International Maternal and Child Health (IMCH), Department of Women’s and Children’s Health, Uppsala University

Postal address: Internationell mödra- och barnhälsovård, Institutionen för kvinnors och barns hälsa, Akademiska sjukhuset, SE-751 85 Uppsala, Sweden
Visiting address: Drottninggatan 4, 4 floor
Web page: http://www.kbh.uu.se/imch/

Contact persons:
• Professor Lars-Åke Persson, Head of the Research group on International Child Health and Nutrition, 
          phone +46 (0)18 611 92 94

• Professor Birgitta Essén, Head of the Research group on International Maternal and Reproductive Health, 
     phone: +46 (0)18-611 5988

The Section for International Maternal and Child Health (IMCH) was formed in 1999 as part of the reorganisation of the Medical Faculty at Uppsala University. IMCH has several well-established research groups, in which PhD and licentiate students work under the supervision of IMCH researchers. Projects currently underway in these groups deal primarily with reproductive and maternal health and health care, maternal and child nutrition, micronutrient deficiencies, and breastfeeding, integrated management of childhood illness. In addition, section staff are working to establish new research programmes on community based rehabilitation, public health in humanitarian assistance.
The research carried out at IMCH contributes to equitable global health with an emphasis on women’s and children’s health and nutrition. IMCH seeks to accomplish this by working with global partners to generate new knowledge through research with a focus on the health-related Millennium Development Goals.
The researchers are organized in two research groups; on International Maternal and Reproductive Health
and on International Child Health and Nutrition.

Masters Programme in International Health

These two groups frequently share the research projects, and so are the collaborative links with partners in Asia, Africa and Latin America. They reproduce the new knowledge through its higher education program, and make efforts to translate knowledge into strategies and practical action. IMCH runs a Master Programme in International Health, preparing professionals with medical or other undergraduate degrees to play leadership roles in promoting global health. The programme equips students from multiple disciplines and all continents with skills to appreciate and analyse global health problems and to develop and evaluate actions to improve public health. A special emphasis is placed on child health, sexual and reproductive health and rights, public health in human-itarian assistance and public health nutrition.
More information about the Masters Programme for 2012/13. 

The department has also run International training programmes on on Sexual and Reproductive Health and Rights since 1992. The participants have been gynaecologists and midwifes who after an initial course in Sweden carried out practical application work/projects in their home institutions. Over the years many South Asian participants have chosen to elaborate projects on different aspects of adolescent health. Professor Gunilla Lindmark has been in charge of these Sida-sponsored courses, in collaboration with Dr Islam Monir from the World Health Organisation WHO in New Delhi, and Professor Kumudu Wijewardena from the Faculty of Medical Science at the University of Jayewardenapura, Sri Lanka.
The department also has run other contracted courses on topics such as Public Health in Humanitarian Assistance.

Ongoing South Asia related research on International Child Health and Nutrition

Professor Lars-Åke Persson (photo to the right) returned to the department in the Spring 2003, after spending four years in Dhaka, Bangladesh, where he worked for the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), as manager for its Research division on Public health. Persson has continued to be connected with ICDDR,B from his new platform at Uppsala. Prof. Persson heads the research programme on International Child Health and Nutrition involving research institutions in Bangladesh, India, Sweden, UK and USA. His main research interest deals with the prevention of low birth rates.

Currently Prof. Lars-Åke Persson is involved in a partner driven Indo-Swedish collaboration project on Infant and Young Child Feeding. The project is entitled ”Combining infant feeding and return to paid work after maternity leave in India” and was granted in December 2010. Associate Professor Pia Olsson and the Nutritionist/postdoc Amal Omer-Salim at IMCH were the main recipients of this grant provided by the the Swedish International Development Cooperation Agency (Sida), through its program for Partner Driven Cooperation (Aktörssamverkan). Other researchers involved are Professor 
Mats Målqvist, and Research Assistant

 Arun Gupta. More information.
They were given SEK 4.5 m for three years (2010-12) for a project entitled ”Using Evidence-Based Advocacy to Improve Infant and Young Child Feeding (IYCF), Health and Survival in India”. This is a collaboration betweenIMCH and the Breastfeeding Promotion Network of India (BPNI). The contact persons at BPNI are Arun Gupta, and J.P. Dadhich. 
Project abstract: Millions of young children die each year around the world. The problem is most severe in India and Nigeria. Most of these deaths could be prevented if children were vaccinated, given vitamin capsules, had safe water to drink and were breastfed. Poor breastfeeding causes almost 13% of all the deaths. The Breastfeeding Promotion Network of India and IMCH, Uppsala University are starting a project that will improve these conditions for mothers and children by, for example, providing correct information and support on breastfeeding. This will be done by widely sharing the latest scientific research in this field and gathering all those involved, including the media, to persuade the Indian government to extend its programs to include the poorer parts of Indian society. Improved coverage of specific nutrition interventions, such as early and exclusive breastfeeding, will reduce the rates of pneumonia and diarrhoea, which are the leading causes of child deaths. Such action thus is warranted in countries like India that has shown little improvement in feeding practices over the past decades and is not currently on track to achieve MDG 4. Lack of programmatic breastfeeding support to women is the main underlying factor as revealed by an assessment of policy and programmes regarding breastfeeding. This Partner Driven Cooperation Project between the Breastfeeding Promotion Network of India and IMCH, Uppsala University will use evidence-based advocacy to expand the provision of full maternity entitlements to all women and to provide women with accurate, unbiased information through skilled counselling and support in six of the worst States. 

