Challenges of Reproductive Health in Complex Emergencies
- 1. Bixby Program in Population & Reproductive Health, March 2007 Stephen Tomlin, VP Program Policy & Planning, International Medical Corps stomlin@imcworldwide.org www.imcworldwide.org The Challenge ofThe Challenge of Reproductive Health in Complex EmergenciesReproductive Health in Complex Emergencies
- 2. COMPLEXCOMPLEX EMERGENCIES:EMERGENCIES: 1985:1985: 55 1992:1992: 1717 1999:1999: 3434 2006:2006: 3838
- 3. COMPLEX HUMANITARIANCOMPLEX HUMANITARIAN EMERGENCIESEMERGENCIES • Civil conflictCivil conflict • Weak or non-existentWeak or non-existent central governmentcentral government • Mass populationMass population movementsmovements • Massive economicMassive economic dislocationdislocation • Food insecurity leadingFood insecurity leading to famineto famine
- 4. Complex Emergency SettingsComplex Emergency Settings • People in need ofPeople in need of humanitarian assistance:humanitarian assistance: – 1989: 36 million1989: 36 million – 1996: 50 million1996: 50 million – 2004: 39 million2004: 39 million • Many more IDPs:Many more IDPs: – 25 m. IDPs / 49 countries25 m. IDPs / 49 countries – 14 m. Refugees14 m. Refugees
- 5. Since 1984…Since 1984… …providing health care through training / developing local capacity …supporting health care delivery through logistic management systems
- 6. IMC Relief, Recovery,IMC Relief, Recovery, & Development Programs - 2007& Development Programs - 2007 • AfghanistanAfghanistan • AzerbaijanAzerbaijan • BurundiBurundi • ChadChad • DR CongoDR Congo • EritreaEritrea • EthiopiaEthiopia • IndonesiaIndonesia • Ingushetia/ChechnyaIngushetia/Chechnya • IraqIraq • KenyaKenya • LiberiaLiberia • PakistanPakistan • Sierra LeoneSierra Leone • SomaliaSomalia • northern Sudan (Darfur)northern Sudan (Darfur) • southern Sudansouthern Sudan • Sri LankaSri Lanka • UgandaUganda • USA (Louisiana)USA (Louisiana)
- 7. Humanitarian Space ShrinkingHumanitarian Space Shrinking View from IMC driver’s seat, Darfur, Feb 28 ‘07View from IMC driver’s seat, Darfur, Feb 28 ‘07
- 8. Humanitarian Space is ShrinkingHumanitarian Space is Shrinking 1997-20051997-2005 • Over 9 year period:Over 9 year period: major acts of violencemajor acts of violence against aid workers doubledagainst aid workers doubled annuallyannually • 408 acts of major violence408 acts of major violence 947 victims947 victims 434 fatalities434 fatalities • Today, most victimsToday, most victims deliberately targeted, w/deliberately targeted, w/ political targeting on the rise.political targeting on the rise. 2006:2006: 83 aid workers killed83 aid workers killed 78 aid workers wounded78 aid workers wounded 52 aid workers kidnapped52 aid workers kidnapped • #1. Afghanistan (26 killed)#1. Afghanistan (26 killed) #2. Sri Lanka (23 killed)#2. Sri Lanka (23 killed) #3. Sudan (15 killed)#3. Sudan (15 killed) • Sudan accounted for 40% ofSudan accounted for 40% of incidentsincidents
- 9. Approach to Security ManagementApproach to Security Management The Evolving Security EnvironmentThe Evolving Security Environment -- Greater exposure, new threats, diminishing respect for IHLGreater exposure, new threats, diminishing respect for IHL The Acceptance StrategyThe Acceptance Strategy - E- Establishing, and then fiercely defending, relationships withstablishing, and then fiercely defending, relationships with local actorslocal actors - Built on trust, transparency, and predictability…as- Built on trust, transparency, and predictability…as perceived by localsperceived by locals - Protection and Deterrence strategies also employed, but- Protection and Deterrence strategies also employed, but secondarysecondary - At IMC, underpinned by strong security management policy and- At IMC, underpinned by strong security management policy and proceduresprocedures ArmsArms -- Humanitarians do not themselves carry weaponsHumanitarians do not themselves carry weapons - With some noteworthy exceptions, they do not employ or- With some noteworthy exceptions, they do not employ or accept armed protection in the course of their workaccept armed protection in the course of their work
