortion services and simply promote contraception, when contraceptive technologies are imperfect, failure rates and abortion rates are high, and the consequences of unsafe abortion are catastrophic for women. Women's health advocates questioned whether it was ethical and responsible to introduce contraceptive methods that are heavily dependent on skilled health personnel in countries where health services are generally poor, and where women may be at higher risk of side effects because of more widespread ill-health generally. The scientists agreed that there was an imperative to improve the delivery of services, especially in developing countries, but that this should not in itself hold back the development and introduction of safe and effective contraceptive methods, and that access to safe contraception might contribute to improving women's overall health status. It was also questioned whether the developers of fertility regulation technologies have an obligation to consider these contextual factors when first initiating work on a new method and throughout the development process, and whether they should be concerned about the ways in which their technologies are likely to be used or abused by the state, service providers or women themselves. The scientists generally felt that, as researchers into new methods of contraception, they could not be responsible for all the contextual problems in different countries of the world, and that this was something to be addressed by many actors, from governments to donor agencies and health service providers. It was generally agreed, however, that such considerations needed to be taken on board in the research agenda of HRP.

Recommendations

A series of recommendations about research priorities and processes were made, which are discussed below, but one specific recommendation was to conduct such dialogue meetings in different regions of the world. This was critical because the impact of just one meeting was likely to be quite limited, not least because, despite the successful outcome of the meeting, there was considerable discontent among some HRP researchers at what was perceived as interference by people who were neither scientists nor unbiased. It was clear that effective implementation of the recommendations required both a dedicated budget and dedicated assigned staff. It was at this point that I was asked to continue working with HRP in order to ensure such implementation.

A series of Creating Common Ground dialogue meetings

Between 1992 and 1997, working with many colleagues both within HRP and outside, I coordinated the organization of four regional meetings, in the Philippines, Kenya, the Dominican Republic, and Morocco; and two further international meetings focusing on fertility-regulating vaccines. Each meeting brought together a carefully selected mix of researchers, policy-makers, women's health advocates and health service providers, from a selected number of countries in each region. Participants were asked to engage in a core principle, that of willingness to talk and to listen to all, across diversity, with respect and recognition that a legitimate outcome was agreement to disagree on some points. To help fulfil this core principle, the chairing was shared between a researcher or policy maker and a women's health advocate. The agenda was elaborated to ensure equal time was given to presentations by scientists and women's health advocates, and that working groups had a balance of people from different disciplines, skills and backgrounds.

The aim was always to find common ground while recognizing diversity, but ensuring that women's voices and perspectives were both heard and ultimately integrated into research and policy-making. The reports from these meetings,^6–11 still seem remarkably “cutting edge” for their time. While the autonomous women's health movement had been raising questions for years about why researchers, policy makers and programme managers did not pay more attention to the reality of women's lives – poverty, ill-health, lack of education, lack of status and autonomy to take control over their own lives and particularly their own fertility – this was the first time that they had been able to come to the table with senior people from ministries of health, national research programmes and professional health associations.

WHO was able to play one of the roles it does best: convening these widely varied actors, often with politically opposing positions, into a space that was relatively neutral. At the Asia meeting, for example, the women's health advocates were able to make a presentation on women's complaints about the follow-up services in the trials of the implantable contraceptive, Norplant. Many women had been unable to find health personnel willing to remove the implants, a clear violation of their rights. Both the representative of the Bangladeshi Ministry of Health and the head of the powerful Indonesian Family Planning Board had to engage with these criticisms. Women at the meeting emphasized that technologies should be introduced only when there is a national plan in which women are key participants, and health infrastructures and facilities are in place.⁶ At the Eastern Mediterranean (covering the Middle East and North Africa) regional meeting in Morocco, there was an attempt to stop one of the women's health advocates making her presentation as it was critical of one government's policies, leading to a major confrontation between the women's health advocates and some of the government representatives. The issue was ultimately resolved by the WHO Morocco country office representative who was able to bring the warring parties to an understanding of the importance of listening to opposing views.

The Asia regional meeting in 1992 closely followed the themes and format of the first international meeting. The subsequent meetings, however, reflected the paradigm shift achieved at the 1994 International Conference on Population and Development (ICPD) and broadened their scope to cover the needs and perspectives of women in reproductive health. Indeed, following ICPD, HRP started to bring its research work closer to its programme and policy work, and ultimately became folded into a new Department of Reproductive Health and Research, giving greater visibility to other aspects of sexual and reproductive health, including maternal health, infertility, STI/HIV, female genital mutilation (FGM) and violence against women, as well as to aspects of health service delivery, such as quality of care, ethical conduct and the respect of human rights.

Each of the dialogue meetings resulted in a series of recommendations on different dimensions and addressed to different actors – WHO Regional Offices, national governments, other UN agencies, professional organizations, NGOs. Some of these were specific to the region, such as FGM in the Middle Eastern and North African countries represented at the meeting in Morocco. These recommendations were more or less well followed up, depending on the commitment of both the WHO regional and country offices and the representatives of national governments. Following the Asia regional meeting, for example, the head of the Indonesian National Family Planning Board instituted a monthly meeting with women's health advocacy groups.