Professor Lars-Åke Persson and his research group are also since many years involved in two major Bangladesh related research projects, one on ”Arsenic in drinking water and public health consequences”, and another one entitled ”MINIMat trial, Bangladesh”. They have resulted in a number of PhD theses at the department.
The first project deals with the health hazards caused by arsenic contaminated wells in Bangladesh, and has been carried out in collaboration with BRAC in Bangladesh, and with Professor Marie Vahter, at the Division of Metals & Health, Institute of Environmental Medicine, Karolinska Institutet, Stockholm. In November 2005 Prof. Persson received SEK 1.15 Million as a two-years (2006-07) research grant from Sida/SAREC for a project titled ”Effect of arsenic exposure through drinking water on reproductive outcome and child survival: epidemiological studies in Bangladesh”.
The second project is a major research project on Poverty and Health, entitled ”Pre- and postnatal influence on chronic disease risk and immune function in early childhood: follow-up of the ‘MINIMat’ maternal food and micronutrient supplementation study in Bangladesh”. This project was given SEK 1.3 Million as a three-years grant (2006-08) from the Swedish Research Council in November 2005, and 1.05 Million from Sida/SAREC. 

– More information about the Arsenic in drinking water project.

– More information about the Matlab project

In October 2012, Prof. Persson, together with research partners Eva-Charlotte Ekström, and Emma Lindström at the same department; Ruchira Naved, Shams Arifeen, Anisur Rahman, Ashraful Khan, and Iqbal Kabir, at ICDDR,B in Dhaka, Bangladesh; and Lars Lindholm, Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, was granted a project grant from the Swedish Research Council of SEK 5.25 m for a follow-up study of the MINIMat Randomised Trial in Bangladesh. The name of this project is ”Developmental Origins of Health and Disease: Equitable Prevention Across Generations”. 
More information on the Swedish Research Council Grants for South Asia related projects in 2012.

Other South Asia related projects by Lars-Åke Persson

In August 2003 Lars Åke Persson was awarded 25 000 SEK as a SASNET planning grant as a contribution for a Network for Interventions against Maternal-Child Malnutrition in South Asia, and he got another planning grant for the same networking project in August 2004.

During a 4-year period of work as director for the Public Health Sciences Division at ICDDR,B, Dhaka, Lars-Åke Persson took the initiative to initiate this network of scientists, and to develop specific intervention studies. An international workshop on Low Birth Weight at ICDDR,B in 1999 formed the background, and from 2001 a large inter-disciplinary intervention project is running, the MINIMat study (Maternal and Infant Nutrition Interventions in Matlab). A first joint meeting of the network was performed in October 2002, where the follow-up of functional consequences of the interventions for mother and child were discussed, as well as research training options for junior scientists from the region. The research projects has mainly been funded by UNICEF and DfID, while the networking and the research training lack organised funding and so far has been jointly achieved by support from the different participating departments and scientists. In May 2003 Persson returned to Sweden to take up the position as professor and chair in International Child Health at Uppsala University. He is keeping the role as the coordinator of the joint effort. More information on the network (as a pdf-file)

The planning grant was used for travelling to a network meeting in October 2003 in Dhaka, Bangladesh, where progress of the collaborative studies was reviewed and plans for 2004 were developed. All different partners in the network were participating. They include paediatricians, nutrition epidemiologists, biochemists, health economists, toxicologists, public health specialists, gender specialists and bacteriologists in Sweden, in South Asia and Internationally.

During 2003 recruitment to the joint study was still ongoing, but during 2004 a phase of analysis and reporting is initiated. A renewed SASNET planning grant for the same networking project was given in August 2004.

The grant was used for for meetings by parts of the group to analyse and discuss the results from the MINIMat study. Mahfuzar Rahman, Nazmul Sohel, Shams El Arifeen and Ed Frongillo visited Uppsala during the period March–June 2005.

In October 2006, Prof. Persson received SEK 600 000 as a grant from Sida’s Developing Country Research Council for a doctorate project titled ”The impact of violence against women on reproductive outcome and child survival. Studies in Nicaragua and Bangladesh”. More information about Sida’s 2006 grants.