- 10. Levels of Activity (community-based/grassroots) Ministry of Health Tertiary referral hospital Provincial Hosp District Hosp Health Center Community Health Workers Health Post Charitable hospitals Charitable hospitals clinics Charitable hospitals clinics clinics For profit hospitals doctorsdoctors doctors doctors doctors Primary Health Care doctors
- 11. Community-based Relief & RecoveryCommunity-based Relief & Recovery HealthHealth • Under-5 Child HealthUnder-5 Child Health • Reproductive HealthReproductive Health • Immunization (EPI)Immunization (EPI) • NutritionNutrition • Mental HealthMental Health Recovery &Recovery & DevelopmentDevelopment • MobilizationMobilization • PsychosocialPsychosocial • Water & SanitationWater & Sanitation • LivelihoodsLivelihoods • Micro-financeMicro-finance SUSTAINABLE WELL-BEING TRAINING
- 12. Uganda: Therapeutic & Supplementary Feeding Programs
- 13. What is Reproductive Health?What is Reproductive Health? • RH is a state of complete physical, mental andRH is a state of complete physical, mental and social well-being, and not merely the absence ofsocial well-being, and not merely the absence of disease or infirmity, in all matters relating to thedisease or infirmity, in all matters relating to the reproductive system and its functions andreproductive system and its functions and processes.processes. • RH implies that people are able to have aRH implies that people are able to have a satisfying and safe sex life and that they havesatisfying and safe sex life and that they have capability to reproduce and the freedom tocapability to reproduce and the freedom to decide, if, when and how often to do so.decide, if, when and how often to do so. 1
- 14. RH Rights Include:RH Rights Include: • The right to health in generalThe right to health in general • The right to reproductive choiceThe right to reproductive choice • The right to RH servicesThe right to RH services • The right of men and women to marryThe right of men and women to marry and found a familyand found a family • The right of the family to have specialThe right of the family to have special protectionprotection • Special right in relation to motherhoodSpecial right in relation to motherhood and childhoodand childhood
- 15. Cycle of Reproductive Ill-HealthCycle of Reproductive Ill-Health Source: WHO. Reproductive Health during Conflict and Displacement: A Guide for Program Managers. Geneva: World Health Organization, Department of Reproductive Health and Research, 2000. 5
- 16. Life Span Profile of Discrimination Against WomenLife Span Profile of Discrimination Against Women Source: WHO. Reproductive Health during Conflict and Displacement: A Guide for Program Managers. Geneva: World Health Organization, Department of Reproductive Health and Research, 2000. 7
- 17. Key Components of RH ProgramKey Components of RH Program • Gender-based violenceGender-based violence prevention and responseprevention and response • Safe motherhoodSafe motherhood • STIs, including HIV/AIDSSTIs, including HIV/AIDS • Family planningFamily planning 1 IMC MCH Clinic, Liberia
- 18. New Orleans
- 19. Iraq – Vulnerable Populations
- 20. IDPs 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 2/2/06 3/24/06 5/13/06 7/2/06 8/21/06 10/10/06 11/29/06 1/18/07 3/9/07 Date DisplacedFamilies IMC MoDM IOM inc. KRG IOM UNHCR Displacement Trends, IraqDisplacement Trends, Iraq
- 21. Gender-based ViolenceGender-based Violence • Sexual violenceSexual violence – Rape, attempted rapeRape, attempted rape – Sexual coercionSexual coercion – Sexual harassmentSexual harassment • Physical violencePhysical violence – Domestic violence,Domestic violence, spouse beatingspouse beating – AssaultAssault • Emotional,Emotional, psychological and socialpsychological and social abuseabuse – HumiliationHumiliation • Harmful traditionalHarmful traditional practicespractices – Female genital cuttingFemale genital cutting (FGC)(FGC) – Early, forced marriageEarly, forced marriage
