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State of the Field

The need for improved reproductive health care services worldwide was established by consensus at the International Conference on Population and Development (ICPD) and the ICPD+5, and is reinforced throughout the literature. According to Population Action International, “98% of the 3.43 million adult deaths from causes related to poor reproductive health occurred in the developing world” in 2000. Furthermore, “[i]n developed countries, a woman has only a 1 in 2,125 risk of dying in pregnancy or childbirth over the course of her lifetime. That risk is 33 times higher, at 1 in 65, for women in developing countries”.1 The World Health Organization (WHO) estimates that 13% of these pregnancy-related deaths are due to complications from unsafe abortion.2

In addition to setting standard definitions for reproductive health, the ICPD in 1994 and 1999 set priorities that would influence government policies and set in motion the process of strengthening global reproductive health care. The Programme of Action that outlined the results of the 1994 conference states that “[a]ll countries should strive to make accessible through the primary health-care system, reproductive health to all individuals of appropriate ages as soon as possible and no later than the year 2015”.3 This call for providing comprehensive reproductive health care includes by necessity, an examination of the reproductive health content in medical schools and health worker training essential to improving the quality of reproductive health care in developing countries (DCs).

Efforts to develop human capacity in the health sector include inservice training, professional exchanges, fellowship programs and traditional preservice training. Through preservice training, medical education institutions can provide a critical foundation for building systems of care and future health professionals’ skills in key areas of reproductive health that could potentially impact maternal mortality and other indicators of reproductive health. In addition, competence in areas such as reproductive rights, provider-client communication, and sociocultural factors will assist providers in delivering effective services that meet clients’ comprehensive needs.4

Levels of Curricular Reform

There are several levels of curricular reform that can occur within medical education: global, national, and institutional or departmental reform. A general principle of curriculum reform is that the broader the scope of the reform, the more general the guidelines for content will be for the core curriculum, i.e. global curricular reform would result in much broader core curriculum than institutional curricular reform because the institution can be very specific according to the circumstances and specific goals within the institution.5

Global Curricular Reform

Globally, there are efforts underway to establish standards and guidelines for preservice medical education. Schwarz and Wojtczak (2002) describe the evolution of this movement beginning with a meeting in 1994 of the WHO and the Educational Commission for Foreign Medical Graduates (ECFMG). In 1999, the Institute for International Medical Education (IIME) was formed for the specific purpose of defining “minimum essential competencies”. IIME’s work is projected to occur in three phases: 1) defining the “global minimum essential requirements” (GMER) and the methods necessary to implement them; 2) piloting the implementation in select medical schools, which is currently in progress; and 3) globalizing the effort by sharing the outcomes of the pilot. The implementation of the GMER does not necessitate uniform curricula but rather requires that each medical institution’s curriculum leads students to develop these competencies.6 The World Federation for Medical Education also has global standards in basic medical education, postgraduate medical education, and continuing professional development.7

There are currently no comprehensive, quantitative or qualitative studies documenting guidelines or standards in medical schools specific to reproductive health curricula. Reference to strengthening general preservice medical education in DCs is primarily found in discussions of reforming or restructuring health systems, or implementing ICPD-influenced policy changes.8, 9 However, there is at least one instance in which researchers documented efforts to implement reproductive health materials in preservice medical education in DCs on a global scale. Taylor and Magarick (1981) published the first documentation of an effort to strengthen international medical education through the distribution of teaching materials.10 This project was initiated by members of a FIGO (International Federation of Gynecology and Obstetrics) committee that “recognized that little attention was given to reproductive health education within the curriculum of medical schools in developing countries, and furthermore, appreciated that resources for the teaching of family planning and reproductive health were in limited supply.”11 This study remains the sole example in which one intervention was studied across a large sample (32 countries, 100 questionnaires). Researchers distributed 700 copies of a comprehensive reproductive health teaching manual to heads of Obstetric/Gynecology departments, maternal/child health divisions, schools of public health and similar institutions in more than 32 developing countries. Returned questionnaires yielded important information regarding the necessity of this teaching manual, subsequent editions, and editions in languages other than English. The manuals were also reportedly used in the instruction of an estimated 30,000 users—a staggering impact. The FIGO Manual was updated by Rosenfield and Fathalla in 1990 through an international academic and funding effort that resulted in a second edition with versions in French, Spanish, and later Chinese. The Manual was distributed to medical schools and medical libraries, and to the deans of the Obstetrics/Gynecology Departments in all developing countries.12

