Reproductive Health in Refugee Situations

Reproductive Health in refugee situations

an Inter-agency Field Manual Reproductive Health in refugee situations

an Inter-agency Field Manual This Inter-agency Field Manual replaces the above field-test version.

Additional copies of the Field Manual can be obtained from the agencies cited on the back cover.

Any comments can be directed to the following:

World Health Organisation (WHO) Department of Reproductive Health and Research United Nations Fund for Population Activities (UNFPA) Emergency Relief Office, Geneva United Nations High Commissioner for Refugees (UNHCR)

This document is issued for general distribution. All rights are reserved. Reproductions and translations are authorised, except for commercial purposes, provided the source is acknowledged. Reproductive health is a right; and like all other human rights it applies to refugees and persons FOREWORD living in refugee-like conditions. To exercise this right, populations caught up in conflict and living in emergency situations must have an enabling environment and access to complete reproductive health information and services so they can make free and informed choices. They also must feel comfortable and secure in discussing their most private concerns with those who seek to help them. Quality reproductive health services must be based on refugees’, particularly women refugees’, needs. They must also respect refugees’ various religious and ethical values and cultural backgrounds while conforming to universally recognised international human rights standards. There- fore, full information on options, and access to reproductive health services should be provided, leaving the decision to the individual. Reproductive health care covers a wide range of services. These are defined as follows in the Programme of Action of the International Conference on Population and Development (ICPD) held in Cairo, Egypt, in September 1994: family-planning counselling, information, education, communication and services; education and services for prenatal care, safe delivery and post-natal care, and infant and women’s health care; prevention and appropriate treatment of infertility; prevention of abortion and the management of the consequences of abortion; treatment of reproductive tract infections, sexually transmitted diseases, including HIV/AIDS; breast cancer and cancers of the reproductive system, and other reproductive health conditions; and active discouragement of harmful traditional practices, such as female genital mutilation. Providing comprehensive and high-quality reproductive health services requires a multi-sectoral integrated approach. Protection, health, nutrition, education and community service personnel all have a part to play in planning and delivering reproductive health services. The best way to guarantee that reproductive health services meet the needs of the refugee community is to involve the community in every phase of the development of those services: from designing programmes to launching and maintaining them to evaluating their impact. Only then will refugees benefit from services specifically tailored to their needs and demands; and only then will they have a stake in the future of those services. This Inter-agency Field Manual on Reproductive Health in Refugee Situations is the result of a collaborative effort of many UN agencies, governmental and non-governmental organisations and refugees themselves. Information in this Manual is based on the normative, technical guidance of the World Health Organization. A draft of the Field Manual was first issued in 1996 and tested extensively in the field. This new version can, and should, be shaped and adapted to suit the particular circumstances and requirements of each refugee situation as it arises and evolves. We are pleased with the progress already made in meeting the reproductive health needs of refugees and persons living in refugee-like situations; but we also know this is no time to lose momentum. We hope the Field Manual will serve to improve the health and well-being of refugees and foster more responsive and appropriate actions in the field.

Gro Harlem Bruntland Nafis Sadik Sadako Ogata Director General Executive Director High Commissioner WHO UNFPA for Refugees UNHCR At an Inter-agency Symposium on Reproductive Health in Refugee Situations held in Geneva, PREFACE Switzerland in June 1995, more than 50 governments, non-governmental organisations (NGOs) and UN agencies committed themselves to strengthening reproductive health (RH) services to refugees. Following the symposium, an Inter-agency Field Manual on Reproductive Health in Refugee Situations was produced and distributed for field-testing around the world.

This 1999 revision of the Field Manual is the result of two years of field use and comprehensive field-testing conducted under the auspices of the Inter-agency Working Group on Reproductive Health in Refugee Situations. More than 100 experienced staff from 50 agencies working in refugee situations in 17 countries applied the Field Manual in their programmes and provided comments and suggestions for improving the content of the publication.

The Field Manual supports the delivery of quality RH services. Technical standards included in the Field Manual are those set by the World Health Organization. In several important areas, the Field Manual provides programmatic direction with frequent reference to additional resource materials that should be obtained and used to ensure comprehensive and reliable RH services for refugees.

Field managers of health services in refugee situations are the primary audience for the Field Manual. Community-services officers, protection officers and others working to meet the needs of refugee women, young people and men should also benefit from the guidance offered in the Field Manual.

The purposes of the Field Manual are:

§ to serve as a tool to facilitate discussion and decision-making in the planning, implementation, monitoring and evaluation of RH interventions;

§ to guide field staff in introducing and/or strengthening RH interventions in refugee situations, based on refugee needs and demands and with full respect for their beliefs and values; and

§ to advocate for a multi-sectoral approach to meeting the RH needs of refugees and to foster coordination among all partners.

Chapter One lays the foundation for the subsequent technical chapters on reproductive health and provides the guiding principles for undertaking all RH care. It should be read carefully.

The components of reproductive health described in the Field Manual are:

§ Minimum Initial Service Package § Safe Motherhood § Sexual Violence § Sexually Transmitted Diseases, including HIV/AIDS § Family Planning § Other Reproductive Health Concerns § Reproductive Health of Young People ACKNOWLEDGMENTS The entities listed contributed to this Field Action Contre la Faim Manual and are among those who believe African Medical and Research Foundation it will facilitate the delivery of reproductive American Refugee Committee health services in refugee situations. CARE Centre for Research on the Epidemiology of Disasters Centro de Capacitación en Ecología y Salud para Campesinos Center for Population and Family Health – Columbia University’s Mailman School of Public Health Family Health International International Centre for Migration and Health International Federation of the Red Cross and Red Crescent Societies Ipas International Planned Parenthood Federation International Rescue Committee International Organization for Migration JSI Research and Training Institute London School of Hygiene and Tropical Medicine Marie Stopes International Médecins du Monde Médecins sans Frontières The UN, NGO and MERLIN (Medical Emergency Relief Government members of International) the Inter-agency Working Group on Reproductive Population Council Health in Refugee Save the Children Fund UK Situations (IAWG) are United Nations Children’s Fund gratefully acknowledged United Nations High Commissioner for Refugees for their continuous review of this Field United Nations Joint Programme on AIDS Manual. United Nations Fund for Population Activities U.S. Agency for International Development U.S. Centers for Disease Control and Prevention U.S. Department of Health and Human Services U.S. Department of State Women’s Commission for Refugee Women and Children World Association of Girl Guides and Girl Scouts World Health Organization Chapters TABLE OF CONTENTS

1Fundamental Principles 1 2Minimum Initial Service Package (MISP) 11 3Safe Motherhood 19 4Sexual and Gender-based Violence 35

Sexually Transmitted Diseases, 5Including HIV/AIDS 47 6Family Planning 65 7Other Reproductive Health Concerns 79 8Reproductive Health of Young People 89 9Surveillance and Monitoring 95

Appendices a1Information, Education, Communication 119 a2Legal Considerations 127 a3Glossary of Terms 131 a4Reference Addresses 137

Each collaborating agency will implement the interventions described in this Field Manual according to its mandate. Fundamental Principles 1

Reproductive health (RH) care 1CHAPTER ONE should be available in all situations Fundamental Principles and be based on the needs and expressed demands of refugees, Contents: n Timely Reproductive particularly women, with full Health Interventions n The Complexity of respect for the various religious Intervening n Guiding Principles and ethical values and cultural 4 Community Participation backgrounds of the refugees 4 Quality of Care 4 Integrating Services while also conforming 4 Information, Education and Communication with universally recognised 4 Advocacy for Repro- ductive Health international human rights. 4 Coordinating Activities n Needs Assessment n The Structure of the The above principle is the cornerstone of this Field Manual and Field Manual should be the basis of all RH interventions.

