Therese McGinn

Reproductive health of war-affected populations: what do we know?

In this article available data are reviewed to determine if and how reproductive health status is affected by refugee or displaced status in war-affected populations. Refugees in stable camp settings are the population most often studied. Also evidence on fertility and family planning safe motherhood sexually transmitted diseases and HIV and sexual and gender-based violence is examined. Social and demographic factors such as age socioeconomic status education and urban/rural residence as well as access to services rather than refugee or displaced status in itself appear to influence fertility desires and health behavior with respect to reproductive health concerns. Moreover it is noted that emergency contraception is an important family planning service for refugees including those whose access to regular contraceptive supplies has been disrupted and where women have been raped. Overall all the studies conducted as well as other fertility reviews suggest that no common fertility pattern emerges among refugees.

Reproductive Health: A Right for Refugees and Internally Displaced Persons

Continued political and civil unrest in low-resource countries underscores the ongoing need for specialised reproductive health services for displaced people. Displaced women particularly face high maternal mortality, unmet need for family planning, complications following unsafe abortion, and gender-based violence, as well as sexually transmitted diseases, including HIV. Relief and development agencies and UN bodies have developed technical materials, made positive policy changes specific to crisis settings and are working to provide better reproductive health care. Substantial gaps remain, however. The collaboration within the field of reproductive health in crises is notable, with many agencies working in one or more networks. The five-year RAISE Initiative brings together major UN and NGO agencies from the fields of relief and development, and builds on their experience to support reproductive health service delivery, advocacy, clinical training and research. The readiness to use common guidance documents, develop priorities jointly and share resources has led to smoother operations and less overlap than if each agency worked independently. Trends in the field, including greater focus on internally displaced persons and those living in non-camp settings, as well as refugees in camps, the protracted nature of emergencies, and an increasing need for empirical evidence, will influence future progress. Résumé Les troubles politiques et civils dans les pays à faibles ressources soulignent le besoin de services spécialisés de santé génésique pour les personnes déplacées. Les femmes déplacées souffrent en particulier d’une mortalité maternelle élevée, de besoins insatisfaits de planification familiale, des complications d’avortements non médicalisés et de la violence sexiste, ainsi que d’IST, notamment le VIH. Les institutions d’aide humanitaire et de développement et les Nations Unies ont préparé du matériel technique et introduit des changements politiques positifs dans les environnements de crise et elles s’efforcent d’améliorer les soins de santé génésique. Des manques importants n’en demeurent pas moins. La collaboration pendant les crises est bonne, beaucoup d’institutions travaillant dans un ou plusieurs réseaux. L’initiative quinquennale RAISE rassemble les principales institutions des Nations Unies et ONG spécialisées dans l’aide humanitaire et le développement, et se fonde sur leur expérience pour soutenir la prestation de services, le plaidoyer, la formation clinique et la recherche en santé génésique. Ces organisations ont accepté d’utiliser des directives communes, de définir conjointement les priorités et de partager les ressources, permettant ainsi de mener des opérations plus harmonieuses et de réduire le nombre d’activités qui se chevauchent. Les progrès futurs seront influencés par les tendances dans ce domaine, notamment la priorité accrue accordée aux personnes déplacées à l’intérieur de leur pays et qui vivent hors des camps, en plus des réfugiés des camps, la durée prolongée des urgences et le besoin croissant de données empiriques. Resumen El continuo descontento político y civil en países con pocos recursos recalca la necesidad continua de proporcionar servicios especializados en salud reproductiva para personas desplazadas. Las mujeres desplazadas en particular afrontan una alta tasa de mortalidad materna, necesidad insatisfecha de planificación familiar, complicaciones después del aborto inseguro y violencia basada en género, así como enfermedades de transmisión sexual, incluido el VIH. Las organizaciones de socorro y desarrollo y organismos de la ONU han elaborado materiales técnicos, realizado cambios positivos a las políticas, específicos a los ámbitos de crisis, y están trabajando para proporcionar mejores servicios de salud reproductiva. Sin embargo, aún existen importantes brechas. La colaboración en el campo de la salud reproductiva en crisis es notable, ya que muchos organismos trabajan en una o más redes. La Iniciativa RAISE de cinco años reúne importantes organismos de la ONU y ONG de los campos de socorro y desarrollo, y se basa en su experiencia para apoyar la prestación de servicios de salud reproductiva, actividades de promoción y defensa, capacitación clínica e investigación. La buena disposición para utilizar documentos de orientación en común, determinar prioridades conjuntamente y compartir recursos ha propiciado mejores actividades y menos traslapo que si cada organismo hubiera trabajado independientemente. Futuros avances serán influenciados por las tendencias en el campo, como un mayor enfoque en las personas desplazadas internamente, aquéllas fuera de los campamentos y los refugiados en los campamentos, la prolongada naturaleza de las urgencias y la creciente necesidad de evidencia empírica.