Lars-Åke Persson participated in the SASNET workshop on ”The role of South Asia in the internationalisation of higher education in Sweden” held in Stockholm 28-29 November 2006, where he gave a presentation about IMCH experiences regarding recruitment of South Asian students in hard sciences in Sweden. Read Prof. Persson’s presentation at the workshop (as a pdf-file)

At the Sida-funded conference on current Swedish development research titled ”Meeting Global Challenges in Research Cooperation” that was jointly organised by Uppsala University and the Swedish University of Agricultural Sciences (SLU) in Uppsala 27-29 May 2008 (more information), Prof. Persson chaired panel no. 2 on ”Improving maternal health and infant child survival”. Several of the research projects carried out within the department were presented, among them a project on ”Equity in birth weight improved by a food and micronutrient supplementation programme: a cluster randomized trial in Bangladesh”, carried out in collaboration with Eva-Charlotte Ekström and A. M. Waheedul Hoque from the same department; Shams El Arifeen and DS Alam from ICDDR,B in Dhaka, Bangladesh; Yuki Shirioshi from UNICEF; and Zeba Mahmud from BRAC, Bangladesh. The study was conducted in two rural sub-districts; Kapasia and Chowdagram in Bangladesh where a National nutrition programme including prenatal food and multiple micronutrient supplementation was to start.

Abstract: Public health efforts to improve maternal and foetal nutrition has included prenatal iron-folate supplementation. Recently multiple micronutrient supplementation (1) has been tested in trials to improve impact on pregnancy outcome. So far, the effects on birth weight are mixed. In settings with high prevalence of maternal malnutrition, food supplementation may also be required (2). The effectiveness of food supplementations in a large scale setting is frequently questioned. As energy and micronutrient deficiencies may co-exist, combinations of food and multiple micronutrient supplements may be required for improved fetal growth. The objective is to evaluate the impact on birth weight of a combination of prenatal food and multiple micronutrient supplementation in a large scale national programme setting.

Other researchers in the International Child Health and Nutrition Research Group

Eva-Charlotte Ekström has coordinated a project related to prenatal food and micronutrient supplementation in Bangladesh. In 2003 she received a planning grant from Sida/SAREC for a project titled ”Are there sustained nutritional benefits of prenatal food and micronutrient supplementation över the reproductive cycle?”.

In November 2005, then PhD candidate Hanna Eneroth received SEK 1.2 Million as a doctorate project grant for two years (2006-07) from Sida/SAREC for a project titled ”Effects of exclusive breastfeeding and prenatal micronutrient supplementation on micronutrient status of infants where low birth weight is prevalent”. In November 2007, additional SEK 1.2 million was given for the period 2009-09 by Sida's Developing Country Research Council (U-landsforskningsrådet) for the same project. More information about the Sida grants 2007.
Project abstract: abstract In a setting with high prevalence of intrauterine growth restriction we will assess whether exclusive breastfeeding(EBF) results in better infant micronutrient(MN) status and if prenatal supplement with multiple MN provide benefits in addition to iron-folic supplement. MN deficiencies are common in the study population and in infancy they can lead to impaired immune function, impaired cognitive and neurological development and restriction of growth. 1000 samples of breast milk and blood at 6 months have been collected in a randomised food- and MN supplementation and EBF promotion trial in Bangladesh. It is expected that EBF will increase MN intake and decrease MN requirements and losses due to reduced infections. Prenatal multiple MN will improve MN status at birth and increase the content of selected MN in breast milk. Thus the interventions will result in an optimized infant MN status.

This project was also presented at the Sida-funded conference on current Swedish development research titled ”Meeting Global Challenges in Research Cooperation” that was jointly organised by Uppsala University and the Swedish University of Agricultural Sciences (SLU) in Uppsala 27-29 May 2008 (more information). The collaboration partners in the project also include Dr. Iqbal Kabir and Dr. Mohammad Bakhtiar Hossain from the Child Health Unit at ICDDR,B in Dhaka, Bangladesh; and Prof. Bo Lönnerdal, Department of Nutrition, University of California, Davis, USA.

In June 2006 Dr. Ekström received SEK 600 000 as a two-years grant from Sida’s Support to HIV/Aids research programme, for a project titled ”Role of infant feeding peer counsellors in prevention of mother-to-child-transmission of HIV”. More information.

PhD Shams El Arifeen, gender specialist and sociologist from Bangladesh, is taking part in the Networking programmes (sponsored by SASNET) mentioned above. Arifeen is involved with a study of what is called MINIMat (Maternal and Infant Nutrition Interventions in Matlab), where 4,500 women in the Matlab District of Bangladesh have been randomized to different forms of nutritional and trace element supplement during pregnancy. He is now working at ICDDR,B in Dhaka. He is participating in the research project about the health hazards caused by arsenic contaminated wells in Bangladesh, along with Prof. Lars-Åke Persson, and Prof. Marie Vahter, Division of Metals & Health, Institute of Environmental Medicine; Karolinska Institutet. More information.

Dr. Arifeen is involved in the project on ”Equity in birth weight improved by a food and micronutrient supplementation programme”, presented above.

PhD Ruchira Naved, Child health epidemiologist from Bangladesh, is responsible for a study on Violence against women in Bangladesh. It is part of coordinated studies carried out in several countries around the World by the World Health Organization, WHO. IMCH is involved with this study and also planning for follow-up studies.
In November 2004 the department received a major two-years grant for this research project on ”Impact of violence against women on reproductive outcome and child survival. Studies in Nicaragua and Bangladesh”. More information.