Special Notes:

a This Field Manual is intended for use in refugee situations. It may also be of use in refugee-like situations, such as in situations with internally displaced persons or returnee-affected areas. a The term “refugee” is used herein to describe the beneficiaries of RH care, regardless of their legal status. a UNHCR defines an emergency as “any situation in which the life or well-being of refugees will be threatened unless immediate and appropriate action is taken and which demands an extraordinary response and exceptional measures.” 2

Fundamental Principles

§ malnutrition and epidemics, which can Definition of further diminish the physiological re- Reproductive Health serves of pregnant or lactating women, thus endangering their health and that of Reproductive health is a state of complete their child; and physical, mental and social well being and not § merely the absence of disease and infirmity, in an absence of law and order, commonly all matters relating to the reproductive system seen in refugee emergencies, which, to- and to its functions and processes. Reproduc- gether with men’s loss of power and tive health therefore implies that people are status, leads to an increased risk of able to have a satisfying and safe sex life and sexual violence. Violence against refu- that they have the capability to reproduce and gee women, rape, sexual abuse, involun- the freedom to decide if, when and how often tary prostitution, even physical assault to do so. Implicit in this last condition are the during pregnancy have been found to be rights of men and women to be informed and far more widespread than was previously to have access to safe, effective, affordable acknowledged. and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable Some General Facts About women to go safely through pregnancy and Reproductive Health childbirth and provide couples with the best chance of having a healthy infant. a 585,000 women die each year–one every minute–from pregnancy-related International Conference on Population and Development – causes. Ninety-nine per cent of Cairo 1994; Programme of Action, para 7.2 these deaths occur in developing countries.

a Girls aged 15-19 are twice as likely to die from childbirth as women in Timely Reproductive Health their twenties. Those under 15 are five times as likely to die from Interventions childbirth.

Providing adequate food, clean water, shelter, a More than 330 million new cases sanitation and primary health care (PHC) are of sexually transmitted diseases (STDs) occur every year, affecting priority activities in any refugee emergency. 1 of every 20 adolescents. These interventions help combat the major a killers in refugee situations: malnutrition, By the year 2000, up to 40 million diarrhoeal diseases, measles, acute respira- people could be HIV-infected. tory infections (ARI) and malaria (where a 120 million women say they do not prevalent). However, RH care is also crucial want to become pregnant, but are for the physical, mental and social well being not using any method of family of any individual. As an integral part of PHC, planning. RH care is important in overcoming such a 20 million unsafe abortions occur problems as: every year–55,000 each day– resulting in some 80,000 deaths and § complications of pregnancy and delivery, hundreds of thousands of disabilities. which are leading causes of death and Source: WHO–World Health Day–Safe disease among refugee women of child- Motherhood–1998 bearing age; Fundamental Principles 3

Unquestionably, women are most affected by § Loss of income reduces the refugees’ CHAPTER ONE reproductive health problems. For refugee ability to make free choices. 1 women, this burden is further compounded by § Women may become solely responsible the precariousness of their situation. for the welfare of their families. Fulfilling the role of breadwinner often represents a great emotional and physical burden The Complexity of Intervening that is not adequately compensated by appropriate services. It is important that RH interventions are not § Attention is often focused exclusively on only timely but also appropriate and consist- immediate life-saving measures; RH care ent with national laws and development prior- is not considered a priority. (Hence the ities. RH programmes affect highly personal development of this Field Manual and the aspects of life, so programmes must be par- recommendations for the Minimum Initial ticularly sensitive to religious and ethical val- Service Package–MISP–described in ues and cultural backgrounds of the refugee Chapter Two.) population.

It may not always be feasible for one organisation to implement the full range of RH services. Providing comprehensive RH services Guiding Principles for may require cooperation and coordination Intervention among agencies. A successful RH programme requires ad- The complexities of reproductive health were equate and well-trained staff, sufficient fund- discussed at the Fourth World Conference on ing, and effective Women (Beijing 1995). Participants listed the following as some of the reasons why many of § community participation the world’s people do not benefit from repro- § ductive health: quality of care § integration of services “... inadequate levels of knowledge about human sexuality; inappropriate or poor-quality § inclusion of information, education and RH information and services; the prevalence communication (IEC) activities of high-risk sexual behaviour; discriminatory § advocacy for reproductive health social practices; negative attitudes towards § women and girls; and the limited power many coordination among relief agencies. women and girls have over their sexual and These principles are applicable to every reproductive lives.” aspect of RH assistance and to all subsequent chapters of this Field Manual. Platform of Action, paragraph 7.3–Beijing 1995

“Adolescents are particularly vulnerable,” they concluded. Community Participation Refugees face even greater difficulties in ob- Community participation is essential at all taining RH services. Among them: stages to ensure the acceptability, appropri- ateness and sustainability of RH pro- § The breakdown of pre-existing family grammes. It is necessary for empowering support networks means that young men refugees, particularly women, to have greater and women lose their traditional sources control over their lives and over the services of information, assistance and protection. that are provided to them. 4

In an emergency, refugees are extremely vul- attitudes and behaviour for the benefit of all. nerable. It may be easy to overlook their par- Although men may be poorly informed about ticular needs in the urgency of providing serv- RH matters, they are often the decision- ices. Their participation is vital in ensuring that makers. Health providers need to be aware this does not happen, and that the services are of the roles and decision-making process adapted to the users rather than vice versa. In within the family so they can provide serv- each situation it is necessary to identify groups ices effectively and in the best interests of and channels through which participation can the whole family. be fostered. However, it is also important to recognise that the leaders may not be best placed or able to provide the information and Quality of Care support needed to successfully adapt RH services to the population concerned. Participation Quality RH services require that organisations, may be best achieved through the family unit. programmes and providers, § It is only by taking into account the cultural, use appropriate technologies and have economic, ethical, legal, linguistic and religious trained staff, backgrounds of the refugees and host country § respect refugees’ rights to informed population that appropriate services can be of- consent by providing adequate informa- fered to and used by refugees. By actively par- tion and counselling, and ticipating, refugees develop the sense of “own- § ership” over programmes that is essential for ensure accessible services, privacy, sustainability. confidentiality, and continuity of care. These aspects of quality of care are also guid- It is through community participation that es- ing principles of medical ethics in the protec- sential information will be gathered to direct the tion of human rights. planning of services. Such information includes: Appropriate Technologies and Skills § identification of the training needs of care Appropriate technologies must be selected ac- providers; cording to internationally accepted standards. Providers must be adequately trained, § selection of appropriate sites to avoid equipped and supervised. Appropriate sup- stigmatisation of users; plies must be available, clean, and, when nec- § analysis of the appropriate level of essary, sterile. All invasive procedures must privacy and confidentiality required by involve infection prevention, proper use of local customs, cultures or beliefs; drugs, etc. All interventions must be safe– which requires a sufficiently staffed health fa- § decisions on whether primarily female cility, technically competent providers, prop- staff must be used; and erly functioning equipment, adequate supplies, § recognition of birthing preferences. and a responsive logistics system.