Male Knowledge, Use and Attitudes Regarding Family Planning in Burkina Faso

A knowledge attitudes and Practices survey of 603 men in Ouagadougou the capital of Burkina Faso revealed that 75% of men knew of at least 1 modern contraceptive method if they were prompted with a brief description of the method and 90% recognized at least 1 modern or traditional method. 25% of men could cite at least 1 modern or traditional method without any prompting. Nearly 19% of the men had used a modern method mainly condoms at some time; however condom use appeared to be more closely associated with prostitutes and disease prevention than with birth control. Among nonusers 64% said they might use a modern method in the future. 1 in 4 of the respondents with children stated that they wanted no more and this proportion increased as the number of children increased. The desired family size was surprisingly low at around 4 for those who did not yet have 4 children. 80% of men said they wanted more information about family planning and 76% said they wanted this information for their wives. Of the 124 men who gave reasons for not wanting to use family planning 31% said that is was bad for the health and 12% said that it was against their religion but most cited personal reasons. Although attitudes toward family planning were in general very positive among men who participated in 4 focus groups it was evident that many of them were misinformed about contraception. Many men expressed fears about the safety and permanence of modern methods. In addition some men perceived that contraceptive use by women would threaten their fidelity in marriage. (authors) (summaries in FRE SPA)

Family planning operations research in Africa: reviewing a decade of experience.

Between 1979 and 1990, Columbia University conducted 26 family planning operations research (OR) projects in 13 sub-Saharan African countries. Most of these projects were implemented in settings where family planning service delivery had not yet been initiated or was new and poorly developed. In keeping with program needs in the early stages of development, the majority of the OR projects were based on demonstration or diagnostic designs. Only four of the 23 projects were comparative or quasi-experimental in design. Projects demonstrated the growing demand for family planning, and the feasibility and acceptability of a range of service delivery models. Sixteen of the projects have been sustained or replicated by national or local governments and institutions following the initial OR phase, replication of two others is planned, and another four resulted in policy formulation or improvements in existing national programs. OR in Africa played an important role in generating political and medical support for contraceptive services, and served to improve project management. OR proved more useful in the implementation and strengthening of individual programs than in generating universal lessons regarding service delivery. In order to maximize ORs utility in Africa, simple research designs and methods should be adopted.

Improving refugees’ reproductive health through literacy in Guinea

Abstract Adult literacy programmes, particularly literacy-for-health programmes that integrate health material in their curricula, are gaining momentum as a means to improve womens and childrens health and increase womens empowerment. However, the relationship between literacy skills and these benefits remains unclear. This paper presents results from a study on the Reproductive Health Literacy (RHL) Project among Sierra Leonean and Liberian women in refugee camps in Guinea. Literacy classes met for 2 hours twice per week for 6 months, with content focused on safe motherhood, family planning, STIs/HIV/AIDS and gender-based violence. A closed-ended interview and a written test of literacy skills were administered to 549 former RHL students to understand the programmes effects. Results indicate that participants had a high level of reproductive health knowledge after participation, and reported an increase in literacy skills. Respondents’ current use of modern contraception was 48%, of which 23% reported using a condom at last sex. Findings suggest an increase from reported pre-RHL behaviour. Participants also reported a dramatic increase in ‘boldness’, the phrase used to describe empowerment. While only a third (32%) of respondents considered themselves ‘more bold’ than other women before RHL, a clear majority (82%) so considered themselves after RHL. A comparison of schooled and unschooled women indicates that those who had had previous schooling did better in RHL than their non-schooled colleagues, but both groups had good knowledge retention, positive behaviour levels and felt more bold after RHL participation.