Dr. Anisur Rahman has worked on arsenic exposure in pregnancy and effects on foetus and child. Dr. Rahman has also been affiliated to the Division of Metals & Health, Institute of Environmental Medicine; Karolinska Institutet, Stockholm. Anisur Rahman defended his doctoral dissertation project titled ”Prenatal Arsenic Exposure and Consequences for Pregnancy Outcome and Infant Health: Epidemiological Studies in Bangladesh” on Tuesday 19 May 2009. The faculty opponent was Prof. Gunnar Nordberg, Dept of Public Health and Clinical Medicine, Umeå University.
Abstract: The aim of this thesis has been to analyse possible effects of prenatal arsenic exposure on foetal and infant health. The setting is Bangladesh, where two cohorts were studied, both part of a health and demographic surveillance system in Matlab. A historical cohort 1991–2000 included 29,134 pregnant women with information on drinking water sources and arsenic testing of tube well water. A prospective cohort study included pregnant women 2002–2003 where urinary arsenic concentrations were assessed twice during pregnancy; 2,924 women and their pregnancy outcomes were evaluated for foetal loss, perinatal and infant mortality; 1,578 mother-infant pairs were analysed for size at birth; and 1,552 were analysed for morbidity during infancy. More information.

PhD candidate Waheedul Hoque (photo to the right) is working on effects nutrition interventions in pregnancy on the women’s nutritional status, and possible effects into the next pregnancy. Dr. Hoque, also working at ICDDR,B in Dhaka, is involved in the project on ”Equity in birth weight improved by a food and micronutrient supplementation programme”, presented above.

PhD candidate Ashraful Islam Khan is working on a dissertation project entited ”The effect of prenatal nutrition interventions on childhood growth and body composition at 5 years. The MINIMat trial in rural Bangladesh”. He is supervised by Prof. Lars Åke Persson, and Dr Iqbal Kabir, Clinical Sciences Division, ICDDR,B, Dhaka. On 9th May 2011 he will do his half-time seminar. More information.
 

Ongoing South Asia related research on International Maternal and Reproductive Health

Most of the IMCH researchers are organised in the Research group on International Maternal and Reproductive Health, headed by Professor Birgitta Essén. They are mostly working on Africa related projects, but also deal with one major India related project and another Sri Lanka related project.

The India project is entitled ”Increasing Access to Comprehensive Abortion Care in the Public Health System, India”, and is funded by Sida. The IMCH researchers involved are Professor Birgitta Essén, Dr. Gunilla Aneblom, and Research assistant Amal Omer Salim,but the project also involves researhers from other Swedish universities: Professor Kristina Gemzell, Karolinska Institutet (KI); Senior Lecturer Marie Klingberg Allvin, Högskolan Dalarna; and PhD candidate Susanne Sjöberg, KI.
The Indian collaboration partners are Vinoj Manning, Research Assistant at IPAS in New Delhi; and Suneeta Mittal, Professor Department of Obstetrics and Gynaecology at All India Institute of Medical Science and the WHO-collaborating centre in New Delhi.
Project description: India as a middle-income country has reduced maternal mortality over the years. However, the contribution of unsafe abortion in relation to overall maternal death is still very high (20%) despite efforts made on both societal and legal levels. Our hypothesis is, that lack of distribution of health providers, as well as their attitudes toward abortion and low access to medical abortion as an alternative to surgical abortion, remain major barriers to safe abortion. A four-armed randomised control trial is planned to study the safety, efficacy and effectiveness of a simplified procedure of medical abortion, including contraceptive counselling, as are exploratory studies of midlevel providers and physicians’ knowledge and attitudes about abortion in general. More information about the project. 

In November 2011, Professor Birgitta Essén received SEK 750 000 as a three year grant (2012-14) from the Swedish Research Links programme (funded by Sida and the Swedish Research Council) for a collaborative research project entitled ”Management of a simplified procedure of medical abortion in India. Facility based RCT studies to improve womens access to safe abortion service” in collaboration with Dr. Suneeta Mittal, All India Institute of Medical Science (AIIMS), Delhi. More information on the Swedish Research Links grants 2012. 
Project abstract: India has reduced their maternal mortality over the years. However, the contribution of unsafe abortion in relation to the all over maternal death is till very high (20%) despite efforts made on both societal and legal levels. One problem related to abortion care in middle-income countries, is the lack of distribution of physicians as well as access of medical abortion (MA) as an alternative to surgical abortion. It has been shown in other settings that midlevel provider's involvement in MA care increases women's access to safe abortion. The MA is however time and resource consuming for both patient and providers and the health sector has been slow in implementing MA. Therefore, a simplified procedure of MA has been suggested as a safe alternative. Our hypothesis is that the simplified procedure would increase acceptability among both providers and women. There is no study published on the safety of a simplified procedure in MA or the involvement of midlevel providers in India. The aim is to study the safety, efficacy and effectiveness of a simplified procedure of MA, provided to women by midlevel providers or physicians. The design is a four-armed randomised control trial. The main outcome measure is successful completion of abortion. The long-term is to provide evidence based information that will contribute to the development of strategies to increase women's access to a higher level of abortion care and attempting to contribute to the MDG 5.