A failure to obtain such information may have a negative impact on the use of services, for Access example, if family members are excluded from Primary health care (PHC) services must be a birth when they have an important cultural available within a reasonable distance from all role to play at such times. patients. A referral network, including transpor- tation, to higher-level facilities should be cou- It is important that both men and women be pled to PHC services. Patients’ access to involved in many aspects of the RH pro- services should not be contingent on social or gramme to promote responsible and caring cultural backgrounds nor on age, marital sta- Fundamental Principles 5

tus, parity, number of male children, sexual ori- Respect CHAPTER ONE entation, or partner or parental consent. Patients All health staff should talk with patients politely should not be required to accept one service in and manage patient care in a compassionate order to gain access to another type of service. and non-judgmental fashion. Patients have the right to ask questions and to expect those questions will be answered in a timely, com- Informed Consent plete and understandable manner. Patients A patient has the right to know, before any pro- need to know how to recognise and manage cedure is performed, what the procedure in- common complications of their condition, signs volves as well as its expected benefits, possi- and symptoms indicating the need for addi- ble risks, duration of treatment, and cost to the tional medical attention, and when and how to patient or her/his family. This information must obtain follow-up care. be presented to the patient in a language that s/he can understand.

Informed consent means that the patient not only has choices, but also can make an edu- Integrating Services cated decision among various options. To It is important to distinguish between different make such a decision, the patient must know aspects of integration. Reproductive health her/his condition and have ample opportunity services should be integrated into primary to ask questions and receive answers from a health care. Integration may occur in relation knowledgeable provider. to the place at which services are provided or the personnel who provide those services. Privacy Visual and auditory privacy must be main- The potential to integrate services provided at tained during all phases of patient care–from any particular site will depend on the skills and presentation through diagnosis, testing, treat- resources available. It is unreasonable to expect ment, and counselling. Examination tables the community health worker to provide too wide should face away from doors and windows so a range of services. A health centre will have that a woman will not risk exposure during ex- greater resources and more skilled personnel, amination, particularly during pelvic examina- and so greater integration at one site becomes tion. Windows should be covered, and parti- possible. The referral-level facility must be able tions placed between examination areas. to provide services to meet all needs. Others within the health facility should not be able to overhear the interaction between the Successful integration is dependent on the patient and health provider. quality of communication among the various personnel, at different levels, within the overall Confidentiality service. All personnel must be fully aware of All information regarding the patient, her/his how the system operates, what services are history, treatment, condition, circumstances, provided at each level, and how those who and prognosis is discussed only between the want to use the services can do so. The staff at patient, the provider and supervisors. No staff one level must be able to provide information member should share patient information with about all other levels. Communication must anyone who is not directly involved in the pa- also ensure that when referrals are made be- tient’s care without the patient’s permission. tween levels, adequate information is received Medical records should be stored in a locked about a patient at both ends of the service. In- room or file cabinet to which only providers and formation must travel in both directions and supervisors have access. Medical records must cover both the reasons for a referral and should never leave the clinic unless required the eventual consequences of any action for patient referral to another clinic. taken. 6

Good communication among levels is essen- Advocacy for Reproductive Health tial to deal satisfactorily with issues relating to The active promotion of reproductive health support, supervision and training, all of which should be part of all refugee assistance pro- are essential in maintaining quality. Specific grammes from the outset. A lack of awareness training of personnel may be necessary to of the issues involved in protecting and pro- ensure that the designated services can be moting reproductive health may be found in all provided at each level by appropriately skilled groups involved in a refugee setting, from the personnel. providers of health care to the community they serve. This lack of awareness may become a RH services should be considered neither real barrier to improved reproductive health as optional nor as special projects. They and responsible sexual behaviour. should be integrated in a timely fashion within PHC and community service activi- However, opportunities to promote RH issues ties. Even when the delivery of RH services may be limited. Any advocacy that is under- calls for special arrangements or re- taken must demonstrate understanding of the sources, this cannot justify their postpone- culture, values and belief systems of the local ment or neglect. population. Advocacy that is insensitive or dis- respectful may be counterproductive and prompt rejection, or even reprisals, within the refugee community. Information, Education and Communication (IEC) Reproductive health requires knowledge and Coordinating Activities Among understanding about human sexuality and ap- Relief Agencies propriate, adequate and accessible informa- Coordination is needed among: tion. § sectors (health, community services, It is important to raise the level of knowledge protection), about reproduction and sexuality. Women, § implementing agencies (government, men and adolescents should understand NGOs, UN agencies), and how their bodies work and how they can maintain good reproductive health. Scientifi- § levels of service providers (doctors, cally validated knowledge should be shared midwives, Traditional Birth Attendants to promote free and informed choice and to [TBAs], health assistants). counter misperceptions and harmful prac- To foster this coordination, it is recommended tices. that an individual be identified as RH Coordina- tor in each refugee situation. This person IEC activities are essential for sharing this would assume the responsibility for overall or- knowledge. Such activities range from “one-to- ganisation and supervision of RH activities, as one” conversations between service providers well as the integration of these services within and refugees to highly developed formal cam- other health services. paigns. The issue of sexual violence provides an ex- There are also effective IEC strategies that cellent illustration of the need to coordinate promote community participation and indi- among sectors. To deal with the causes and vidual commitment to changing behaviours. consequences of violence, health professionals must work closely with staff in the protec- IEC essentials can be found in Appendix tion and community services sectors. By doing One. so, staff can develop detailed procedures on Fundamental Principles 7

appropriate care for survivors and strategies to experience to design new RH programmes, CHAPTER ONE prevent the occurrence of sexual violence. assess existing capacity and monitor services. The refugee community should be involved in Coordination among implementing agencies the needs assessment process from the begin- requires that, although each agency has its ning. Refugees should participate in: own expertise and range of qualified staff, there should be a standard approach used by § conceptualising the needs assessment all agencies involved. Even though an agency framework, may not provide a full range of RH services, § site selection for the assessment, coordination with others would ensure that the end product is complementary and compre- § translation/interpretation of tools, hensive RH care. Uncoordinated activities § interviewing fellow refugees, result in inappropriate allocations of scarce § data analysis and interpretation, resources and reduced impact of the project. § feedback to the community, § design or redesign of the RH programme based on the needs assessment findings. Needs Assessment

RH services must be based on the expressed The Structure of the Field needs and demands of refugees. RH needs Manual assessments should be carried out when the emergency situation has stabilised. This Field The principles that have been developed within Manual does not give detailed guidance on this introduction apply to all chapters through- conducting needs assessment, but refers the out the Field Manual. field staff to a set of tools created by the Repro- ductive Health for Refugees (RHR) Consor- Not all components of RH service provision are tium for this purpose. (See Further Reading) appropriate within the initial phases of a refugee situation. This Field Manual is intended to The following RH needs assessment tools assist field staff in implementing such services have been developed by the RHR Consortium: in phases, moving from minimal to comprehensive services as the situation gradually stabi- § Refugee Leader Questions lises. § Group Discussion Questions In recognition of the urgency in dealing with § Survey (for analysis by computer) some RH issues, Chapter Two of this Field § Survey (for analysis by hand) Manual describes in detail the components of a “Minimum Initial Service Package” (MISP). It § Health Facility Questionnaire and is a range of core RH activities to be carried out Checklist from the beginning of the emergency. The These tools assist relief workers in gathering activities outlined within MISP should be con- information to assess attitudes toward RH ducted alongside other initial-phase interven- practices, local medical practices and policies, tions that take place in any newly identified the scope of needed services and the degree refugee or emergency situation. to which current services provide what is needed. A more comprehensive package of RH interventions must then be provided as the situa- The tools, which should be adapted to each tion stabilises. These interventions should situation, are designed to be used by people be integrated into Primary Health Care serv- with field management experience and/or RH ices. 8

The remaining chapters of the Field Manual and the main goal of each are:

CHAPTER 2: MISP OVERALL GOAL: initiate selected RH activities as soon as feasible 2 in an emergency

CHAPTER 3: Safe Motherhood OVERALL GOAL: prevent excess maternal and peri/neonatal 3 mortality and morbidity

CHAPTER 4: Sexual and Gender-based Violence OVERALL GOAL: prevent and manage the consequences of 4 sexual and gender-based violence

CHAPTER 5: Sexually Transmitted Diseases (STDs) including HIV/AIDS 5OVERALL GOAL: prevent and treat STDs, reduce the transmission of HIV infection, and assist in caring for those affected

CHAPTER 6: Family Planning OVERALL GOAL: enable refugees to decide freely the number and 6 spacing of their children

CHAPTER 7: Other RH Concerns OVERALL GOAL: prevent excess maternal morbidity and mortality 7 due to the complications of spontaneous and unsafe abortions and promote the eradication of Female Genital Mutilation.