National Curricular Reform

In 1995, De Castro Buffington presented JHPIEGO’s framework for integrating reproductive health material into health professional training using a system-wide approach in 19 countries.13 This was the introduction of a national model that JHPIEGO continued to develop as the standard for reforming reproductive health training. This model describes a process that includes revisions of national policies and guidelines, preservice reproductive health training, inservice training, and the development of clinical training sites. In addition to the model, De Castro Buffington presents important arguments for integrating preservice and inservice training which include resource conservation, sustainability, immediate application of skills, and linking the health care, political, and higher education systems. The De Castro Buffington article documents interventions with smaller impacts than Taylor and Magarick, but which are more culturally and politically specific for each country. A more comprehensive version of JHPIEGO’s training model is currently published as part of a suite of materials available on JHPIEGO’s Website (www.jhpiego.org).

The multitude of stakeholders involved in health sector reform need to create a framework for dialogue about integrating reproductive health content in health professional training. Lubben et al. (2002) present a framework focused on nine questions that help stakeholders achieve consensus on concepts and policy contexts, identify possible links between reproductive health curriculum reform and health sector reform, understand cause and effect relationships behind policy decisions, and recognize some of the macro influences on a national health care system.14

Also at the national level, Bodart et al. (2001) discuss the state of the health care system in Burkina Faso and the utility of sector reform given the current donor levels and commitment of the Ministry of Health. The authors cite the 1997 International Center for Childhood and the Family report, Eight years of Bamako Initiative implementation, to demonstrate the magnitude of the situation: “Despite the high priority given to the social sector by governments and donors in general, there is growing evidence that in many countries the existing health systems have limited impact on health conditions because they do not reach the majority of women and children, and the quality of health services delivered is often too low to make a difference”.15

Institutional Curricular Reform

Several models of curriculum reform have been developed and implemented at the institutional or departmental level. Olatunbosun and Edouard (2002) discuss the potential to use medical education reform to integrate an approach based on “reproductive health, problem-based learning, and evidenced based medicine”.16 The authors describe three approaches to incorporating reproductive health into medical school curricula: 1) adding independent courses specific to reproductive health; 2) adding reproductive health content to existing curricula; and 3) adding new interdisciplinary courses to the curricula. Olatunbosun and Edouard emphasize specific content areas, stating that, “curriculum reform is specially needed for physicians to meet service needs regarding sexuality, gender, male involvement, life cycle, communication skills, counseling, and the promotion of individual needs in the context of rights-based programming. Further, in reproductive health education, there tends to be a dearth of instruction on the biological and social determinants and consequences of diseases from a gender perspective.” Haslegrave and Olatunbosun (2003) anticipate the development of a model curriculum on sexual and reproductive health and suggest including specific methodologies such as problem-solving and case-based learning. 17

Though the need to revise reproductive health content in medical school curricula remains to be fully elucidated, the expert opinions represented in the literature agree that DCs benefit from strengthening reproductive health content in preservice education for all health professionals. The current literature presents a range of options for intervention. The process, as described in the literature, needs to consider the policy context and the available resources, involve the stakeholders, and define priorities for the country.

Organizational Resources and Reports

While there is a dearth of published studies and literature specifically related to the field of preservice medical education in reproductive health, the community of non-governmental organizations (NGOs) has produced several resources and reports over the last two decades that relate specifically to preservice training. In recent years NGOs have begun to incorporate preservice medical education into their inservice activities, and thus there are several more reports that address inservice training with only scant reference to a preservice component.