Pia Olsson, Kumudu Wijewardena and Malin Jordal.

The Sri Lanka project deals with Sexual and Reproductive Health, and is entitled ”Reproductive health risks, gender and women’s internal migration in Sri Lanka”. It is being coordinated by Associate Professor Pia Olsson (photo) and also involves Professor Birgitta Essén, and PhD candidate Malin Jordal at IMCH. The srilankan collaboration partner is Professor Kumudu Wijewardena, Department of Community Health, University of Jayewardenapura.
Kumudu Wijewardena was a Guest Professor at IMCH during the period June–December 2009.
She has had a special relation to SASNET, since she is a member of SASNET’s South Asian Reference group, more information.
Project description: Young women migrating from rural areas to work in urban factories is a growing phenomenon in Free trade zones (FTZ) in Sri Lanka and worldwide. This contributes to increased economic independence of women and poverty reduction in countries. However, negative sexual and reproductive health and rights (SRHR) consequences as harassment, sexually transmitted infections, unwanted pregnancies and illegal abortions are reported. This research program has a qualitative design and aims at understanding strategies in handling changing gender relations and SRHR risks of young, unmarried women migrating from rural to urban factory areas. Interviews and group discussions will be done with women working in FTZs, and men residing in or near the FTZ areas. The knowledge generated will be used for in community SRHR programs, refinement of curricula for nurses, doctors, social scientists and for theory development. More information about the project. 

Malin Jordal was originally a Norwegian nurse. Her PhD dissertation project aims to explore and describe female factory workers’ perception of reproductive health issues in Free Trade Zones in Sri Lanka. Thirteen female factory workers from two Free Trade Zones in Sri Lanka were interviewed using in-depth and semi structured interviews in order to gather as great a range and depth in perceptions as possible. Qualitative content analysis was used to analyse the interview transcripts, and eight categories and twenty-nine sub-categories were identified during the analysis. The results show that female factory workers in FTZ in Sri Lanka face various challenges, concerns. 

Previous research connected to South Asia

Professor Emeritus Gunilla Lindmark (photo to the left) was given a research planning grant from SASNET in August, 2002, for a project called ”Promoting adolescent reproductive health: Networking in Asia”. The network intends to give an opportunity to promote and utilise knowledge and contacts between participants from four South Asian countries (Sri Lanka, India, Pakistan and Bangladesh) and Sweden. The idea of creating a network originated from former Asian participants and facilitators in Sida-sponsored courses on Sexual and Reproductive Health and Rights (SRHR), organised by the department since 1992 (more information, see below).
The grant was used to organise a planning workshop in Colombo, Sri Lanka, 10–11 February 2003 (hosted by Professor Kumudu Wijewardena chairman of the Department of Community Health, University of Jayewardenapura (and formerly a visiting professor at IMCH), and resulted in the setting-up of SANAH (South Asian Network on Adolescent Health). The focal point of SANAH was decided to be Sri Lanka, where a secretariat will be formed under the UNICEF Adolescent Health Program Officer in Colombo, Dr Harischandra Yakandawala, and with IMCH being the focal point for the Swedish contribution to the network. The goal for SANAH’s activities will be to achieve optimum health and development among adolescent in South Asian sountries with emphasis on sexual and reproductive health. Further contacts have later been taken between MAMTA Health Institute for Mother and Child in New Delhi, India; the WHO Regional office; and IMCH, to develop the SANAH network. Besides IMCH has entered into a formal research and training collaboration with the University of Jayewardenapura, and one of the topics is adolescent health. More information about the Sri Lanka collaboration.

In November 2005 Prof. Gunilla Lindmark received SEK 400 000 as a two-years (2006-07) research grant from Sida/SAREC for a South Asia related project titled ”Does counselling of abused women using primary level health care promoters help the women?”. More information on Sida funded South Asia related research projects in 2005.

Associate Professor Pia Olsson coordinated a research project titled ”Adolescent childbearing and abortion in Sri Lanka. A qualitive interview investigation”. In November 2005 she received SEK 600 000 from Sida/SAREC as a two-years grant (2006-07) for this project. More information on Sida funded South Asia related research projects in 2005.
The project was carried out in collaboration with Prof. Kumudu Wijewardena, and it was also presented at the Sida-funded conference on current Swedish development research titled ”Meeting Global Challenges in Research Cooperation” that was jointly organised by Uppsala University and the Swedish University of Agricultural Sciences (SLU) in Uppsala 27-29 May 2008 (more information).
Abstract: Induced abortion in Sri Lanka is permitted only on strict maternal health indication. However a great number of women undergo abortions on other indications at relatively well established clinics. Single motherhood is not culturally accepted and there is no state welfare system to support single mothers. The process of deciding on abortion is unclear and factors contributing to the decision are unexplored from the women’s perspective. The aim of the study was to describe the circumstances of becoming pregnant, the process of making the decision on abortion and the reasons for seeking abortion in a sample of unmarried women in Colombo, Sri Lanka. Participants were recruited from a centre for reproductive health services in Colombo, where trained doctors conducted terminations under sterile conditions, up to 12 gestational weeks. Individual qualitative research interviews were carried out with 19 women, 18-30 years of age. Ethical clearance was obtained and the informants gave their informed consent.