CHAPTER 8: RH of Young People OVERALL GOAL: promote and support reproductive health of 8 young people

CHAPTER 9: Monitoring and Surveillance OVERALL GOAL: set objectives, measure progress and make 9 programmatic decisions based on evidence Fundamental Principles 9

APPENDIX One: Information, Education, Communication CHAPTER ONE OVERALL GOAL: promote reproductive health of refugee a1 populations based on the refugee population’s needs and desires

APPENDIX Two: Legal Considerations OVERALL GOAL: provide information on reproductive a2 rights

APPENDIX Three: Glossary of Terms a3OVERALL GOAL: define important terms

APPENDIX Four: Reference Addresses OVERALL GOAL: assist the reader in obtaining additional a4 reference documents

Each chapter of the Field Manual begins with an overall goal and provides detailed guidance Further Readings on the elements of the RH component. These “Declaration and Platform for Action”, Fourth elements need to be adapted to each refugee World Conference on Women, Beijing, 1995. situation in close collaboration with host-country authorities. A checklist for establishing the “Medical Ethics and Human Rights: Guiding particular RH component is provided at the end Principles”, Commonwealth Medical Associa- of each chapter. This list can also be used for tion, London, 1997. supervising and monitoring. Further refer- ences can also be found at the end of each “Programme of Action”, International Confer- chapter. ence on Population and Development, Cairo, 1994. This Field Manual does not address a number of other issues related to reproductive health, “Refugee Reproductive Health Needs Assess- either because they are relatively less signifi- ment Field Tools”, Reproductive Health for cant in terms of public health, or because they Refugees Consortium, New York, 1997. may be approached as in normal situations and information on the issue is abundant else- “Refugee Women and Reproductive Health where. This is the case for most needs of post- Care: Reassessing Priorities”, Women’s Com- menopausal women, elective abortion, repro- mission for Refugee Women and Children, ductive tract cancers and infertility. New York, 1994.

“Reproductive Health Services During Conflict and Displacement: Guidelines for the Design and Management of Reproductive Health Pro- grammes” (in preparation), WHO, Geneva, 1998.

Reproductive Health One and Five Day Train- ing Packages, RHR Consortium, New York, 1998. 10 Minimum Initial Service Package 11

This Chapter describes a series of actions 2CHAPTER TWO needed to respond to the reproductive health Minimum Initial (RH) needs of populations in the early phase Service of a refugee situation (which may or may not Package (MISP) be an emergency). The Minimum Initial

Service Package (MISP) can be implemented Contents: n Objectives of the MISP without any new needs assessment since n Components of the MISP 4 Identify an organisa- documented evidence already justifies its use. tion(s) and individual(s) to facilitate the coordination and The MISP is not just kits of implementation of the MISP equipment and supplies; it is a 4 Prevent and Manage the Consequences of set of activities that must be implemented Sexual Violence 4 Reduce HIV in a coordinated manner by appropriately Transmission 4 Prevent excess neonatal and maternal trained staff. morbidity and mortality 4 Plan for the provision of comprehensive RH services, integrated into Primary Health Care, as soon as possible n Broad Terms of Reference for a RH Coordinator/Focal Point n Material Resources n Monitoring and Surveillance

Special Note:

a The reader must refer to the relevant chapters in the Manual to properly implement the MISP. 12

Minimum Initial Service Package (MISP)

The major killers in refugee emergencies–diarrhoea, measles, acute respiratory infections Components of the MISP (ARI), malnutrition and malaria, where prevalent–are well documented. Resources should not be diverted from dealing with these prob- Identify an Organisation(s) and lems. However, there are some aspects of re- Individual(s) to Facilitate the productive health that also must be addressed Coordination and Implementation in this initial phase to reduce mortality and of the MISP morbidity, particularly among women. A qualified and experienced person should be Please remember that the components of identified to coordinate RH activities at the MISP form a minimum requirement. The ex- start of the emergency response. The overall pectation is that the comprehensive services leading agency should be responsible for the as outlined in the rest of this Field Manual will designation of such a person, and the person be provided as soon as the situation allows. appointed should work under the supervision of the overall Health Coordinator.

Objectives of the MISP: RH focal points should be designated within each camp, and within each implementing § IDENTIFY an organisation(s) and agency. These health professionals, experi- individual(s) to facilitate the enced in reproductive health, should be in coordination and implementation of post for a minimum of six months, as it is likely the MISP; to take this long to establish comprehensive § PREVENT and manage the RH services. consequences of sexual violence; § REDUCE HIV transmission by All relief organisations should, in accordance with their mandates, and within the framework 4 enforcing respect for universal precautions against HIV/AIDS of emergency preparedness and response, and train and sensitise their staff on RH issues and 4 guaranteeing the availability of gender awareness. (See Terms of Reference free condoms; for the RH Coordinator at the end of this chapter.) § PREVENT excess neonatal and maternal morbidity and mortality by 4 providing clean delivery kits for use by mothers or birth attend- Prevent and Manage the ants to promote clean home Consequences of Sexual Violence deliveries, 4 providing midwife delivery kits Sexual violence is strongly associated with (UNICEF or equivalent) to situations of forced population movement. facilitate clean and safe In this context, it is vital that all actors in the deliveries at the health facility, and emergency response are aware of this issue and preventive measures are put in place. 4 initiate the establishment of a referral system to manage The UNHCR Guidelines for Prevention and obstetric emergencies; and Response to Sexual Violence against Refugees (1995) should be adhered to in § PLAN for the provision of comprehensive RH services, integrated into the emergency response. Measures for as- Primary Health Care (PHC), as the sisting refugees who have experienced situation permits sexual violence, including rape, must also be established in the early phase of an emergency. Minimum Initial Service Package 13