Of the NGO-published reports focused on preservice reproductive health education and training, the majority have been dominated by the JHPIEGO model of strengthening preservice education which is elucidated fully in Preservice Implementation Guide: A process for strengthening preservice education.18 JHPIEGO pioneered this specific approach to preservice training for medical and allied health professionals and has implemented it in several settings. This JHPIEGO resource provides useful definitions of preservice education, rationale, typical challenges faced in the process, a description of the process, and evaluation methods.

JHPIEGO has also developed the Instructional Design Process which details the “systematic process of designing education and training courses from start to finish”.19 It is used for a variety of training contexts, including preservice. The process includes five phases: 1) establish the need for training; 2) design learning events; 3) develop high quality training materials; 4) use appropriate strategies or approaches in implementing learning events; and 5) evaluate the training event. For a specific description of JHPIEGO’s results in preservice training, see: Preservice Education in Reproductive Health: Results from the Field.20

The Sante Familiale et Prevention du SIDA, or SFPS Project (Family Health and AIDS Prevention Project) was a collaborative USAID-funded effort between Tulane University, JHPIEGO, Johns Hopkins University Center for Communications Programs, and Population Services International that was implemented between 1996 and 2001.21 Though this project did not have preservice education reform listed as an explicit objective, over the course of implementation, preservice training in reproductive health was incorporated into larger strategies to “reinforce national capacity in training”. For example, in 1996 the SFPS Project organized and hosted a regional forum in Ouagadougou for 150 people that focused on preservice education in reproductive health.

The Training in Reproductive Health Project (TRH), a project of JHPIEGO at Johns Hopkins University, facilitated the development of resources to improve performance and develop human resources between 1993 and 2004.22 Under the auspices of this project JHPIEGO implemented several preservice education reform efforts, including projects in Ghana, Turkey, and the Philippines. The TRH Project resulted in a number of useful resources for use in reproductive health curriculum reform. For example, JHPIEGO’s Preservice Education for Reproductive Health Professionals information sheet confirms the efficiency and sustainability of preservice education, stating that it “reduces the need for recurrent inservice training cycles, thus conserving scarce training resources. Having providers who have the necessary skills to immediately begin providing services upon graduation leads to improved RH [reproductive health] service delivery and helps ensure that women and families have access to the services they need.”23 The project was concluded in March 2004, with the presentation of the project results and lessons learned.24

The Commonwealth Medical Trust (Commat) published the proceedings of meetings held in London (2001) and Uganda (2002) that focused on defining the core components of sexual and reproductive health at the primary health care level, and reviewing goals and strategies for their incorporation into preservice medical education. These workshops were attended by representatives from DCs in the Commonwealth, experts in curriculum development, and representatives from inter-governmental organizations and NGOs.25 Participants also reviewed different types of reproductive health medical curricula in preparation for the production of an integrated reproductive health curriculum model that specifically represents the ICPD Programme of Action priorities in reproductive health.26 The third and final meeting in this series was co-hosted by Commat and the Reproductive Health Initiative in New Delhi, India in April 2004. At this meeting, participants discussed the progress achieved in integrating reproductive health content into their medical school curricula, obstacles and potential solutions, and reviewed a draft outline of a reproductive health curriculum proposed for preservice medical education. Participants confirmed that within their responsibilities for delivering lectures on reproductive health topics, access to content was among their greatest challenges, especially for those whose departmental curricular requirements already reflected a comprehensive perspective on reproductive health.27

There is a selection of USAID-funded projects that address obstacles to accessing high quality reproductive health care; several of these projects include preservice education as an important element or as an aspect of training that is positively influenced by the projects’ efforts. The Performance and Quality Improvement project (PROQUALI), Maximizing Access and Quality (MAQ) Initiative, and PRIME II project are examples of USAID-funded projects or initiatives that focus on human capacity development and reproductive health care services. The PROQUALI project presents a performance improvement approach to increase access to and improve the quality of reproductive health care. The MAQ initiative encourages USAID, cooperating agencies, and communities to pursue “practical, cost-effective, and evidence-based interventions aimed at improving both the access to and quality of family planning and reproductive health services”.28 The program’s primary focus is on removing obstacles to accessing reproductive health services; preservice training is a secondary objective. PRIME II has a broader scope to improve global family planning and reproductive health services through enhanced performance of primary care providers. Training and performance improvement are core elements in this project.29

