Population Reports

1. Population Reports Coping with Crises: How Providers Can Meet Reproductive Health Needs in Crisis Situations Prepared by: Deepa Ramchandran Robert Gardner Series J, Number 53 December 2005

2. Millions Need Care in Crises • Every year natural disasters and conflicts kill and displace millions of people. • Conventionally, humanitarian and relief workers have focused on providing basic emergency services. • Reproductive health care is a serious public health issue in crises that deserves more attention.

3. Overview • Crises Pose Major Challenges for Reproductive Health Care • Range of reproductive health care needed • Providers face unique challenges • International Response • Reproductive Health Care Providers Can Help • Joining the Inter-Agency Working Group • Disaster preparedness • Following guides to crisis care • Building links • Focusing on refugees not in camps • What to do first in a crisis • After the crisis

4. Crises Pose Major Challenges for Reproductive Health Care

5. Range of Reproductive Health Care Needed • Safe motherhood • Protection and response to sexual and gender-based violence • Prevention and treatment of STIs including HIV/AIDS • Family planning • Adolescent reproductive health

6. Safe Motherhood • In crisis situations 15% of pregnant women suffer life-threatening complications of pregnancy and delivery. • Maternal complications are riskier for women in crisis situations. • Better care could prevent most maternal deaths. • Study of Afghan refugees in Pakistan found that, compared with women who died of other causes, those who died of maternal causes faced greater barriers to health care.

7. . Armed conflict leads to widespread sexual and gender-based violence (SGBV). Occurs during all phases of conflicts Most often women and girls, but men and boys also affected. SGBV increases with loss of security, trauma, ethnic tensions and breakdown of society. Domestic violence also increases. East Timor: Half of women reported abuse by intimate partners, both during the crisis and afterwards. Sexual and Gender-based Violence

8. Caring for Survivors: Ask a client about abuse. Providers should be alert to physical injuries, health conditions, and clients’ behavior that indicates trauma. Provide appropriate care. Document the woman’s condition. Support women’s self-esteem. Preventing Violence in Camps: Work with camp management. Work with refugee health care providers. Advocate leadership by women. Work with security forces. Involve the community. Health Care Providers Can Help Reduce Violence

9. HIV/AIDS and Other STIs • Coupled with crisis situations, HIV and other STIs can spread rapidly. • Poverty, powerlessness, food insecurity, and displacement make refugees more vulnerable. • In Liberia, HIV prevalence was estimate at 8%. STI screenings after the war showed 93% of male combatants and 83% of female combatants had at least one STI.

10. Family Planning • Family planning is in as much demand during a crisis as it was beforehand. • Refugees have far less access because services and supplies are disrupted. • Results are unintended pregnancies and rising abortion rates. • Women relying on contraceptive methods may have to discontinue abruptly.

11. Adolescent Reproductive Health • Adolescents, especially girls are at risk of forced sex and sexual coercion in exchange for food, shelter and protection. • Unsafe sex and risk-taking among youth increase in crisis. • In a refugee camp in Kenya, despite availability of free condoms 70% of young men and women had unplanned sex without condoms.

12. Health Care Providers Face Unique Challenges • Crises disrupt services • Crises overwhelm health systems • Crises come on top of existing problems • Conflicts and natural disasters create different problems for providers

13. International Response Improving • Reproductive health care for refugees has improved, but gaps remain. • In the last 20 years the international community has paid increasing attention to the reproductive health needs of refugees. • Relief agencies and local agencies working together can avoid duplication of services and wasting resources.

14. International Relief Agencies Provide Reproductive Health Care • UNHCR • RHRC Consortium • The Inter-Agency Working Group on Reproductive Health in Refugee Situations (IAWG) • UNICEF, UNFPA, and UNRWA • The International Medical Corps (IMC) • Refugees International (RI) • US Government Agencies • ECHO

15. Not Enough Funding • Relief agencies often cannot provide complete reproductive health care for refugees due to lack of funds. • United States and European Union, provide most of the funding. • Since 2000, funding for reproductive health care has declined as donor priorities have shifted.