- 22. Factors Contributing to GBVFactors Contributing to GBV • Lack of police protection and lawlessnessLack of police protection and lawlessness • Coercion around food and other ration distributionsCoercion around food and other ration distributions • Insecure living quarters; distance women have toInsecure living quarters; distance women have to travel to collect firewood, to latrines, etc.travel to collect firewood, to latrines, etc. • Political motivationPolitical motivation • Collapse of traditional family and societal supportCollapse of traditional family and societal support • Strains of life when displaced from homeStrains of life when displaced from home 6
- 23. GBV Prevention and Response (1)GBV Prevention and Response (1) • PreventionPrevention – Involve refugee womenInvolve refugee women – Public informationPublic information – Camp design, locationCamp design, location – Food and other distributionsFood and other distributions • ProtectionProtection – Ensure physical safetyEnsure physical safety • PsychosocialPsychosocial – CounselingCounseling – Support groupsSupport groups – Community education toCommunity education to decrease stigmadecrease stigma – Justice/legal supportJustice/legal support • Policy/managementPolicy/management – Train and monitor authoritiesTrain and monitor authorities and staff to reduce sexualand staff to reduce sexual extortionextortion – Ensure proper documentationEnsure proper documentation for womenfor women – Increase women protectionIncrease women protection officersofficers – Increase visibility of problemIncrease visibility of problem and seriousness of responseand seriousness of response – Document cases, care andDocument cases, care and other responsesother responses • LegalLegal 7
- 24. • MedicalMedical – Trauma careTrauma care – EmergencyEmergency contraceptioncontraception – Pregnancy testingPregnancy testing – Voluntary testing forVoluntary testing for HIVHIV – Voluntary testing andVoluntary testing and treatment for STIstreatment for STIs – Awareness andAwareness and sensitivity of staffsensitivity of staff – ConfidentialityConfidentiality – Referral for legal, socialReferral for legal, social and other servicesand other services GBV Prevention and Response (2)GBV Prevention and Response (2) International Women’s Day, Refugee Camp, Chad
- 25. Uncomplicated pregnancy, delivery, postpartum period Complication Severe Complication Life Threatening Complication Well Recovered short and long-term morbidity possible Death Maternal Morbidity and Mortality Survived near miss
- 26. Complications are UnpredictableComplications are Unpredictable • At least 15% of pregnantAt least 15% of pregnant women in any population arewomen in any population are expected to have life-expected to have life- threatening complications.threatening complications. • Cannot predict or preventCannot predict or prevent complications: any deliverycomplications: any delivery can become complicated andcan become complicated and require emergency interventionrequire emergency intervention • Best practice:Best practice: reduce delaysreduce delays through training in recognitionthrough training in recognition danger signs and referral todanger signs and referral to health facilityhealth facility IMC Trained Midwife, Darfur
- 27. Perinatal DeathsPerinatal Deaths • 28 weeks gestation28 weeks gestation through 7 days afterthrough 7 days after birthbirth • 7.6 million perinatal7.6 million perinatal deaths/yeardeaths/year 4.3 million stillbirths;4.3 million stillbirths; 3.3 early neonatal3.3 early neonatal deathsdeaths • Leading causes ofLeading causes of Perinatal DeathPerinatal Death – SyphilisSyphilis – Infection (sepsis)Infection (sepsis) – AsphyxiaAsphyxia – TraumaTrauma – Neonatal tetanusNeonatal tetanus – Complications of pretermComplications of preterm deliverydelivery
- 28. Key Strategies for Preventing MaternalKey Strategies for Preventing Maternal and Perinatal Deathsand Perinatal Deaths • Prevent unwantedPrevent unwanted pregnancies through familypregnancies through family planningplanning • Early recognition ofEarly recognition of complications, with referralcomplications, with referral • Access to skilledAccess to skilled attendants and emergencyattendants and emergency obstetric careobstetric care • Management of post-Management of post- abortion complicationsabortion complications • Breastfeeding supportBreastfeeding support • Essential newborn careEssential newborn care Rabia Balki Hospital for Women, Kabul
