Reproductive Health in Crisis Situations

1. Emergency Health and Nutrition Training Reproductive Health in Crisis Situations Moving from Initial Minimum Response to Comprehensive Reproductive Health Programs

2. Learning objectives • Understand the main causes of Maternal Mortality and Morbidity • Describe the rationale for providing reproductive health services to communities affected by emergencies • Understand the key reproductive health interventions in different phases of an emergency • Understand the rationale and components of the Minimum Initial Service Package • Know - how to access resources for Minimal Initial Service Package • Understand the components of Comprehensive Reproductive Health Services in crisis situations • Know - how to conduct assessment for Comprehensive Reproductive Health In Crisis Situation • Know – how to plan for CRHC

3. What is Reproductive Health? ‘RH is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes’ ICPD Cairo 1994; programme of action, para 7.2

4. MATERNAL MORTALITY & MORBIDITY Who, when, why

5. Who • Majority of maternal deaths occur in sub-Saharan Africa and South Asia • The lifetime risk of maternal death in sub-Saharan Africa is 1:16 and South Asia 1:43 as compared to 1:30,000 in Sweden • Afghanistan and Sierra Leone have the highest lifetime risk at 1:6 • Maternal mortality is the ‘largest discrepancy of all public-health statistics’ between developed and developing countries

6. Cont’d • Every year an estimated 500,000 maternal deaths occur • Over 130,000 million couples would like to delay or prevent pregnancy, but are not currently using any form of contraception to help them achieve this goal. • Countries in conflict or some form of instability remain to have the highest maternal mortality rate, and poor reproductive health indicators[1]. • Fewer than 15 percent of births are attended by skilled health personnel in Afghanistan, Chad, Nepal • Less than 5 percent of women use modern contraception in Chad, Democratic Republic of the Congo (DRC), Afghanistan

7. Cont’d • Globally, by December 2006, there were an estimated 9.9 million refugees and 24.5 million persons internally displaced due to conflict[1][2] • Approximately 4% of the population will be pregnant at a given time, and among these an estimated 15% will experience obstetric complications • All pregnancy and delivery need to be considered at-risk, it is difficult to predict or prevent complications: any delivery can become complicated and require emergency intervention • Health care services are usually disrupted during crisis situation • Reproductive health is usually not prioritized in crisis situations (RHRC 2004 report) [1] 2006 Global Trends: Refugees, Asylum-seekers, Returnees, Internally displaced and stateless persons, UNHCR July 2007 [2] Internal Displacement Global Overview of Trends and Developments in 2006, Internal Displacement Monitoring Center

8. When • Majority of maternal deaths are clustered around labor, delivery, and the immediate postpartum period (e.g. Matlab, Bangladesh) • Labor/delivery, and the first day being the highest • There is growing evidence that risk of maternal death exists after the ‘traditional’ 42 days of postpartum

9. Why • Causes of maternal deaths – are categorized as : a) direct causes - due to complication that develops directly as a result of pregnancy, delivery, or the postpartum period e.g. hemorrhage; and b) indirect causes - due to medical conditions that are made worse by pregnancy or delivery e.g. malaria, HIV/AIDs • In sub-Saharan Africa the main causes of maternal mortality are: hemorrhage, hypertensive disorder, and sepsis/infections

10. Main causes of morbidity among women of reproductive age group Source: WHO. Reproductive Health during Conflict and Displacement: A Guide for Program Managers. Geneva: World Health Organization, Department of Reproductive Health and Research, 2000. 4

11. Reproductive Health Response in Crisis Situations

12. Technical components of Reproductive Health Response • Maternal and Newborn Health (Safe motherhood) • Family Planning • Reproductive tract infections • HIV/AIDS • Gender-based violence

13. Phased approach in the establishment of reproductive health service • Minimum Initial Service Package (MISP) In the initial phase of an emergency there are competing needs – shelter, water, sanitation, food. In health, infectious diseases are prioritized – measles vaccination, diarrhea, pneumonia, malaria Thus the recommendation to prioritize and limit the reproductive health interventions to the MISP at the initial phase of any emergency b) Comprehensive Reproductive Health Program (CRH) Needs to start as soon as feasible Needs to be context specific Needs to be informed by a comprehensive needs assessment

14. Minimum Initial Service Package (MISP) What is the MISP? the MISP is a coordinated set of priority activities designed to: prevent excess maternal and neonatal mortality; reduce HIV transmission; prevent and manage the consequences of sexual violence; coordination of reproductive health services; and plan for comprehensive reproductive health services in the early days and weeks of an emergency Is part of the SPHERE minimum standard in disaster response 2004 version Goal of MISP:reduce mortality and morbidity among populations affected by crisis, particularly women and girls.

