Making reproductive health services a priority in emergencies: Iraq
Emergency situations, especially those involving conflict, require that effective co-ordination mechanisms be in place and include sufficient attention to reproductive health responses. However, findings by the Humanitarian Response Unit UNFPA indicate that this is not always the case. While there is co-ordination between UNFPA, UNHCR, RHRC Consortium and other partners, inclusion of the RSH sector into the overall co-ordination mechanism of the consolidated interagency appeals seems to be weak. The appeals do not give the same visibility to reproductive health needs (not even within the larger health sector) as they give to the sectors of shelter, food, and sanitation. Furthermore, agencies implementing RSH programs are often excluded from the consultative mechanisms, thus resulting in a disproportional response to the RSH sector. Yet it is widely acknowledged that early planning for RSH services can reduce the adverse impacts of the crisis on an individual’s RSH status ( DeLargy et al. 2003 ).
The Iraq crisis was a positive example of effective co-ordination before the crisis erupted. UNFPA pre-positioned basic RSH supplies inside Iraq, preparing for anticipated influxes of Iraqi refugees in neighbouring countries, and setting up training for the proper use of supplies and how to incorporate RSH services into the initial phase of the emergency. Not only was the pre-positioning of RSH supplies and co-ordination with national authorities and other NGOs in neighbouring countries an important step, but an identified gap was addressed: the training of healthcare officials including senior government officials and officials from the UN and other NGOs. This was an important step to ensuring that quality services could be provided and that providing RSH services was more than the promotion of family planning. There was a greater understanding by all that early RSH interventions were necessary during the initial phases of conflict to avoid preventable mortality and morbidity. Healthcare officials had not been previously trained in these situations because they didn’t realize it was necessary ( McKenna 2003 ).
Post-abortion care in refugee settings: Thailand
In countries where abortion is illegal and there are influxes of forcibly displaced populations, post-abortion care services are especially essential. Each refugee situation should have a protocol for reducing death and suffering from the complications of unsafe and spontaneous abortions. This means equipment and trained staff are available and able to deal with the situation. Systems must be in place to manage incomplete abortions and life-threatening complications; provide family planning counselling and services; and make links between PAC services and other RSH services.
However, while it is widely recognized that the management of abortion-related complications is an integral component of comprehensive reproductive health care, and UNFPA’s emergency RH Kit #8 includes equipment and supplies for management of abortion complications, there is no mechanism to train relief workers on proper use of the kit. Nor is there systematic training on management of abortion complications, use of Manual Vacuum Aspiration (MVA) equipment, or provision of quality comprehensive post-abortion care (PAC) services that include counselling and referral to other reproductive health services. In addition, formally trained medical staff are not always available in refugee settings.
Engender Health provides positive lessons learned in providing support for PAC in Thai refugee camps along the Thai/Burmese border. Engender Health conducted its first Post-Abortion Care (PAC) workshop for informally trained health workers in a refugee setting with equipment provided by IPAS for the training and clinics represented at the training. The need was identified through RSH service providers, particularly the Mae Tao Clinic, which has seen increasing numbers of patients requiring PAC. In 2001, 457 women visited the clinic seeking PAC services. Post-abortion care services are often urgent in refugee settings, as many delay before seeking care due to fear of arrest (abortion is illegal in both Thailand and Burma), lack of transportation and shame.
Because of the pressing need in the community and the lack of medically trained professionals, informal health workers were chosen to be trained in PAC. Most of those attending the training were refugees with no formal training, but who had already been providing health services of some sort: either they had received previous training from community health education programmes or NGOs, or had direct work experience. Key to their training was to precisely identify their skill level and target the training curriculum accordingly, in order to account for their diverse and varied levels of knowledge. The training was conducted on-site to ensure that the services could be implemented immediately. The training incorporated the PAC into the existing service system to ensure that it was not placing a burden on the site's service capacity and that the team members were integral to making the new system operational.