16. Reproductive Health Care Providers Can Help

17. Join the Inter-Agency Working Group • Inter-Agency Working Group on Reproductive Health in Refugee Situations (IAWG) seeks to improve interagency collaboration and reproductive care for those in crisis situations. • Providers can join IAWG electronic mailing list to receive updates on reproductive health care in crisis. • Providers can join or start a national, district, or local interagency working group that can serve as a focal point to collaborate with relief agencies. • For further information, contact Nadine Cornier at UNHCR <CORNIER@unhcr.ch>

18. Develop Emergency Preparedness Plans • If local communities and NGOs are trained and prepared for disasters, a quicker response can be mounted. • International organizations offer disaster preparedness training courses. • Health Emergencies in Large Populations (H.E.L.P.) course offered by International Committee of the Red Cross (ICRC). • Public Health in Complex Emergencies course offered by International Rescue Committee (IRC). • In addition, numerous training tools specifically address reproductive health in conflict situations.

19. Pay Attention to Logistics • Crisis situations present special logistical challenges. • Any reproductive health program can design and use a basic logistics management information system. • Contraceptive Logistics Guidelines for Refugee Settings (DELIVER) outlines basic principles of logistics management: -calculating contraceptive needs -calculating average monthly consumption -how to store contraceptives.

20. Create a Skills Roster • Providers need to quickly identify people with essential skills. • Many refugees have training in health care, but their skills can be used in a relief effort only if they are known. • Without a skills roster, expertise can go unused. • In Tanzanian camps after the Rwandan genocide, some providers knew how to insert and remove implants, but relief workers did not know about provider skills. Women who needed these services did not have access.

21. Establish a Relationship with the News Media • Governments and humanitarian agencies should have a plan of working with news media. • Media can provide survivors with critical information. • News media are often the first to define an event as an emergency and raise public awareness and concern.

22. Working with the News Media • Find ways to help the media report the news by providing them with accurate facts. • Respect media deadlines. • Always be truthful and factual. • Use language that is clear, concise, and easy to understand.

23. Follow Guides to Crisis Care • The Inter-Agency Field Manual is a key tool. • Use the Minimum Initial Service Package (MISP). • Applies to both conflict and natural disasters. • A series of activities and supplies designed to deal with reproductive health issues in crisis situations. • Intended for the acute phase of a crisis. • Can be implemented immediately without a needs assessment.

24. Build Links • Coordination between relief organizations and local health systems can combine the experience/expertise of relief workers and local health care providers. • Local providers can take the first step and offer their services. • Local agencies may receive funding, supplies, and equipment from UN and other international agencies.

25. Focus on Refugees Not in Camps • International relief organizations and NGOs can work with local reproductive health care providers to offer care for refugees who are not in camps. • Refugees living in host communities often receive less health care. • Health care providers who are able to continue serving their regular clients may be able to incorporate refugees into their services.

26. Approach someone working for a UN organization and ask which organizations and/or individuals are coordinating RH care or the MISP. Offer your services and provide your qualifications. If your clinic/hospital has the skills or equipment to provide any component of the MISP, start immediately. Ask for supplies from relief organizations. Also ask that they include your clinic in distribution of supplies. Go to reproductive health care coordination meetings If there are many displaced people, talk to relief workers organizing shelter, water, latrines and food. If you know how to set up water pumps and latrines let them know. Work with those distributing food rations to make sure women are equally represented. Make sure sanitary supplies as well as clean delivery kits are distributed with food rations. What To Do First in a Crisis

27. After the Crisis: From Disaster to Development • Even after conflicts or natural disasters end, suffering often continues. • People need continued support to help rebuild their lives. • During the transition to post-emergency relief and recovery, humanitarian providers can cooperate with other local providers and coordinate activities that focus on sustainability.

28. Photo Credits • Slide 1:Sandra Krause, Women’s Commission for Refugee Women and Children • Slide 3: EC/ECHO, New Delhi/Alam Aftab • Slide 15: CCP, Courtesy of Photoshare

29. Ordering Information You may order the report in one of four ways: Online at http://www.jhuccp.org/cgi-bin/orders/orderform.cgi; by sending an e-mail to orders@jhuccp.org; by sending a fax to 1-410-659-6266; or by writing to INFO Project Distribution 111 Market Place Suite 310 Baltimore, MD 21202 USA