A handful of themes and topics, which HRP then took up in its global work, were common across nearly all the meetings.

Barrier methods

There was a strong recommendation for research on female barrier methods as being both user-controlled and potentially protective of certain STIs as well as pregnancy. Following the Asia meeting, HRP, the Population Council and Family Health International supported coordinated research in three countries, Turkey, Colombia, and the Philippines, on the acceptability of the diaphragm. Results of the studies, which indicated overall a high interest and relatively good acceptability rate, were published in various peer-reviewed journals.^12,13 However, availability of diaphragms is still highly limited outside of countries like Australia, Ireland, the UK or the USA. With the advent of new silicone diaphragms, there is clearly room for an important marketing and awareness campaign to make them available elsewhere in the world.

HRP also coordinated and published a review of all that was known on the female condom which, at the time, was only just beginning to emerge as a feasible barrier method. This initiative contributed to giving higher visibility to the method, which is now available in most regions of the world. Soon after publication of the review, HRP sponsored programmatic research with NGOs and the government in South Africa on strategies for introducing and making female condoms widely available, as part of the Strategic Approach work (see below). HRP also sponsored research on the feasibility and safety of washing and reuse of the female condom in South Africa, to acknowledge the prevailing widespread practice among women using the method (resulting from its high cost), and thereby addressing the interplay between women's perspectives, practices and method safety.¹⁴

Fertility regulating vaccines

At the first Creating Common Ground meeting in particular, women's health advocates had expressed concern about HRP's research on what was essentially an anti-pregnancy vaccine. They felt that there were inherent pitfalls in the vaccine approach, as the idea of a vaccine is to give life-long protection against a disease whereas pregnancy is not a disease and women do not necessarily want life-long protection against it. It was a method that would clearly not be under the control of the user. In addition, in the context of the emerging HIV pandemic at that time, a method that uses the immune system was thought to be highly dubious.

Responding to this concern, we organized two additional dialogue meetings focused entirely on the anti-pregnancy vaccine (in 1992 and 1994).^10,11 These dialogues resulted in a series of recommendations concerning the conduct of the vaccine trials, which at that point were only at Phase I, testing initial safety. Emphasis was given to the elaboration of specific guidelines, which would include, inter alia, appropriate representation of potential users at all stages of the research, as well as the provision of full information at all stages. Ultimately, research on the anti-pregnancy vaccine was abandoned both because of the pressure from women's health advocacy groups, and also because of the difficulties in resolving safety issues in the Phase I clinical trials, which were likely to become very costly to resolve.

Male methods of contraception

Research on male methods was mentioned in a number of the meetings, along with the need for research on men's knowledge, attitudes and practice in relation to both their own and women's reproductive health. How to “involve” men more in issues of sexual and reproductive health and the provision of services was also flagged for research.

From the beginning, HRP had a unit dealing with male methods of contraception, including the development of a hormonal “male injectable” or “male pill”. Research was also conducted on both women's and men's attitudes to a possible male method of this kind. The recommendations from the dialogue meetings contributed to keeping this research – which was not always high on the agenda – on the table.

Ethics in research

A recurring theme in all the dialogue meetings was the question of ethical procedures in research, but also in service delivery. Often this distinction became blurred, as contraceptive trials are usually conducted in regular health service settings, and cases had been documented of women being unaware that the method they were being offered was still being tested. Informed consent was mentioned again and again, not only for contraceptive services but for any sexual and reproductive health service as well as research. Highlighted, too, was the content of the information being given about a method or an intervention. The institutionalization of ethics committees, with the participation of women's health advocates, to review research at country level, was recommended at a number of the meetings.

As a direct result of this, HRP organized a series of regional training workshops with researchers and other potential or actual members of national ethics committees (where they existed), including representatives of women's health advocacy groups from the countries in question. It was clear, however, that this kind of training should not be a one-off affair, but should be institutionalized if possible, recognizing that it requires considerable investment in terms of people, time and money.

HRP also supported research into informed consent procedures in three countries, with a view to coming up with an optimal informed consent procedure. The conclusion, however, was that each particular situation and context requires its own approach, while ensuring that ethical principles are adhered to. HRP modified its own research application forms and guidelines to include questions about the impact of the proposed research on women and on men, and as to whether communities were to be involved in the design and conduct of the research and the implementation of results.

Introducing fertility regulation methods nationally

In the 1970s and 1980s, contraceptive methods like the pill and the IUD had been developed and allowed to somehow make their own way into countries around the world. Beginning in the 1990s, a number of researchers launched the idea of “introductory trials” as a final stage of contraceptive development, designed to bring new contraceptive methods into countries in a more gradual and systematic way. HRP was in the process of developing a more elaborate methodology for introduction, in which different stakeholders would be involved in assessing the situation on the ground and making recommendations to the ministry of health about what seemed appropriate.