15. Components of the MISP 1. Prevent maternalandneonatal mortality 2. Prevent HIV/AIDS 3. Prevent and manage the consequences of sexual violence 4. Plan forcomprehensive RH services 5. Coordination: need for an organization or individual to facilitate implementation

16. Preventing Maternaland Neonatal Mortality Activities Provide Clean delivery kits for pregnant women - the six cleans Provide Midwife delivery kits at facility level. Ensure that Neonatal resuscitation kit is part of midwife kit Organize a referral system for Obstetric and neonatal emergencies and Ensure that there is quality emergency obstetrics and neonatal service at the referral center Materials needed Clean delivery kits: RH Kit 2 – 200 clean delivery package, adequate for a population of 10,000 for 3months Materials for basic EmOC RH kit 6,8 BANDA ACEH, 19 January 2005 —Zakira was born on a plastic tarp in an improvised camp for people who lost their homes in the Dec. 26 tsunami. She was born without the use of any medicines, sanitary supplies, even a piece of soap.

17. Reduce the transmission of HIV/AIDS Activities • Enforce respect for Universal Precautions Staff understand and practice universal precautions; clean health facility; reduce unnecessary procedures; use protective barriers (disposable gloves); use disposable syringe and needle (sharp management system); have incinerator and sterilization facilities • Ensure safe blood transfusions Blood transfusions should be done in health facilities where laboratory facilities exist to screen donors for HIV and other infection, to cross-match blood and to manage complications due to blood transfusions • Ensure availability of free condoms • Needle exchange program – in contexts where it is needed • Continuation of ART and PMTCT Materials needed RH Kit 1 – Condom sub-kit RH Kit 12 – Blood transfusion sub-kit

18. Prevent and manage the complications of sexual violence Systems to prevent violence are in place • Women have their own registration card for – shelter/food/supplies distribution • Ensure inclusion of female workers in food distribution, health care • Code of Conduct in place with reporting mechanisms • Ensure compliant reporting system is in place at all service delivery points Health services able to manage cases • Emergency Contraceptives (within 7days) • Post Exposure Prophylaxis (PEP) for HIV/AIDS (72hours) • Hepatitis B vaccination • Presumptive treatment for STIs • Tetanus toxoid and tetanus immunoglobulin

19. Indicators to measure progress • % service sites with adequate supplies for universal precautions • Number of condoms distributed per 1,000 • Number of clean delivery kits distributed per 1,000 pregnant women • Number of facilities that provide basic EmOC services (1:30,000) – (suggested 1:10,000) • Number of facilities that provide comprehensive EmOC services (1:150,000) • Incidence of sexual violence

21. Key maternal & newborn health interventions

22. Baseline Reproductive Health Assessment Facility based assessment & Population based assessment Purpose of assessment: • Provides baseline data to inform program planning and evaluation • The population based assessment methodology and the facility based assessment have been tested in multiple sites by CDC/AMDD/SC • It provides pre-programmed key indicators and data analysis tables • The data can be compared across countries and other conflict-affected populations • It covers broad range of reproductive health issues • The facility based assessment provides – information on primary data collection and reporting systems Slides adapted from CDC

23. Population based survey: CDC tool Kit • Planning checklist • Sampling instructions • Training manual • Questionnaire • Pre-programmed data entry • Analysis guide • Suggestions for data use

24. Background characteristics Safe motherhood Family planning Marriage and live-in partnerships Sexual history Sexually transmitted infections (STIs) HIV/AIDS Gender-based Violence Female genital cutting Emotional health Questionnaire Topics