In an evaluation of USAID’s human capacity development programs, the Population Technical Assistance Project (POPTECH) surveyed and/or interviewed key USAID staff from the Bureau of Global Health in the population, health, and nutrition sectors, country coordinators, and cooperating agency representatives about current USAID activities in human capacity development and areas of need. Results indicate that respondents felt inservice training was overused to address human resource needs and that “invariably, a policy of using inservice training in lieu of preservice education is practiced”. 30 It was recommended that inservice training be used more specifically for training issues such as new technology or added job requirements.31

Respondents to the POPTECH survey also acknowledged the difficulties professional education institutions face in funding, technology, and current training techniques. It was noted that it is particularly difficult to address needs for clinical expertise for HIV/AIDS prevention and treatment while balancing training needs for other essential reproductive health services. The evaluation results recommended that USAID recommit to preservice education, specifically “supporting regional and local educational and training institutions and U.S. partnering mechanisms”.32 It was also recommended that USAID include ministries of finance and labor in preservice training discussions to address issues such as funding for education, work conditions, and salary levels. Finally, it was mentioned that human capacity development management should be incorporated into preservice and inservice training programs in order to strengthen these skills.33

In response to the POPTECH evaluation, USAID’s Bureau of Global Health, Offices of Population and Reproductive Health and HIV/AIDS designed the Human Capacity Development Project (HCDP) with the objective of improving human capacity to implement quality health care programs. The project addresses issues of workforce planning; allocation and utilization; preservice, inservice, and continuing education to improve worker skills; and strengthening systems for sustained worker performance on the job. An objective of this project is to ensure that preservice curricula of medical and allied health professionals includes knowledge and skills in reproductive health, HIV/AIDS, child survival, maternal health and infectious diseases.34

Vision for the Future

Reproductive health content in preservice medical education is a relatively unexplored field of study with enormous potential. Opportunities for research in this area include quantitative and qualitative studies of reproductive health content in medical curricula, investigating processes and longevity involved in instituting changes from within medical schools, and documenting physicians’ experiences with improved training. There are also many areas for intervention, including providing appropriate resources and textbooks, training faculty, and reinforcing current efforts.

An important avenue of intervention is to transfer many of these efforts to improve preservice education in reproductive health to the allied health professional sectors. While it is important to train physicians because they are more often in the position of influencing national policies and setting standards of care, Haslegrave and Olatunbosun (2003) state that “[it] is equally important that nurses, midwives, and other mid-level and primary health care workers should receive appropriate instruction in sexual and reproductive health care, as they are more likely to attend the majority of women and adolescent girls in developing countries than are doctors”.35

An area with potential for significant impact is improving health professionals’ access and management of information vital to curricular content, practicing evidence-based care, and remaining abreast of current information in one’s field. Without access to information, many of the interventions discussed here cannot be implemented or sustained long-term. Geyoushi et al. (2003) call this challenge “information poverty” and discuss efforts to disseminate information including free access to journals and WHO’s Reproductive Health Library.36 Bailey and Pang (2004) confirm the need for increased research on the use and need for health information and point to the disparity in the direction of the information flow, from more developed to less developed countries.37 Medical schools and medical school faculty need to be included in this dialogue of challenges and prospective solutions, as they are crucial in providing each generation of physicians with a foundation that includes current scientific knowledge.

There are extensive obstacles and challenges to be overcome; funding, technology, appropriate content resources, exam structure and content, faculty training, overcrowded curricula, and competing curricular priorities have all been cited in research or anecdotal experience. The phenomenon of “brain drain”, the tendency of highly trained professionals to migrate from areas of need to areas of higher compensation or standard of living , also needs to be considered as a potential impediment to achieving improved access to high quality reproductive health services.38 To meet these challenges and make progress in research and implementation, the community of professionals interested in these issues must learn from efforts to improve other aspects of preservice medical education, from the efforts undertaken in inservice training in reproductive health, as well as from each other.

