Bixby Program in Population & Reproductive Health, March 2007
Stephen Tomlin, VP Program Policy & Planning, International Medical [email protected] 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 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 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 armed protection in the course of their workaccept armed 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
clinics
clinics
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
pla
ced
Fam
ilies 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 Train and monitor authorities
and staff to reduce sexual and staff to reduce sexual
extortionextortion
– Ensure proper documentation Ensure proper documentation
for womenfor women
– Increase women protection Increase women protection
officersofficers
– Increase visibility of problem Increase visibility of problem
and seriousness of responseand seriousness of response
– Document cases, care and Document cases, care and
other responsesother responses
• 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
Recovered
short and long-term morbidity possible
Death
Maternal Morbidity and Mortality
Survived
near miss
Complications are UnpredictableComplications are Unpredictable
• At least 15% of pregnant At least 15% of pregnant women in any population are women in any population are expected to have life- expected to have life- threatening complications.threatening complications.
• Cannot predict or prevent Cannot predict or prevent complications: any delivery can complications: any delivery can become complicated and become complicated and require emergency interventionrequire emergency 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