Pia Olsson was also involved in the major Sida funded projects on reproductive and child health in India, that IMCH administered in Rajasthan, India. Dr. Olsson has made a study on ”Adolescents’ perceptions on sexuality and reproductive health risks. A qualitative study in rural Rajasthan, India”. It was presented at the Sida-funded conference on current Swedish development research titled ”Meeting Global Challenges in Research Cooperation” that was jointly organised by Uppsala University and the Swedish University of Agricultural Sciences (SLU) in Uppsala 27-29 May 2008 (more information).
Abstract:In rural Rajasthan female literacy is low, early and arranged marriages are practiced, maternal mortality is high and the HIV epidemic is advancing. Unmarried adolescents’ sexuality is not culturally recognized which make them vulnerable for reproductive health problems. Adolescents’ perceptions are important when designing adequate and acceptable sexual and reproductive health (SRHR) programs. The aim of the study was to describe adolescents’ perceptions on sexuality, pregnancies and STI/HIV as preparation for SRHR interventions in rural Rajasthan. Both adolescents boys and girls turned out to discuss sexual issues with great openness in the FGDs. They described premarital sexuality as important in their lives. It was reported that most boys had sex secretly with girlfriends or with girls they paid. Boys experienced double roles as boyfriends and guardians of sisters’ and family reputation. The adolescents got information on sex and reproduction from media and friends but seldom from parents. They wanted their parents to have more knowledge about SRHR issues and to be more open to discuss dilemmas of traditional norms on SRHR. Premarital pregnancies were perceived as dangerous but worth the pleasure of having sex, according to the boys who usually got out of the problem with the honor intact. Girls were also reported to enjoy sex but also to be punished by their families in case of a pregnancy since she dishonored the entire family. The risks of late abortions were highlighted by girls. The adolescents had heard of contraceptives but such were seldom accessible. Superficial knowledge and misconceptions about STI/HIV were revealed for example combining vaginal wash with anti-malarial drugs to prevent STI. Boys perceived that girls with knowledge about STI/HIV were difficult to attract for sex.

Other IMCH collaboration projects with India

In March 2005 the Swedish Government decided on a new country strategy for India for the period 2005-2009. The strategy implied a new kind of co-operation between Sweden in India mainly focusing on technical assistance and building partnerships of mutual interests between Swedish and Indian actors. The focus areas were: Respect for democracy and human rights; Environmental protection that will benefit the poor; and Scientific cooperation in selected areas that will benefit the poor. In light of the comparative advantage that Sweden has in Sexual and Reproductive Health & Rights, Children's Rights and HIV/AIDS, the Swedish International Development Cooperation Agency, Sida, therefore supported and allocated funds to a number of projects and partnerships involving Swedish universities.
IMCH has been involved in two of these projects being funded by Sida:

Project name: Integrating social support for reproductive and child health and rights, Phase II
Sida contribution: SEK 15 million for the period June 2005 – June 2010
Project partners: A network of ten NGOs in Rajasthan viz. Sara, Prayatna Sansthan, Tilonia Shodh evam Vikas Sansthan, Vihaan, Vishakha, Manthan, Kumarappa Institute of Gram Swaraj, Family Planning Association India, Humana People to People, and with its secretariat at Aadhar Research Institute in Jaipur, are working together for reproductive and child health and rights (RCHR).
Project description: The program has developed links with the International Maternal and Child Health (IMCH), Uppsala University, Sweden. The project attempts to respond to the health needs of the poor by generating a demand for health services among women, men and adolescents and also strengthening links with the public health system and local governance to respond to these needs. The key programme strategies include strengthening and developing an approach of networking, community participation in local governance impacting RCHR, institutional linkages and advocacy for influencing policy environment to improve access to quality and gender-sensitive health services in rural areas and for everyone to realise their right to health.
In view of the competitive edge of IMCH, in addition to providing technical support and guidance to the network, the partnership will undertake community-based research and thereby increase knowledge and understanding of key issues in maternal and child health in resource-poor settings.
By end of the project period, community groups at village and Panchayat levels will be strengthened to generate demand and ensure that reproductive and child health services reach the target groups as their right. The project will also ensure that sustainable institutional linkages are formed between the various key stakeholders along with an enabling policy environment, and that the network is firmed up in terms of structure, functioning and capacity.