Relevant research and resources available in the field have been compiled to produce the Resource Guide for International Preservice Medical Education in Reproductive Health (Resource Guide) as a first step towards further defining the field and improving access to this information. The Resource Guide should provide a foundation on which a community of professionals can work together to identify coherent strategies and accelerate the rate of progress being made in translating the goals of the ICPD from policy to action. IRHMedEd, the newly formed listserv for people interested in reproductive health in medical education, is a corresponding effort to continue this dialogue. Join IRHMedEd at http://lists.infoforhealth.org/mailman/listinfo/irhmeded.

  1. How Family Planning and Reproductive Health Services Affect the Lives of Women, Men, and Children. Population Action International Website; April 3, 2003. Available at http://www.populationaction.org/resources /publications/ worldof difference/rr2_factsheets.htm. Accessed April 19, 2004.
  2. The World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva, Switzerland: The World Health Organization; 2003:10.
  3. United Nations Population Fund. Programme of Action of the International Conference on Population and Development, ed. Reproductive Rights and Reproductive Health: Objectives. Available at http://www.unfpa.org/icpd/icpd_poa.htm#ch7. Accessed April 14, 2004.
  4. Makoul G, Schofield T. Communication Teaching and Assessment in Medical Education: An International Consensus Statement. Patient Educ Couns. March 1999; 137:191-95.
  5. Bandarayanake R. The Concept and Practicability of a Core Curriculum in Basic Medical Education. Med Teach. November 2000; 22(6):560-64.
  6. Schwarz RM, Wojtczak A. Global Minimum Essential Requirements: A Road Towards Competence-Oriented Medical Education. Med Teach. 2002; 24(2): 125-29.
  7. Lilley PM, Harden RM. Standards and Medical Education. Med Teach. July 2003 ;25(4):349-51.
  8. Globalization Committee Reproductive Health Affinity Group. Globalization, Health Sector Reform, Gender and Reproductive Health. New York: The Ford Foundation; 2003. Available at http://www.fordfound.org/publications/recent_articles/docs/globalization/front_matter.pdf. Accessed August 3, 2004.
  9. Bodart C, Servais G, Mohamed YL, Schmidt-Ehry B. The Influence of Health Sector Reform and External Assistance in Burkina Faso. Health Policy and Plan. 2001; 16(1): 74-86.
  10. Taylor HC, Magarick RH. An International System for the Education of Students of Medicine and Other Health Professionals in Human Reproduction, The FIGO Teaching Manual: A Status Report. Int J Gynaecol Obstet. 1981; 19:3-12.
  11. Taylor HC, Magarick RH. An International System for the Education of Students of Medicine and Other Health Professionals in Human Reproduction, The FIGO Teaching Manual: A Status Report. Int J Gynaecol Obstet. 1981; 19:3-12.
  12. Rosenfield A, Fathalla M.F. The FIGO Manual of Human Reproduction. Int J Gynaecol Obstet. 2004;86:264-266.
  13. De Castro Buffington S. A Framework for Establishing Integrated Reproductive Health Training. Baltimore: JHPIEGO Corporation. Advances in Contraception. 1995; 11:317-24.
  14. Lubben M, Mayhew SH, Collins C, Green A. Reproductive Health and Health Sector Reform in Developing Countries: Establishing a Framework for Dialogue. Bull World Health Organ. 2002; 80:667-74.
  15. Bodart C, Servais G, Mohamed YL, Schmidt-Ehry B. The Influence of Health Sector Reform and External Assistance in Burkina Faso. Health Policy and Plan. 2001; 16(1): 74-86.
  16. Olatunbosun OA, Edouard L. Curriculum Reform for Reproductive Health. Afr J Reprod Health. 2002; 6(1):15-9.
  17. Haslegrave M, Olatunbosun O. Incorporating Sexual and Reproductive Health Care in the Medical Curriculum in Developing Countries. Reprod Health Matters. 2003; 11(21):49-58.