Women who have experienced sexual vio- Guarantee the Availability of Free Condoms CHAPTER TWO lence should be referred to the health services Availability of condoms should be ensured as soon as possible after the incident. Protec- from the beginning so that they can be pro- tion staff should also be involved in providing vided to anyone who requests them. Sufficient protection and legal support to survivors of supplies should be ordered immediately. (See sexual violence. Annex 3, Chapter Five, Prevention and Care of Sexually Transmitted Diseases including HIV Key actions to be taken during the emergency and AIDS for calculating condom supplies.) to reduce the risk of sexual violence and respond to survivors are: As well as providing condoms on request, field § staff should make sure that refugees are aware design and locate refugee camps, in that condoms are available and where they can consultation with refugees, to enhance be obtained. Condoms should be made avail- physical security able in health facilities especially when treat- § ensure the presence of female protection ing cases of STDs. Other distribution points and health staff and interpreters should be established so that those requesting condoms can obtain them in privacy. § include the issues of sexual violence in the health coordination meetings § ensure refugees are informed of the Prevent Excess Neonatal and availability of services for survivors of Maternal Morbidity and Mortality sexual violence § Provide Clean Delivery Kits for Use by provide a medical response to survivors Mothers or Birth Attendants to Promote of sexual violence, including emergency Clean Home Deliveries contraception, as appropriate A refugee population will include women who § identify individual or groups who may be are in the later stages of pregnancy, and who particularly at risk to sexual violence will therefore deliver within the initial phase. (single female heads-of-households, Simple delivery kits for home use should be unaccompanied minors, etc.) and address made available for women in the late stages of their protection and assistance needs. pregnancy. These are very simple kits that the women, themselves, or traditional birth attend- See Chapter Four for further information on ants (TBAs) can use. They can be made up on elements of prevention and response to site and include: one sheet of plastic, two sexual violence. pieces of string, one clean razor blade and one bar of soap. UNFPA also supplies this kit. Reduce HIV Transmission A formula, based upon the Crude Birth Rate Enforce Respect for Universal Precautions (CBR), is used to calculate the supplies and Against HIV/AIDS services required. With a CBR of three to five per cent per year, there would be some 75-125 Universal precautions against the spread of births in a three-month period in a population of HIV/AIDS within the health care setting must 10,000. From this, a calculation can be made be emphasised during the first meeting of as to how many kits should be ordered. Health Coordinators. Under the pressure of an emergency situation, it is possible that field staff are tempted to take short cuts in proce- Provide Midwife Delivery Kits (UNICEF or dures which can jeopardise the safety of pa- equivalent) to Facilitate Clean and Safe tients and staff. It is essential that universal Deliveries at the Health Facility precautions be respected. (See Chapter Five In the early phase of an emergency, births will for details on universal precautions.) often take place outside the health facility with- 14

out the assistance of trained health personnel. tial phase. If not, the provision of these serv- Approximately 15 per cent of births will involve ices may be delayed unnecessarily. When some complications. Complicated births planning, it is important to include the following should be referred to the health centre. The activities: supplementary unit of the New Emergency Health Kit 98 (NEHK-98) has all the materials § The collection of background information needed to ensure safe and clean normal deliveries. Many obstetric emergencies can be on maternal, infant and child mortality, managed with the equipment, supplies and available HIV/STD prevalence and contra- drugs contained in the NEHK-98. Obstetric ceptive prevalence rates (CPR). This complications that cannot be managed at the information can be obtained from the health centre should be stabilised before trans- refugees’ country of origin from such fer to the referral hospital. sources as WHO, UNFPA, the World Bank and Demographic and Health Survey (DHS). Gathering this information Initiate the Establishment of a Referral could be the responsibility of the System to Manage Obstetric Emergencies Headquarters of implementing agencies Approximately three to seven per cent of deliver- who may have ready access to these ies will require Caesarean section. Additional data. obstetric emergencies may need to be referred to a hospital that is capable of performing com- § The identification of suitable sites for the prehensive essential emergency obstetric care. future delivery of comprehensive RH serv- (Refer to Chapters Three and Seven for informa- ices (as described in the remainder of this tion on pregnancy and delivery complications.) Field Manual). It is important to address As soon as the situation permits, a referral sys- the following factors when selecting suit- tem that manages obstetric complications must able sites: be available for use by the refugee population 4 24 hours a day. Where feasible, a host-country security both at the point of use and referral facility should be used and supported to while moving between home and the meet the needs of refugees. If this is not feasible service delivery point because of distance or the inability of the host- 4 accessibility for all potential users country facility to meet the increased demand, then an appropriate refugee-specific referral fa- 4 privacy and confidentiality during cility should be provided. In either case, it will be consultations necessary to coordinate with host-country authorities concerning the policies, procedures 4 easy access to water and sanitation and practices to be followed within the referral facilities facility. The protocols of the host country should be followed, although some variation may have 4 appropriate space to be negotiated. Be sure there is sufficient transport, qualified staff and materials to cope 4 aseptic conditions with the extra demands. § An assessment of the capacity of staff to undertake comprehensive RH services Plan for the Provision of should be made and plans put in place to Comprehensive RH Services, train/retrain staff. Equipment and supplies Integrated Into Primary for comprehensive RH services should be Health Care, as Soon as Possible ordered. This will allow comprehensive It is essential to plan for the integration of RH services to begin as soon as the situation activities into primary health care during the ini- stabilises. Minimum Initial Service Package 15

CHAPTER TWO Broad Terms of Reference for a RH Coordinator/ Focal Point

Under the auspices of the overall health coordination framework, the RH Coordinator/Focal Point should

a be the focal point for RH services and provide technical advice and assistance on reproductive health to refugees and all organisations working in health and other sectors as needed. a liaise with national and regional authorities of the host country when planning and implementing RH activities in refugee camps and among the surrounding population, where appropriate. a liaise with other sectors (protection, community services, camp management, education, etc.) to ensure a multi-sectoral approach to reproductive health. a create/adapt and introduce standardised strategies for reproductive health which are fully integrated within PHC. a initiate and coordinate various audience-specific training sessions on reproductive health (for audiences such as health workers, community services officers, the refugee population, security personnel, etc.). a introduce standardised protocols for selected areas (such as syndromic case management of STDs, referral of obstetric emergencies, medical response to survivors of sexual violence, counselling and family planning services, etc.). a develop/adapt and introduce simple forms for monitoring RH activities during the emergency phase that can become more comprehensive once the programme is consolidated. a report regularly to the health coordination team.

Material Resources What is in the NEHK-98 to implement the MISP New Emergency Health Kit–98 (NEHK-98) § Materials for universal precautions The revised NEHK-98 (for 10,000 people for for infection control three months) contains the following supplies § Equipment, supplies and drugs for to implement the MISP: deliveries at health centres

§ Equipment, supplies and drugs for some obstetric emergencies

§ Equipment, supplies and drugs for post-rape management 16

A booklet-describing the NEHK-98 and how it can be What is in the UNFPA ordered is available RH Kit from WHO. § For use at primary health care/health centre level: 10,000 population for three months 0 Training and Administration 1 Condoms 2 Clean delivery sets 3 Post-rape management 4 Oral and injectable contraceptives Reproductive Health Kit 5 STD Drugs § A RH Kit for Emergency Situations has been For use at health centre or referral developed by UNFPA, in cooperation with level: 30,000 population for three months others, for use in refugee situations. It comple- 6 Professional midwifery delivery kit ments the NEHK-98 and should be ordered as 7 IUD insertion needed to launch the MISP and support the 8 referral system. The RH Kit is made up of Management of the complications 8 of unsafe abortion 12 sub-kits, which can be ordered separately. 9 Suture of cervical and vaginal Materials and supplies in Subkits 3 and 6 are 8 tears already available in the NEHK-98. To order RH 10 Vacuum extraction sub-kits from UNFPA, contact the UNFPA Country Director in the country of asylum, the § For use at the referral level: UNFPA Emergency Relief Office in Geneva or 150,000 population for three months the UNFPA Procurement Office in New York. 11 A – Referral-Level Surgical 11 (reusable equipment) The RH Kit is targeted for use in the initial 11 B – Referral-Level Surgical acute phase of the emergency. Once the situa- 11 (consumable items and drugs) tion stabilises, procurement of RH materials 12 Transfusion (HIV testing for blood and supplies should be done along with other 11 transfusion) health programme supply and drug ordering.

A booklet describing the RH Kit and how it can be ordered is available from UNFPA. (See Appendix Four for contact addresses.) Minimum Initial Service Package 17

Monitoring and Surveillance CHAPTER TWO

During the early phase of the emergency, a limited amount of data should be collected to assess the implementation of the MISP. Infor- mation on mortality and morbidity by age and sex should be routinely collected during the early phase of an emergency. Refer to Chapter Nine for more information on these indicators.