- 29. Antenatal careAntenatal care • Health assessmentHealth assessment • Detection and management ofDetection and management of complicationscomplications • Maintenance of maternal nutritionMaintenance of maternal nutrition • Health educationHealth education • Health promotion interventionsHealth promotion interventions such as tetanus toxoid (TT)such as tetanus toxoid (TT) vaccinations, folic acid and ferrousvaccinations, folic acid and ferrous sulfate supplements, malariasulfate supplements, malaria prophylaxis or presumptiveprophylaxis or presumptive treatment, and testing for syphilis,treatment, and testing for syphilis, depending on the contextdepending on the context TBA Training, Pakistan
- 30. Training TBAs in Darfur
- 31. Intrapartum/Delivery CareIntrapartum/Delivery Care • 100% of women who100% of women who develop a complicationdevelop a complication should be treated by ashould be treated by a skilled attendant in anskilled attendant in an emergency obstetric careemergency obstetric care facilityfacility • Basic emergency obstetricBasic emergency obstetric care (equipped healthcare (equipped health center)center) • Comprehensive emergencyComprehensive emergency obstetric care (referralobstetric care (referral hospital)hospital) • Transport for deliveriesTransport for deliveries outside an equipped healthoutside an equipped health facilityfacility • Support for breastfeedingSupport for breastfeeding Sudanese mother, Chad
- 32. Rabia Balki Hospital for Women, Kabul
- 33. Chad
- 34. Postpartum CarePostpartum Care • Monitor for danger signsMonitor for danger signs and referand refer • Postpartum visitPostpartum visit • EducationEducation • Newborn weighing andNewborn weighing and referralreferral • Support for breastfeedingSupport for breastfeeding • Promoting health ofPromoting health of newborn, including thermalnewborn, including thermal protection, eye care, cordprotection, eye care, cord care, vaccinationscare, vaccinations • Postpartum family planningPostpartum family planning
- 35. Sexually Transmitted Infections (STIs)Sexually Transmitted Infections (STIs) • TrichomoniasisTrichomoniasis • HIVHIV • ChancroidChancroid • Hepatitis BHepatitis B • Genital WartsGenital Warts • HerpesHerpes • SyphilisSyphilis • GonorrheaGonorrhea • ChlamydiaChlamydia Elders meeting, NWFP, Pakistan In women between 15 and 44 years of age, the morbidity and mortality associated with STIs, not including HIV, are second only to maternal causes.
- 36. Regional HIV / AIDSRegional HIV / AIDS • WorldwideWorldwide – 17.7 million17.7 million – 48% Women48% Women • Sub-SaharaSub-Sahara AfricaAfrica – 13.3 million13.3 million – 59 % Women59 % Women • South & SouthSouth & South East AsiaEast Asia – 2.2 million2.2 million – 29% Women29% Women • CaribbeanCaribbean – 120,000120,000 – 50% Women50% Women Community Mobilizers, Kibera slum, Nairobi
- 37. Kibera slum, population 800,000
- 39. Family PlanningFamily Planning • Saves women’s livesSaves women’s lives – Avoids unsafe abortionAvoids unsafe abortion – Limits exposure to the health risks ofLimits exposure to the health risks of pregnancy and childbirthpregnancy and childbirth – Limits births to the healthiest agesLimits births to the healthiest ages – Limits the number of birthsLimits the number of births • Saves children’s livesSaves children’s lives • Offers women more choicesOffers women more choices • Encourages adoption of safer sexualEncourages adoption of safer sexual behaviorbehavior Effective Programs: Coordinated Robust logistic systems Extensive training & education Discrete
- 40. Gender InequalityGender Inequality Women’s autonomy andWomen’s autonomy and decision-makingdecision-making authority areauthority are traqditionally limitedtraqditionally limited 45
- 42. IMC Training Highly ValuedIMC Training Highly Valued