25. Facility based assessment tool - RAISE • Provides data over 12months period • Covers all signal functions for basic and comprehensive EmoC • Provides data on UN process indicators • Provides data on human resource, and barriers to health service e.g. user fees • Provides information on availability of drugs and medical supplies essential for the provision of comprehensive reproductive health service in crisis situation • Provides information on primary data collection system, and information gaps • Useful to determine if facility (assessed) is EmOC facility

26. Key Maternal Interventions Provision of maternal and newborn service along the continuum • Focused Antenatal Care • Focused ANC – is targeted assessment and individualized provision of care that address the priority health issues affecting a woman, and her fetus • Assumes that while most woman have normal pregnancies, complications can occur at anytime and can not always be predicted • Optimal standard schedule is 4 goal oriented visits at specified times for those pregnant women that are classified for standard care • Each visit: • Promotes health and prevents diseases (TT, IPTp, ITN, de-worming, Iron/Folate) • Early detection and treatment of existing diseases (malaria, UTIs, syphilis testing and treatment, HIV/AIDS) • Early detection and management of complications (pregnancy induced hypertension) • Birth preparedness and complications readiness

27. Con’t 2.Labor and Delivery • Key recommendations: a) Labor surveillance and delivery need to be provided by skilled care b) childbirth should take place in a setting with adequate supplies and drugs, and a setting that has access for emergency referral; c) key interventions include: infection prevention, labor monitoring (partograph), active management of third stage of labor, PMTCT, newborn resuscitation, client satisfaction • The Six cleans: clean hands of the attendant; clean surface; clean blade; clean cord ties; clean towels to dry the baby and wrap the baby; and clean cloth to wrap the mother – ‘ clean delivery kits’ to be provided at third trimester • It is estimated that about 15% of pregnant women would develop obstetric complications, requiring emergency obstetrics care. The signal basic EmOC functions need to be provided at primary health care level, the signal functions include: administer parenteral antibiotics; administer parenteral oxytoxics; administer parenteral anticonvulsants; perform manual removal of placenta; perform removal of retained products e.g. MVA; perform assisted vaginal births e.g. vacuum extraction. Neonatal resuscitation and linkage to ENC should be part of EmOC function

28. Cont’d 3. Postnatal care Postnatal care package includes: • Mother- a) detect and manage complications e.g. bleeding, infection; b) support breastfeeding, care of baby, and recognition of danger signs; c) prevent infection – hygiene, vitamin A, ITNs; d) counseling – family planning • Baby – a) prevent and manage complication for LBW, preterm, b) Immediate and exclusive breastfeeding, c) early detection and care seeking, d) promote hygiene and good skin, eye, cord care; e) skin-to-skin care for LBW and preterm babies

29. Family Planning Access to family planning services, and method choice is limited in emergencies, as soon as the situation stabilizes humanitarian agencies need to offer voluntary family planning information and services Contraceptive methods • Barrier method e.g. condoms • Oral contraceptive pills • Injectable contraceptives • Intrauterine contraceptive methods • Implants • Natural methods (LAM) • Surgical contraception • Emergency contraception Family planning delivery sites • Health facility • Community Distribution Agents

30. References • Reproductive health in refugee situations: an interagency field manual 1998 • Minimum Initial Service Package for Reproductive Health in Crisis Situations: a distance learning module 2007 • Reproductive Health Services for Refugees and Internally Displaced persons: report of an inter-agency global evaluation 2004 • Raising Awareness for Reproductive Health in Complex emergencies: a training manual RHRC • HIV/AIDS prevention and control: a short course for humanitarian workers. RHRC 2004 • Tsunami response MISP evaluation report, women’s Commission • Reproductive health assessment toolkit for conflict-affected women, CDC 2007 • Clinical management of Rape survivors: a guide to the development of protocols for use in refugee and internally displaced persons situations WHO/UNHCR 2004 • Guidelines for Gender-based Violence Interventions in Humanitarian Settings: Focusing on prevention of and response to sexual violence in emergencies . Interagency standing committee task force on gender and Humanitarian assistance, 2005 • Integrated Management of pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. WHO, UNFPA, UNICEF, WB 2003