Consider selecting MISP indicators from the following list.

MISP Indicators

a Incidence of sexual violence: Monitor the number of cases of sexual violence reported to health services, protection and security officers. a Supplies for universal precautions: Monitor the availability of supplies for universal precautions, such as gloves, protective clothing and disposal of sharp objects. a Estimate of condom coverage: Calculate the number of condoms available for distribution to the population. a Estimate of coverage of clean delivery kits: Calculate the number of clean delivery kits available to cover the estimated births in a given period of time. 18

Checklist for the RH MISP

a Collect or estimate basic demographic information

§ Total population § Number of women of reproductive age § Number of men of reproductive age § Crude birth rate § Age-specific mortality rate § Sex-specific mortality rate § Number of pregnant women § Number of lactating women

a Prevent and manage the consequences of sexual and gender-based violence

§ Systems to prevent sexual violence are in place § Health service able to manage cases of sexual violence § Staff trained (retrained) in prevention and response systems for cases of sexual violence

a Prevent HIV transmission

§ Materials in place for adequate practice of universal precautions § Condoms procured and distributed § Health workers trained/retrained in practice of universal precautions

a Prevent excess neonatal and maternal morbidity and mortality

§ Clean delivery kits available and distributed § UNICEF midwife kits (or equivalent) available at the health centre § Staff competency assessed and retraining undertaken § Referral system for obstetric emergencies functioning

a Plan for the provision of comprehensive RH services

§ Basic information collected (mortality, HIV prevalence, CPR) § Sites identified for future delivery of comprehensive RH services

a Identify an organisation(s) and individual(s) to facilitate the MISP

§ Overall RH Coordinator in place and functioning under the health coordination team § RH focal points in camps and implementing agencies in place § Staff trained and sensitised on technical, cultural, ethical, religious and legal aspects of RH and gender awareness § Materials for the implementation of the MISP available and used Safe Motherhood 19

3CHAPTER THREE Safe Motherhood programmes are designed to Safe reduce the high numbers of deaths and illnesses Motherhood resulting from complications of pregnancy and Contents: childbirth. In too many countries, n MISP and Safe Motherhood maternal mortality is a leading cause n Safe Motherhood in Stabilised Situations of death for women of reproductive n Providing antenatal, delivery and postpartum Most maternal deaths result from care to the mother and age. immediate care of the neonate haemorrhage, complications of unsafe abortion, n Support for Breastfeeding n Integrating Services and pregnancy-induced hypertension, sepsis and Information, Education and Communication obstructed labour. Safe Motherhood programmes (IEC) n Human Resource seek to address these direct medical causes and Requirements n Monitoring Service undertake related activities to ensure women Provision have access to comprehensive reproductive Also Included: n Mother-Baby Package health services. Interventions n Checklist for Establishing Safe Motherhood Services n Prototype Home-based Maternal Record n WHO Partograph Causes of Maternal Mortality Globally

a Severe bleeding 25% a Indirect causes 20% a Infection 15% a Unsafe abortions 13% a Eclampsia 12% a Obstructed labour 8% a Other direct causes 8%

WHO: World Health Day–Safe Motherhood–1998 20

Safe Motherhood

In this Field Manual, Safe Motherhood in- ered. Services should be able to deal with cludes antenatal care, delivery care (including obstetric and other medical emergencies. For skilled assistance for delivery with appropriate obstetric emergencies, it is preferable to sup- referral for women with obstetric complica- port host-country services rather than estab- tions) and postnatal care, including care of the lish new and refugee-specific facilities that will baby and breastfeeding support. Sexually not be maintained in the long term. transmitted disease (STD)/HIV/AIDS prevention and management, family planning serv- Approximately 15 per cent of pregnant ices, and other RH concerns should be inte- women will develop complications that re- grated with Safe Motherhood activities and quire essential obstetric care, and up to five are discussed in Chapters Five, Six and per cent of pregnant women will require Seven, respectively. some type of surgery. The following ratios have been found to be successful in many situations:

MISP and Safe Motherhood § one health post/clinic with trained community health workers and tradi- Please refer to Chapter Two for the aspects of tional birth attendants (TBAs) able to Safe Motherhood which must be dealt with in identify problems and refer for every the initial phase of a refugee situation. 5,000 people; The activities within the MISP related to Safe § one equipped health centre providing ba- Motherhood help prevent excess neonatal sic essential obstetric care for every and maternal morbidity and mortality by: 30,000-40,000 people;

§ providing clean delivery kits for use by § one operating theatre and staff, capable mothers or birth attendants to promote of performing 24 hour comprehensive es- clean home deliveries; sential obstetric care, for every 150,000 to 200,000 people. § providing midwife delivery kits (UNICEF or equivalent) to facilitate clean and safe To make sure that the services provided are deliveries at the health facility; and by appropriate and of the highest quality and will § initiating the establishment of a referral be fully used, it is essential to: system to manage obstetric emergencies. § identify skilled care providers involved in The individual appointed as RH Coordinator childbirth (physicians, midwives, experi- should be responsible for all RH services in- enced nurses, trained TBAs); cluding Safe Motherhood, to ensure optimum § integration of all the various aspects of repro- provide refresher training and close ductive health. supervision as indicated; § be aware of and discuss community beliefs and practices and health-seeking Safe Motherhood in Stabilised behaviour related to delivery, such as Situations position for delivery, presence of relatives for support and traditional practices both positive (breastfeeding) and harmful As soon as feasible, comprehensive serv- (female genital mutilation); and ices for antenatal, delivery and postpartum care must be organised. Planning for such § ensure that all refugee women and their services should take into account existing families know where to obtain assistance facilities for the local population. Both refugee for antenatal care and delivery and how and local population needs should be consid- to recognise signs of complications. Safe Motherhood 21

Antenatal care eases, anaemia, diabetes, malaria or an STD, CHAPTER THREE The primary objective of antenatal care is to are less obvious and require more detailed establish contact with the women, and physical examination. Treatment for existing identify and manage current and potential health conditions should be undertaken. risks and problems. This creates the oppor- Syphilis testing is recommended at least once tunity for the woman and her health care pro- during pregnancy, preferably before the third vider to establish a delivery plan based on her trimester. Systematic testing for syphilis in unique needs, resources and circumstances. pregnancy is cost-effective if the prevalence of The delivery plan identifies her intentions syphilis is one per cent or more in the general about where and with whom she intends to population. give birth and contingency plans in the event of complications (transport, place of referral, etc.). Screening for Syphilis in Pregnancy using RPR At least three antenatal visits are recommended, ideally with the first visit early in the Syphilis and other STDs contribute to the pregnancy. This number may vary based on transmission of HIV, maternal morbidity national policies. Appropriate antenatal care and negative pregnancy outcome. In a recent study of 3,591 HIV-negative Malawi should include: women with an active syphilis rate of 3.6 per cent, 21 per cent of perinatal deaths, Assessment of maternal health. This in- 26 per cent of stillbirths, 11 per cent of cludes not only determining the pregnant neonatal deaths and 8 per cent of infant woman’s overall health status, but also identi- deaths were attributable to syphilis. fying factors which may adversely affect preg- Testing for syphilis in pregnancy can be nancy outcome. These factors include: age undertaken at the antenatal clinic by using (younger than 17 or older than 40), grand the RPR (rapid plasma reagin) test. Staff must be trained, but sophisticated multipara, significantly short stature, and laboratory equipment is not needed for obstetric history of any previous complica- routine RPR testing. Periodically, quality tions, including surgery. While this screening control of RPR testing with laboratory may help identify some women who will verification using Treponema Pallidum develop complications, it will not identify all of Haemagglutination test (TPHA) should be them. Thus it is critically important to identify undertaken to ensure accuracy of RPR and manage complications as they arise testing. among all pregnant women. The home-based RPR testing for syphilis in pregnancy has maternal record at the end of the Chapter been successfully undertaken in refugee should be adapted and used to record care camps in Tanzania. Prevalence of syphilis in pregnancy using RPR ranged from 7 to provided to women during pregnancy. 20 per cent.