The women's health advocates at the first dialogue meeting firmly supported such an approach, recommending that women's health advocates should be involved in all phases of the introduction process, including the design, provider training, management, implementation, monitoring and evaluation. It was stressed, too, that approaches to method introduction should be reviewed to encourage use of integrated health services, other aspects of quality of care and more participatory approaches.

The HRP introduction process was to become the “Strategic Approach”, a highly innovative and successful methodology that stressed the need to understand women's and communities' perspectives, and how these interacted with existing service capacity and the existing method mix, as set in a specific social, cultural and economic context. Based on this understanding of women's needs and perspectives, it emphasized that introduction of a new method was not always the best option and, indeed, in some circumstances removal of unsafe or inappropriate methods was more important than introducing new ones, particularly methods with similar characteristics to those already available. The approach was grounded in the principles of quality of care, gender equity and reproductive rights, very much reflecting the recommendations of the dialogues. The Strategic Approach has now been used in more than 35 countries, not only for the introduction of contraceptives but more broadly for other sexual and reproductive health interventions, including those to address the prevention of unsafe abortion and/or the provision of safe abortion care.¹⁵ The Creating Common Ground meeting recommendations came at a time when support for such an approach was essential.

Participation of women's health advocacy groups

The Strategic Approach aside, all the Creating Common Ground meetings consistently recommended, across the board, the involvement of women's health advocacy groups in the research priority-setting, design, and conduct of research, including the final interpretation and dissemination of results.

What HRP did to address this at the global level was to create a Gender Advisory Panel (GAP) to review the work of the Programme in an ongoing way, to ensure that women's perspectives, and gender and rights dimensions were taken on board. Again, this was highly innovative for its time, launched as a result of a resolution by HRP's governing board in 1996. GAP was to meet annually to evaluate critical aspects of HRP's research agenda and later RHR's programmatic and policy work, from a gender and rights perspective. GAP's membership of twelve (initially eight women and four men) gave precedence to representatives of women's health advocacy groups and scientists with a demonstrated gender and rights perspective. It should not go without mention here that the first chair of GAP was none other than the founding editor of Reproductive Health Matters, Marge Berer! She led the Panel in a way that both reassured scientists and policy-makers and sharpened the approach to controversial issues such as male circumcision.

An account of the life of GAP and its impact warrants an entire article to itself, and indeed two major evaluations of GAP have been conducted since its inception, one in 2001 and more recently in 2014.¹⁶ But it is important to note that it has as its predecessors the Creating Common Ground meetings.

Training for service providers

All the dialogue meetings highlighted how poor health services can lead to ill-use or misuse of contraceptive methods, contributing to their poor efficacy or unsafe use. The solution proposed was training for service providers so that they can ensure informed choice, provide counselling and follow up, as well as dealing with method complications, method removal, side effects or unwanted pregnancy.

Two key initiatives of HRP could be seen as growing indirectly from this recommendation. The first is the gender and rights training manual for health system managers, a collaborative effort of HRP with NGOs across all WHO regions.¹⁷ Noteworthy is the fact that at least two participants in one of the Creating Common Ground meetings were involved in elaborating this course. The other is the more recent guide to core competencies for sexual and reproductive health care in primary health care settings, which lays out not only technical competencies but also skills related to ethical and rights aspects of providing sexual and reproductive health services, including contraception.¹⁸

Concluding reflections

This commentary is not intended to be an assessment of the Creating Common Ground meetings which took place, for the most part, more than 20years ago. But it is a reminder to us that research priority setting, and thus knowledge or evidence production, is not, or should not be, some kind of monolith encased in scientific methods that are largely inaccessible to those who will be on the receiving end of what the research results will bring. This story of bringing user or community points of view into the research priority setting exercise demonstrates how it was possible to ensure some of the issues of concern to women who were working with urban and rural communities were introduced into the research agenda of WHO's jointly-sponsored research programme on human reproduction. It shows, too, how the very process of bringing those voices to the table raises issues that go beyond research and evidence generation, and that may, in fact, be better addressed, not by research, but by other processes such as training.

Acknowledgement

This is a historical note written from a personal perspective. Many people were involved in the creation and success of the Creating Common Ground meetings and their follow-up, both within WHO/HRP and in the women's health advocacy community. They are too numerous to name here, but all their contributions were essential. One person, however, must be named: Adrienne Germain, at the time Vice-President of the International Women's Health Coalition. She was the inspiration behind the dialogue meetings and was instrumental both in getting them launched and in supporting the follow-up work within HRP. I must also emphasize that none of this could have been done without the sustained leadership of some visionary and dedicated people, in particular Mahmoud Fathalla, who had the courage to conceive the idea and approach IWHC for the first dialogue meeting, Peter Hall and Joanne Spicehandler who initiated and carried out the work at the beginning, and Paul Van Look, who supported and helped sustain the work under his directorship from 1998 until his retirement in 2009.

Notes

* IWHC was founded in 1984 to advance the sexual and reproductive health and rights of women and young people, particularly adolescent girls, in Africa, Asia, Latin America and the Middle East, and advocates for supportive international and USA policies, programmes and funding. http://iwhc.org/about-us/.