Post-abortion care will continue as a crucial health need in refugee situations, and the lack of formally trained doctors and nurses should not prevent services from being delivered. Organizations must creatively design programs that use available community resources, such as the training of health workers in PAC above. Such creativity can prevent the maternal death and disability that often accompany incomplete abortion ( Venghaus, Maung, and Landry 2003 ).
The importance of research in planning adolescent refugee reproductive health programmes: Nepal and Tanzania
Adolescence can be a tumultuous period in every young person's life. This situation can become more confusing and difficult if a young person is forcibly displaced from his/her home, has lost or become separated from family members, has suffered violence and may become head of household by default. The breakdown of family and community can shift responsibilities onto the young person, often without the necessary support. The idleness, boredom and monotony of camp life can lead to increased risky behaviours, especially sexual behaviours. Without reproductive and sexual health knowledge and protection, these behaviours can lead to reproductive ill-health. Case studies of Nepal and Tanzania reveal different programming approaches based on the different needs and levels of sexual and reproductive health awareness demonstrated by the youths.
In Eastern Nepal, approximately 100,000 Bhutanese refugees have been living in a camp atmosphere for approximately ten years. Of these refugees, approximately 38 per cent are aged 10-24. The frustration, futility and stress of the general situation affect the lives of these adolescents. Because of the open border with India and the close proximity of the camps, there is frequent movement across the border by the Bhutanese refugees. Girl trafficking, cross-border trips for IV drug use and prostitution are commonly observed phenomena. These behaviours greatly increase chances of reproductive ill-health including STIs and HIV/AIDS.
The Association of Medical Doctors of Asia (AMDA)–Nepal, which has been providing RSH services since 2001, realized the need for specific interventions aimed at adolescents. In order to design an appropriate adolescent reproductive health program, (AMDA) –Nepal undertook a knowledge, attitude and practices (KAP) survey. The aim of the survey was to determine the level of understanding these youths had of general RSH, STIs and HIV/AIDS, in order to design appropriate curriculum for peer awareness education and to design appropriate RSH services for the young people.
The results of the KAP survey revealed important information for the design phase of the program, including types of information to be disseminated as well as service gaps. Key findings included that basic RSH information needed to be covered, such as signs of puberty, menstruation and pregnancy, in addition to information on avoiding pregnancy, other aspects of family planning, gender-based violence, STIs and HIV. It was identified that the topics needed to be relevant to the immediate conditions of the adolescents, rather than generalized information. In addition to peer workers, mass education of a wider audience that included community members and mothers was recognized as a supportive element. Finally, refresher traditional birth attendants (TBA) trainings were identified, as many of the girls stated they preferred home births ( Rimal et al. 2003 ).
In Tanzania, approximately 25 per cent of all refugees in eleven refugee camps are aged 10-24 years. Umati Refugee Project has been addressing adolescent RSH health in three camps since 2000. Umati’s baseline survey in 2000 revealed that poverty, idleness and boredom were factors leading to early pregnancy and early marriages. A project was designed around these findings to provide sexual and reproductive health services to the youth centres and community. At a mid-term survey in 2002, data revealed that there were no significant changes, and this signalled that programming changes were required. Rather than directly distributing RSH messages, Umati decided to target the associated factors as a way of improving the youths' RSH. Activities were directed at addressing idleness, boredom and poverty, such as skills training, income generation, sports and cultural activities. Within these activities were educational materials with messages addressing RSH. Peer educators were still utilized, and youths were encouraged to discuss the RSH messages within the context of the activity or training that was taking place.
Results of the 2003 survey revealed that a positive change had occurred. The number of youths using condoms had increased, youths felt freer to discuss sexual matters and early marriage had decreased. The combination of providing targeted sexual and reproductive health messages to youths at the same time as addressing contributing factors leading to poor RSH has resulted in positive changes in regulating youths' sexuality ( Muhingo and Boniface 2003 ).
The two case studies above illustrate the importance of using research to plan and modify RSH programmes. Planning adolescent RSH services does not have to involve a lot of extra technical input. Both studies revealed the importance of baseline information at the onset as well as throughout the programming cycle. The KAP survey is relatively easy to conduct, cost-effective and can provide rich information about the RSH needs of adolescents.