Bixby Program in Population & Reproductive Health, March 2007

Stephen Tomlin, VP Program Policy & Planning, International Medical Corpsstomlin@imcworldwide.org www.imcworldwide.org

The Challenge of The Challenge of Reproductive Health in Complex EmergenciesReproductive Health in Complex Emergencies

COMPLEX EMERGENCIES:COMPLEX EMERGENCIES: 1985:1985: 5 51992:1992: 17171999:1999: 34342006:2006: 3838

COMPLEX HUMANITARIAN COMPLEX HUMANITARIAN EMERGENCIESEMERGENCIES• Civil conflictCivil conflict• Weak or non-existent Weak or non-existent

central governmentcentral government• Mass population Mass population

movementsmovements

• Massive economic Massive economic dislocationdislocation

• Food insecurity leading Food insecurity leading to famineto famine

Complex Emergency SettingsComplex Emergency Settings

• People in need of People 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

Since 1984…Since 1984…

…providing health care through training / developing local capacity

…supporting health care delivery through logistic management systems

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)

Humanitarian Space ShrinkingHumanitarian Space Shrinking

View from IMC driver’s seat, Darfur, Feb 28 ‘07View from IMC driver’s seat, Darfur, Feb 28 ‘07

Humanitarian Space is ShrinkingHumanitarian Space is Shrinking

1997-20051997-2005• Over 9 year period:Over 9 year period:

major acts of violence major acts of violence against aid workers doubled against aid workers doubled annuallyannually

• 408 acts of major violence408 acts of major violence947 victims947 victims434 fatalities 434 fatalities

• Today, most victims Today, 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 killed78 aid workers wounded78 aid workers wounded52 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% of Sudan accounted for 40% of incidentsincidents

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 with stablishing, and then fiercely defending, relationships with local local actorsactors- Built on trust, transparency, and predictability…as - Built on trust, transparency, and predictability…as perceived by perceived by localslocals- 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 procedures procedures

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 accept armed protection in the course of their workarmed protection in the course of their work

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

clinicsCharitable hospitals

clinicsclinics

For profit hospitals

doctorsdoctorsdoctors

doctors

doctors

Primary Health Care doctors

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

Uganda: Therapeutic & Supplementary Feeding Programs

What is Reproductive Health?What is Reproductive Health?

• RH is a state of complete physical, mental and RH is a state of complete physical, mental and social well-being, and not merely the absence of social well-being, and not merely the absence of disease or infirmity, in all matters relating to the disease or infirmity, in all matters relating to the reproductive system and its functions and reproductive system and its functions and processes.processes.

• RH implies that people are able to have a RH implies that people are able to have a satisfying and safe sex life and that they have satisfying and safe sex life and that they have capability to reproduce and the freedom to capability to reproduce and the freedom to decide, if, when and how often to do so.decide, if, when and how often to do so.

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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 marry The right of men and women to marry

and found a familyand found a family• The right of the family to have special The right of the family to have special

protectionprotection• Special right in relation to motherhood Special right in relation to motherhood

and childhoodand childhood

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

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

Key Components of RH ProgramKey Components of RH Program• Gender-based violence Gender-based violence

prevention and responseprevention and response• Safe motherhoodSafe motherhood• STIs, including HIV/AIDSSTIs, including HIV/AIDS• Family planningFamily planning

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IMC MCH Clinic, Liberia

New Orleans

Iraq – Vulnerable Populations

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

Dis

plac

ed F

amili

es IMC MoDM

IOM inc. KRG IOM

UNHCR

Displacement Trends, IraqDisplacement Trends, Iraq

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 social psychological and social abuseabuse– HumiliationHumiliation

• Harmful traditional Harmful traditional practicespractices– Female genital cutting Female genital cutting

(FGC) (FGC) – Early, forced marriageEarly, forced marriage

Factors Contributing to GBV Factors 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 to Insecure 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

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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 to decrease Community education to decrease stigmastigma

– Justice/legal supportJustice/legal support

• Policy/managementPolicy/management– Train and monitor authorities and Train and monitor authorities and

staff to reduce sexual extortionstaff to reduce sexual extortion

– Ensure proper documentation for Ensure proper documentation for womenwomen

– Increase women protection Increase women protection officersofficers

– Increase visibility of problem and Increase visibility of problem and seriousness of responseseriousness of response

– Document cases, care and other Document cases, care and other responsesresponses

• LegalLegal

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• MedicalMedical– Trauma careTrauma care– Emergency Emergency

contraceptioncontraception– Pregnancy testingPregnancy testing– Voluntary testing for Voluntary testing for

HIVHIV– Voluntary testing and Voluntary testing and

treatment for STIstreatment for STIs– Awareness and Awareness and

sensitivity of staffsensitivity of staff– ConfidentialityConfidentiality– Referral for legal, social Referral 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

Uncomplicated pregnancy, delivery, postpartum period

Complication

Severe Complication

Life Threatening Complication

Well

Recoveredshort and long-term morbidity

possible

Death

Maternal Morbidity and Mortality

Survivednear miss

Complications are UnpredictableComplications are Unpredictable

• At least 15% of pregnant women At least 15% of pregnant women in any population are expected to in any population are expected to have life- threatening have life- threatening complications.complications.