  18. Schaefer L. Preservice Implementation Guide: A process for strengthening preservice education. Baltimore: JHPIEGO; October, 2002. Available at http://www.jhpiego.jhu.edu/ Accessed September 30, 2004.
  19. JHPIEGO. JHPIEGO’s Instructional Design Process. Baltimore: JHPIEGO; 2003. Available at http://www.reproline.jhu.edu/english/6read/6training/process/3ids.htm. Accessed August 26, 2004.
  20. Magarick R. “Preservice education in reproductive health: Results from the field”. Paper presented at Developing the Next Generation of FP/RH Service Providers: Trends and Issues in Workforce Development. December 3-5, 2003; Baltimore, USA. Available at http://www.gatesinstitute.jhsph.edu/whatsnew/presentations/lf2003/rmagarick.pdf. Accessed April 16, 2004.
  21. The Family Health & AIDS/Sante Familiale et Prevention du SIDA. SFPS Website; 2004. Available at http://www.tulane.edu/~spfs/index.htm. Accessed April 13, 2004. Information is currently being transferred to http://www.fha-sfps.org/
  22. Training in Reproductive Health. JHPIEGO Website. Available at http://www.jhpiego.org/trh/index.htm. Accessed April 13, 2004.
  23. JHPIEGO. Preservice Education for Reproductive Health Professionals. Baltimore: JHPIEGO; November, 2002. Available at http://www.jhpiego.org/pubs/infoshts/prsrvcrh.pdf. Accessed April, 2004.
  24. “Strengthening Providers Performance in Reproductive Health: Innovations, Lessons Learned, and Results Achieved,” a symposium held at the National Press Club, Washington, D.C., March 2, 2004. Available at http://www.jhpiego.org/ events/ trh/index.htm. Accessed April, 2004.
  25. “ Sexual and reproductive health in the medical curriculum” , a symposium held at the Royal College of Obstetricians and Gynaecologists, London, March 21-24, 2001, London: Commonwealth Medical Association Trust.
  26. Haslegrave M, Olatunbosun O. Incorporating Sexual and Reproductive Health Care in the Medical Curriculum in Developing Countries. Reprod Health Matters. 2003; 11(21):49-58.
  27. Reproductive Health Initiative. Executive Summary of the Sexual and Reproductive Health in Medical Education Workshop. New Delhi, India , April 26-29, 2004. Available at http://www.amwa-doc.org/RHI/Internationalhttp://www.amwa-doc.org/RHI/International. Accessed October, 2004.
  28. About the MAQ Initiative: USAID's Office of Population and Reproductive Health Maximizing Access and Quality Initiative (MAQ). MAQ Website. Available at http://www.maqweb.org/maqinitiative.shtml. Accessed April, 2004.
  29. About Prime II. Prime II Website. Available at http://www.prime2.org/prime2/section/31.html. Accessed April, 2004.
  30. Bancich C, Kantner A. Evaluation of USAID Human Capacity Development in Health. Washington, D.C.: The Populations Technical Assistance Project (POPTECH); 2003.
  31. Bancich C, Kantner A. Evaluation of USAID Human Capacity Development in Health. Washington, D.C.: The Populations Technical Assistance Project (POPTECH); 2003.
  32. Bancich C, Kantner A. Evaluation of USAID Human Capacity Development in Health. Washington, D.C.: The Populations Technical Assistance Project (POPTECH); 2003.
  33. Ibid Bancich C, Kantner A. Evaluation of USAID Human Capacity Development in Health. Washington, D.C.: The Populations Technical Assistance Project (POPTECH); 2003
  34. Lois Schaefer (email communication September 1, 2004)
  35. Haslegrave M, Olatunbosun O. Incorporating Sexual and Reproductive Health Care in the Medical Curriculum in Developing Countries. Reprod Health Matters. 2003; 11(21):49-58.
  36. Geyoushi BE, Matthews Z, Stones RW. Pathways to Evidence-based Reproductive Health in Developing Countries. BJOG. 2003 May; 110(5):500-7.
  37. Bailey C, Pang T. Health information for all by 2015? Lancet. 2004; 364:223-24.
  38. F. Mullan, "Some Thoughts on the White-Follows-Green Law," Health Affairs (Jan/Feb 2002): 158-159.

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