Female genital mutilation is a particular risk in some countries (see Chapter Seven). Women who have been subjected to this procedure, Observation and recording of clinical data. especially to infibulation, should be identified Height, blood pressure, search for oedemas, during the antenatal period. proteinuria and haemoglobin (if indicated by clinical signs), uterine growth, fetal heart rate Detection and management of complica- and presentation should be recorded. tions. Special emphasis should be placed on identifying the acute complications of unsafe Maintenance of maternal nutrition. The rec- abortions or ante-partum haemorrhages. ommended minimum nutritional requirements Other complications, such as hypertensive dis- for a pregnant woman have been set at 22

2,300 kcal per day of a balanced and culturally laxis (anaemia occurs in about 60 per cent of acceptable diet. Supplementary food may be pregnant women in developing countries); required if the basic food ration available or tetanus toxoid immunisation; Vitamin A sup- distributed to refugees is inadequate. The offer plements; antimalarials (according to country of supplemental food can be a good incentive policies) and antihelminthics (hookworms) in to get women to attend for antenatal care. endemic areas. Iodized oil/salt may be given in Health care providers should be alert to signs areas of moderate or severe IDD and following of iron-deficiency anaemia and iodine defi- national protocols. ciency disorder (IDD).

Health education. The following topics should Delivery Care be part of the educational activity related to antenatal care: This Field Manual does not contain details of how to conduct deliveries. See the Further § choosing the safest place for delivery; Reading list for this information. § clean delivery; Even with the best possible antenatal screening, § the major symptoms of complications any delivery can become a complicated one re- (bleeding, severe abdominal pain, quiring emergency intervention. Therefore, headache); skilled assistance is essential to delivery care. In the absence of midwives or nurses, TBAs § where and when to seek care for (who usually perform home deliveries, often as a complications; source of income) should be trained to identify § exclusive breastfeeding; complications, provide immediate first aid, and § maternal nutrition; know when and where to refer women for additional care. It should also be remembered that: § STD/HIV/AIDS prevention; § the first priority for a delivery is to be safe, § immunisation; and atraumatic and clean; and § family planning. § most maternal deaths are due to a fail- Prevention of major diseases. Preventive ure to get skilled help in time for delivery measures should include: iron folate prophy- complications. It is critical to have a well-coordinated system to identify complications and ensure their man- Vitamin A Supplementation agement with immediate first aid and/or refer- in Pregnancy ral. As a rule, the further away the referral facility, the earlier you intervene. Where Vitamin A Deficiency is endemic among children and maternal diets are low Delays in obtaining help may be at the commu- in Vitamin A, health workers should provide: nity level (in identifying and referring women § a daily supplement not exceeding with difficulties); en route to the referral facility 10,000 IU vitamin A during pregnancy or (inability to get transport, poor road condi- § a weekly supplement not exceeding tions); or on arrival at the referral facility (ab- 25,000 IU Vitamin A after the first sence of staff, lack of drugs or other materials). trimester. These supplements will benefit All three possibilities for delay must be mini- the mother and her developing fetus with mised. little risk of harm to either § after the mother gives birth, she should Midwives and TBAs should also take care of receive 200,000 IU vitamin A. the newborn by: clearing the airway, keeping the baby warm, providing eye and cord care, Safe Motherhood 23

helping mothers begin breastfeeding (and not tions of delivery, such as ante-partum haemor- CHAPTER THREE giving any other foods or liquids to the baby), rhage, eclampsia, prolonged labour, uterine rup- and identifying complications which require re- ture, post-partum haemorrhage, repair of vagi- ferral. Birth weights should also be measured. nal and cervical tears, and retained placenta.

Deliveries outside an equipped health facil- These facilities should therefore be equipped ity. TBAs or family members will often assist with broad spectrum injectable and oral anti- deliveries. Therefore, early identification of biotics (ampicillin, penicillin, doxycycline, midwives or TBAs within the community, their gentamicin, metronidazole), plasma expand- training and supervision on the proper use of ers, anti-convulsants, oxytocics, ergometrine, clean delivery kits (clean place, clean hands, analgesics, magnesium sulphate, suturing proper cord care) and identification and man- kits, “high” sterilisation techniques, gloves, agement of complications (when and where to syringes and needles, delivery equipment, and refer), are essential to prevent excess mater- materials for universal precautions. nal morbidity and mortality. These facilities should also be able to provide Deliveries in equipped health centres. for resuscitation and basic care of the newborn These health facilities, whether temporary or (e.g., management of hypothermia and permanent, should be equipped with the ap- hypoglycemia), including measurement of birth propriate human and material resources to weight. A readily available prophylactic to pre- take care of all but surgical cases. Wherever vent neonatal ophthalmia, ideally tetracycline possible, national health facilities should be eye ointment, should be given to all newborns. used and supported. The following basic essential obstetric care should be provided and Deliveries at referral hospitals. A referral standard protocols used to monitor and man- hospital in which surgical procedures can be age labour. These include: performed may exist in some major refugee § operations. However, very often, severe com- initial assessment, duration, use of a plications will be managed at the nearest major partograph (see Annex 2); health facility of the host country. In this case, § assessment of fetal well being; try to avoid swamping the facility with the de- § episiotomy; mands of the refugee population to the detri- ment of the local people. § special care for women who have undergone genital mutilation (see Timely and appropriate support to the local Chapter Seven); health facility must be given as soon as possible. The agreement and support of the Ministry § use of vacuum extractor; of Health should be secured in order to formal- § management of haemorrhage; ise the integration and coordination of obstetric § management of eclampsia; services between the refugee settlement and the local health facility. § multiple birth; § breech delivery; and The referral hospital should be able to perform safely comprehensive essential obstetric care, § procedures for referral to next level such as Caesarean sections, laparotomy, hys- of care, if necessary. terectomy, repair of cervical and severe (third de- Protocols must be taught to health staff, pub- gree) vaginal tears, care for complications due to licly displayed and made available in all health unsafe abortion, and safe blood transfusion. centres. An appropriate referral system requires refer- Basic essential obstetric care should be per- ral protocols specifying when and where to re- formed at the health-centre level to address, or fer and an adequate record of referred cases. stabilise before referral, the main complica- This implies coordination, communication, 24