Forced migrants—turning rights into reproductive health

Worldwide more than 35 million people live as forced migrants. These are people displaced from their homes by complex humanitarian emergencies—crises that result from environmental hazards or armed conflict combined with adverse social economic and political influences. Forced migrants may find refuge within the boundaries of their own country (internally displaced persons) or across an international border (refugees). Some of these refugees are granted asylum to resettle in other countries. In this paper we focus on the right of access to reproductive health care for forced migrants and in particular for the majority who live in conflict zones in the developing world. We discuss the extraordinary risks to reproductive health faced by forced migrants and the obligation of humanitarian agencies to respond to reproductive and sexual health needs. (authors)

Barriers to Reproductive Health and Access to Other Medical Services in Situations of Conflict and Migration

People living in situations of conflict and forced migration do not receive the health care they need and want, and to which they have a right. There are many factors contributing to this lack of adequate care. The purpose of this paper is to examine these factors, using reproductive health care as the lens through which barriers to providing and using health care are reviewed.

A Study of Health Facilities: Implications for Reproductive Health and HIV/AIDS Programs in Southern Sudan

In October 2001, a pilot project to design strategies to reduce HIV/AIDS transmission and improve related reproductive health practices was initiated in southern Sudan. A health facility assessment was conducted in order to determine the type and scope of care given to clients with sexually transmitted infections (STIs). It was found that many health care practitioners did not have basic training in STI diagnosis and management, and no practitioner had training in the syndromic approach. Standardized drug kits received by public facilities did not provide enough STI drugs to serve the population. Private drug stores were the only facilities where condoms were available, though condoms were not sold to women who came to purchase them without their husbands. An adequately functioning health system will be difficult to achieve without ongoing training and supervision, adequate supplies and equipment, and proper rebuilding of infrastructure and systems, such as roads, communication, and education.

The 2018 Inter-agency field manual on reproductive health in humanitarian settings: revising the global standards

Abstract Since the 1990s, the Inter-agency field manual on reproductive health in humanitarian settings (IAFM) has provided authoritative guidance on reproductive health service provision during different phases of complex humanitarian emergencies. In 2018, the Inter-Agency Working Group on Reproductive Health in Crises will release a new edition of this global resource. In this article, we describe the collaborative and inter-sectoral revision process and highlight major changes in the 2018 IAFM. Key revisions to the manual include repositioning unintended pregnancy prevention within and explicitly incorporating safe abortion care into the Minimum Initial Service Package (MISP) chapter, which outlines a set of priority activities to be implemented at the outset of a humanitarian crisis; stronger guidance on the transition from the MISP to comprehensive sexual and reproductive health services; and the addition of a logistics chapter. In addition, the IAFM now places greater and more consistent emphasis on human rights principles and obligations, gender-based violence, and the linkages between maternal and newborn health, and incorporates a diverse range of field examples. We conclude this article with an outline of plans for releasing the 2018 IAFM and facilitating uptake by those working in refugee, crisis, conflict, and emergency settings.

Implementing sexual and reproductive health care in humanitarian crises

1770 www.thelancet.com Vol 391 May 5, 2018 one in five women in complex emergencies having suffered sexual violence. Clinical management of rape is a minimum standard in the delivery of humanitarian health services, as set forth in guidance from the InterAgency Standing Committee and WHO. Nevertheless, implementation of this life-saving care remains on an ad-hoc basis, even in settings where ample evidence exists that sexual violence is widespread, such as in the eastern Democratic Republic of the Congo. Further research and innovation relating to health in humanitarian crises are needed; however, research and innovation alone are insufficient to meet the health needs of crisis-affected populations. It is important that humanitarian actors apply existing evidence to reduce preventable mortality and morbidity, and to promote wellbeing. During humanitarian crises, donors, aid agencies, and ministries of health should prioritise and reinforce the application of the highest standard of health care, including for sexual and reproductive health. We already know that these interventions save lives and are feasible in humanitarian settings—now we must systematically use this evidence.