Project name: Increasing Access to Comprehensive Abortion Care Services in India
Sida contribution: SEK 10 million for the period December 2005 – June 2009
Project partners:The project is implemented by a consortium of organisations/institutions that include Centre for Enquiry into Health and Allied Themes (CEHAT), the Federation of Obstetric and Gynecological Societies of India (FOGSI), FPA India/International Planned Parenthood Federation, International Unit Maternal and Child Health (IMCH) Uppsala University, Indian Society of Midwives, Population Council and Ipas, who also coordinates the programme.
Project description: The consortium members are established organisations involved in working on safe abortion issues either nationally, regionally or globally. Project brief The overall goal of the project is to increase access to legal, safe and comprehensive abortion services, that also includes post-abortion family planning services, in the public health system with focus on the rural poor and thereby contribute to the reduction in maternal mortality and morbidity and enhance women's ability to exercise their SRHR at both public and private health delivery systems in the country.
The project also aims to strengthen collaborations with Swedish institutes/organisations in the area of advocacy, medical abortion and involvement of midlevel providers. Given the controversy related to abortions, the collaborative effort build on the strengths and capacities individual members/organisations, will gain in advocate efforts. Apart from developing effective district level model for comprehensive abortion care in the public health system for improving supply-demand of safe and legal abortion services, the project will develop pilot models for expanding the provider base and technology choices for safe abortion services and thereby enable changes in policy, legal and implementation framework. Moreover, considering the involvement of a variety of organizations, a significant outcome could be the strengthening of partnerships and developing a common understanding and vision for a long term impact. The Packard Foundation co-funds the project.

INFORM (International Network for Online Resources & Materials)

In 2003, information activities at IMCH were consolidated into INFORM (International Network for Online Resources and Materials), with the aim of delivering health information training not only in Sweden but also onsite in lower-income countries. Among the first countries to arrange INFORM workshops was Sri Lanka, where four workshops were run at the University of Sri Jayewardenepura between 2003 and 2006.
In addition, INFORM continued to develop and deliver training for ITPs associated with IMCH. One of these was the ITP on child survival held at Uppsala in the spring of 2007, with participants from eight Asian countries, including Afghanistan, Bangladesh, India, Nepal, and Pakistan. Another was the autumn 2007 ITP on strengthening midwifery competence, which was organized by Karolinska Institute in collaboration with the Swedish Association of Midwives and IMCH. The midwives participating in the training were from Afghanistan, Bangladesh, India, Nepal, Pakistan, and Sri Lanka, as well as five other Asian countries.

The programme is led by IMCH researcher Dr Martha J Garrett (photo), and Anders Wändahl, a librarian at Karolinska Institutet in Stockholm.
INFORM’s first training in South Asia was commissioned by Professor Kumudu Wijewardene at the University of Sri Jayewardenepura in Sri Lanka (more about Prof. Wijewardena, see above). INFORM trainers have also been involved in information training in other SASNET countries, including India (for the Reproductive and Child Health and Rights Network in Jaipur, Rajasthan), Afghanistan (for the Afghanistan Midwives Association), and Pakistan (for the Higher Education Commission at Dow Medical University in Karachi and for the Ministry of Health at the Health Services Academy in Islamabad). Grants from SASNET have helped to finance some of this work.

Outside the SASNET region, INFORM has provided information training in China for the Raoul Wallenberg Institute—on the topic of international law and human rights—and in Vietnam, where INFORM-trained master trainers are now providing workshops for doctors throughout the country.

INFORM’s next major activity will be a regional programme in Asia. Health professionals working on reproductive health and maternal-and-child health in 10-12 Asian countries, mostly in south Asia, will receive intensive training about where to find free, high-quality materials for teaching, clinical practice and policy formulation. After the training, they will carry out their own information projects and also exchange information through an online forum. INFORM has invited SASNET to be a partner in the programme.
More information about INFORM can be found online at the programme’s new website at http://www.inform-network.org.
Some of INFORM’s many sourcebooks are also available at the same site and can be downloaded free-of-charge.

SASNET has been strongly involved in the development of INFORM.
Already in August 2002, SASNET provided a planning grant to Dr. Martha Garrett, to enhance this educational collaboration project, that was then planned together with Professor Wijewardene. This project aimed to give master’s students at IMCH the possibility to carry out their data collection for their master’s studies in Sri Lanka, under the local supervision of that university’s medical faculty.
The first data collection to be done under the arrangement was carried out during the spring term 2004 by Ms. Alemnesh Mirkuzie, an Ethiopian nurse in the Master’s Programme in International Health at IMCH. The research led to a master’s report entitled ‘Health Care Providers’ Perceptions of Adolescent Reproductive Health Problems in Colombo, Sir Lanka’. A scientific article based on the research and co-authored by Ms Mirkuzie, Professor Wijewardene, and Dr Pia Olsson (the IMCH advisor) was being prepared for publication. A workshop was held in Sri Lanka in 2006, see photo.

In August 2007, Dr. Garrett received SEK 150 000 as another SASNET Planning grant for an educational programme, now to set up a ”Regional Networking for Information on Child Survival”. See the full list of SASNET planning grants 2007.
INFORM was also able to get support from several other funding sources in addition to the SASNET planning grant. This made it possible for Dr. Garrett and her team to lead three on-site workshops (see photo from an India workshop in 2009), and do network-building in Afghanistan and Pakistan. Later also, through another arrangement, training in India.
Read the final report for the SASNET funded INFORM regional project (as a pdf-file)
An INFORM team were supposed to visit Pakistan early 2010 for two more workshops if the situation at the universities allows it. Key persons committed to the network now work in countries throughout Asia, and new proposals for support are given to international funding agencies.