• Cannot predict or prevent Cannot predict or prevent complications: any delivery can complications: any delivery can become complicated and require become complicated and require emergency interventionemergency intervention

• Best practice:Best practice: reduce delays reduce delays through training in recognition through training in recognition danger signs and referral to danger signs and referral to health facilityhealth facility

IMC Trained Midwife, Darfur

Perinatal DeathsPerinatal Deaths

• 28 weeks gestation 28 weeks gestation through 7 days after through 7 days after birthbirth

• 7.6 million perinatal 7.6 million perinatal deaths/yeardeaths/year

4.3 million stillbirths; 4.3 million stillbirths; 3.3 early neonatal 3.3 early neonatal deathsdeaths

• Leading causes of Leading causes of Perinatal DeathPerinatal Death– SyphilisSyphilis– Infection (sepsis)Infection (sepsis)– AsphyxiaAsphyxia– TraumaTrauma– Neonatal tetanusNeonatal tetanus– Complications of preterm Complications of preterm

deliverydelivery

Key Strategies for Preventing Maternal Key Strategies for Preventing Maternal and Perinatal Deathsand Perinatal Deaths

• Prevent unwanted Prevent unwanted pregnancies through family pregnancies through family planningplanning

• Early recognition of Early recognition of complications, with referralcomplications, with referral

• Access to skilled Access to skilled attendants and emergency attendants 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

Antenatal careAntenatal care• Health assessmentHealth assessment• Detection and management of Detection and management of

complicationscomplications• Maintenance of maternal nutritionMaintenance of maternal nutrition• Health educationHealth education• Health promotion interventions Health promotion interventions

such as tetanus toxoid (TT) such as tetanus toxoid (TT) vaccinations, folic acid and ferrous vaccinations, folic acid and ferrous sulfate supplements, malaria sulfate supplements, malaria prophylaxis or presumptive prophylaxis or presumptive treatment, and testing for syphilis, treatment, and testing for syphilis, depending on the contextdepending on the context

TBA Training, Pakistan

Training TBAs in Darfur

Intrapartum/Delivery CareIntrapartum/Delivery Care• 100% of women who 100% of women who

develop a complication develop a complication should be treated by a should be treated by a skilled attendant in an skilled attendant in an emergency obstetric care emergency obstetric care facilityfacility

• Basic emergency obstetric Basic emergency obstetric care (equipped health care (equipped health center)center)

• Comprehensive emergency Comprehensive emergency obstetric care (referral obstetric care (referral hospital)hospital)

• Transport for deliveries Transport for deliveries outside an equipped health outside an equipped health facilityfacility

• Support for breastfeedingSupport for breastfeeding Sudanese mother, Chad

Rabia Balki Hospital for Women, Kabul

Chad

Postpartum CarePostpartum Care• Monitor for danger signs Monitor for danger signs

and referand refer• Postpartum visitPostpartum visit• EducationEducation• Newborn weighing and Newborn weighing and

referralreferral• Support for breastfeedingSupport for breastfeeding• Promoting health of Promoting health of

newborn, including thermal newborn, including thermal protection, eye care, cord protection, eye care, cord care, vaccinationscare, vaccinations

• Postpartum family planningPostpartum family planning

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.

Regional HIV / AIDSRegional HIV / AIDS• WorldwideWorldwide

– 17.7 million17.7 million– 48% Women48% Women

• Sub-Sahara Sub-Sahara AfricaAfrica– 13.3 million13.3 million– 59 % Women59 % Women

• South & South South & South East AsiaEast Asia– 2.2 million2.2 million– 29% Women29% Women

• CaribbeanCaribbean– 120,000120,000– 50% Women50% Women Community Mobilizers, Kibera slum, Nairobi

Kibera slum, population 800,000

Family PlanningFamily Planning

• Saves women’s livesSaves women’s lives– Avoids unsafe abortionAvoids unsafe abortion

– Limits exposure to the health risks of Limits 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 sexual Encourages adoption of safer sexual behaviorbehavior

Effective Programs:

CoordinatedRobust logistic systemsExtensive training & educationDiscrete

Gender InequalityGender Inequality

Women’s autonomy and Women’s autonomy and decision-making decision-making authority are authority are traqditionally limitedtraqditionally limited

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Livelihoods & Micro-Finance

Micro-Finance

IMC Training Highly ValuedIMC Training Highly Valued