Library service and International collaboration

In support of its educational activities, IMCH maintains a library on health care in low-income countries, the largest such library in Scandinavia. The literature can be searched through Libris.
IMCH staff members do consultancy work for national and international organisations including WHO, UNICEF, and the World Bank. The section also collaborates with other institutions in Sweden and throughout the world. In South Asia collaborative partners include the Christian Medical College in Vellore, India; BRAC; and Dhaka University in Bangladesh.

International Nutrition Research Group

For 19 years, until August 2004, Associate Professor Ted Greiner was working at the Dept. of Women’s and Children’s Health. He was Head of the separate International Nutrition Research Group. He now works as a Senior Nutritionist at the Programs for Appropriate Technologies in Health (PATH), Washington DC, USA. The International Nutrition Research Group has been amalgamated into Prof. Lars-Åke Persson’s research group on International Child Health and Nutrition
Ted Greiner has in the past worked in and published a lot of material on Bangladesh and India.
He has also been the team leader for a Sida evaluation and later for a review of its support to the Integrated Child Development Services in India, resulting in ”Reaching Out to Children in Poverty. The Integrated Child Development Services in Tamil Nadu, India” (contributions by Greiner, Brolin, Mittal, Puri, Paulraj and Gupta A) – Swedish International Development Cooperation Agency Evaluation 00/02, 2000. A summary is found in Sida Evaluations Newsletter 3/00 (pdf-file).
Greiner represents Sida at ACC/SCN (The United Nations Standing Committee on Nutrition); and works as a co-ordinator for the Research Task Force, World Alliance for Breastfeeding Action.
Ted Greiner is currently working as Professor of Nutrition at Hanyang University in Seoul, South Korea. See Greiner’s personal web page. 

PhD Viveka Persson was a member of the International Nutrition Research Group, and was engaged in research on South Asia. She carried out a school based nutritional study in Bangladesh on the effect of anthelminthic treatment on vitamin A status during childhood. Viveka Persson defended her doctoral dissertation on 8 October 2001. The title of the thesis was ”Vitamin A intake, status and improvement using the dietary approach, Studies of vulnerable groups in three Asian countries”. The three Asian countries were India, Bangladesh and Indonesia. Abstract to be found at Uppsala University´s web site. Viveka Persson has later worked for Sida/SAREC.

Centre for Public Health in Humanitarian Assistance (PHHA)

The Centre for Public Health in Humanitarian Assistance, connected to International Maternal and Child Health, Dept of Women's and Children's Health, was established at the end of 2001, in response to clearly recognized needs and demands in Sweden for training, technical advice, research and a resource centre in this specialized area. Disaster affected populations, refugees and displaced persons are amongst the most disadvantaged in the world. They are often dependent on humanitarian assistance for their survival. Globally, humanitarian crises are growing in scale and complexity. Most disasters have multiple impacts affecting different sectors and therefore require a multi-sectoral and multi-disciplinary response.
The Centre linked up with other disciplines that do not normally sit together, particularly those of Public health and nutrition, Economics, Disaster management, Peace and conflict studies, Cultural anthropology and Trans-cultural Psychiatry. While the main focus of the Centre is on Public Health in Humanitarian Assistance, it will link very closely with these other disciplines to facilitate a multi-disciplinary approach to disaster related studies.
PHHA was involved in running NOHA, an Erasmus Mundus Programme on International Humanitarian Aid.

Dr. Patricia M Diskett worked for some time at the Centre. Originally educated as a district nurse and midwife, she received her MSc in 1987, and in 1997 she defended her doctoral dissertation on ”Evidence-based decision-making and managerial chaos in population displacement emergencies. A Case Study of Rohingya Refugees in Bangladesh 1992-93” at the Liverpool School of Tropical Medicine.

She has worked for Oxfam for many years, eventually as coordinator of the Emergency Public Health Team for Oxfam’s UK office. As a Health Coordinator for the United Nations High Commission for Refugees, she had responsibility for coordinating a health programme involving over 20 NGOs and serving over a quarter million refugees. Dr Diskett has had field assignments in Honduras, Somalia, Brazil, Bangladesh, Nepal, and most African countries. Her areas of expertise include disaster preparedness, prevention, mitigation, management, response and rehabilitation; population displacement emergencies; complex emergencies; drought, famine and floods; emergency health care systems and policies; disease and epidemic control strategies: nutrition and food security, international relief system; support of emergency public health teams; training and training needs assessments. She has done research and been an adviser for research projects in many of these topics and has also served on UNHCR and WHO advisory groups responsible for identifying research priorities in emergency public health.
Dr Diskett’s current research, which is supported by a Leverhulme grant, is on the challenges facing NGOs trying to implement emergency public health programmes in an environment where human rights abuses are committed by the controlling authorities.