confidence and understanding between the and its birth weight measured. Newborns TBAs and their supervisors (usually midwives) should be referred to the under-five clinic to and between the health centre and the hospital start immunisations, growth monitoring and with surgical facilities. An effective referral sys- other well-child services. tem will also have to take into account security, geographical and transport constraints. Community Health Workers (CHW) and TBAs should be trained for appropriate referral of postpartum complications, such as haemor- Essential Obstetric rhage, sepsis, perineal trauma, breastfeeding problems, and newborn complications, such Services as prematurity or failure to thrive, that may require additional surveillance and/or treatment. Basic Essential Obstetric Care § parenteral antibiotics § parenteral oxytocic drugs § parenteral sedatives for eclampsia Integrating Services and IEC § manual removal of placenta § manual removal of retained products In the stabilisation phase, antenatal and postnatal services should be offered in an appropri- Comprehensive Essential Obstetric Care ate environment, in the same location as family § Basic Care PLUS planning, STD services, the “baby clinic” and § surgery any other services related to primary health § anaesthesia care. § safe blood transfusion (HIV testing) Some situations may benefit from a “women’s house” which offers peer support, counselling and health promotion in a non-threatening Postpartum Care environment. This resource is especially im- Since up to 50 per cent of maternal deaths oc- portant for adolescent and new mothers. Such curs after delivery, a midwife or a trained and a place might also provide a suitable venue for supervised TBA should visit all mothers as small-scale income-generating or female lit- soon as possible within the first 24-48 hours eracy activities. after birth. The midwife or TBA should assess the mother’s general condition and recovery Effective dissemination of information is vital if after childbirth and identify any special needs. women are to enjoy access to available serv- This attention is particularly important when ices. The community’s knowledge and atti- the woman is alone as head of the family. tudes regarding medical care during pregnancy and childbirth must be assessed. If The postpartum visit provides an occasion for there is suspicion and fear of medical interven- assessing and discussing issues of cleanliness, tions, such as hospital delivery, Caesarean care of the newborn, breastfeeding and appro- section or blood transfusion, appropriate IEC priate methods and timing of family planning activities may be necessary. New procedures, (see Chapter Six). Health providers should sup- such as screening blood for syphilis, should be port early and exclusive breastfeeding, and dis- preceded by educational activities that explain cuss proper nutrition with the mother. Iron folate and dispel misconceptions about the proce- tablets should be continued and Vitamin A and dures. Health workers should consider inviting iodised oil/salt should be provided when neces- a companion who will be present at the time of sary. delivery to attend antenatal clinics with the pregnant woman. Through TBAs and/or During the postpartum visit, the health and well CHWs, the refugee population, as a whole, being of the newborn should also be assessed should be made aware of the warning signs Safe Motherhood 25

of impending complications in pregnancy CHAPTER THREE and labour and encouraged to plan how to Monitoring Service Provision reach the equipped medical facility, if neces- Services should be continuously reviewed. Ef- sary. Given that men and older family mem- forts should be made to collect reliable infor- bers often make the decisions within the fam- mation on maternal deaths. Every maternal ily, it is particularly important that educational death should be investigated to determine activities target these groups. the cause and action taken and to ensure that the referral system is responding appropriately Human Resource Requirements to obstetric emergencies. Record keeping (adapted to the literacy level A midwife or an experienced nurse is best of record keepers) is essential for appropriate suited to organise and supervise the Safe surveillance. Home-based maternal records Motherhood programme. A midwife can effec- (see Annex 1), kept by the mother, have tively supervise 10 to 15 TBAs for an estimated proven advantages. population of 20,000-30,000. The following is a list of suggested indicators In many societies, TBAs are usually the key for monitoring Safe Motherhood interventions people at the community level who will influ- in refugee situations. Refer to Chapter Nine for ence maternal and newborn care, although further information. their influence and skills may vary from culture to culture. In general, one TBA can look after 2,000 to 3,000 refugees. With a crude birth rate Safe Motherhood Indicators of three per cent per year, this means roughly five to eight deliveries per month per TBA. a Indicators to be collected from the health-facility level With adequate training and supervision, some § experienced TBAs can: Crude birth rate § Neonatal mortality rate § identify complications; § Stillbirth ratio § refer women with delivery complications § Coverage of antenatal care to appropriate medical facilities; § Coverage of syphilis screening § provide care for normal pregnancy § Coverage of trained delivery through labour, delivery and the services postpartum period; and § Coverage of postpartum care § Incidence of obstetric § offer family planning information and complications services. a Indicators collected at the TBAs, however, are no substitute for a more community level skilled attendant at birth. The knowledge of the community regarding safe motherhood Bear in mind that female health care provid- interventions should be assessed ers are usually preferred to attend births. periodically. Training and supervision of health workers in a Indicators concerning Safe Motherhood practices should be evaluated training and quality of care and planned in coordination with the community Supervisors should periodically (both refugee and host), NGOs and UN agen- assess the skills of health care cies. The nature of the training will vary depend- providers to ensure quality of care ing on the services the health worker provides of Safe Motherhood interventions. and the skills required for those services. 26

Support for Breastfeeding

Breastfeeding is particularly important in emergency situations because of the increased risk of diarrhoea and other infections, and because the warmth and care which breastfeeding provides is crucial to both mothers and children. In these situations, it may be the only sustainable source of food for infants and young children. The well-known risks associated with bottle feeding and breast milk substitutes are dramatically increased due to poor hygiene, crowding and limited water and fuel. Since breastfeeding is also an important traditional activity for women, it can help uprooted women preserve a sense of their self-worth. For information on HIV and breastfeeding, refer to Chapter Five.

Optimal Feeding Practices in Emergencies

§ Initiate breastfeeding within one hour of birth. § Promote colostrum as a health benefit to newborns, while being sensitive to commonly held beliefs to the contrary. § Implement the “Ten steps to successful breastfeeding” (1989 Joint WHO/UNICEF statement, protecting, promoting and supporting breastfeeding). § Encourage frequent, on-demand feeding (including night feeds). § Promote exclusive breastfeeding. On-demand breastfeeding during the first six months provides 98 per cent contraceptive protection, provided menses has not returned, and no other food is given to the baby. § Surrogate feeding/wet nursing is an alternative for an orphaned child or if the mother is disabled or absent. § Supplement breast milk with appropriate weaning foods starting at six months of age. § Encourage breastfeeding well into the second year of life or beyond. § HIV-positive mothers may need special support and counselling–see Chapter Five. § During a child’s illness, breastfeeding frequency should be increased, as it should after a child’s illness so the child can catch up on its growth. § 2,500 kcal per person per day of culturally appropriate food is recommended as a minimum requirement for lactating women. The distribution of supplementary food to lactating women may be necessary when the diet available to the refugee population is inadequate.

Counteracting Common Misconceptions about Breastfeeding in Emergencies

MYTH: Women under stress cannot breastfeed. a TRUTH: Women under stress CAN successfully breastfeed. Milk production is stable; but milk release (let down) can be affected by stress. The treatment for poor milk release and for low production is increased suckling and social support. The most effective support for a breastfeeding woman comes from other breastfeeding women.

MYTH: Malnourished women don’t produce enough milk. a TRUTH: Malnourished women DO produce enough milk. It is extremely important to distinguish between true cases of insufficient milk production (very rare) and mis- Safe Motherhood 27

CHAPTER THREE taken perceptions. Milk production remains relatively unaffected in quantity and quality except in extremely malnourished women. Malnourished women and children are best served by feeding the mother and letting her breastfeed the infant. By doing so, you protect the health of both mother and child. Giving supplements to infants decreases suckling and so can reduce milk production. The treatment for insufficient milk production–real or perceived–is to increase suckling frequency and duration, ensure the mother has sufficient food and liquids, and offer reassurance from other breastfeeding women.

MYTH: Breast milk substitutes are needed during an emergency. a TRUTH: Usually, breast milk substitutes are NOT appropriate. There are good guidelines on the use of breast milk substitutes and other milk products in emergencies. They include the WHO International Code of Marketing of Breast Milk Substitutes (May 1981), the UNHCR guidelines on the use of milk substitutes (July 1989), and the World Health Assembly resolution 47.5 (May 1994). Under the Code, donors must ensure that any child who receives a breast milk substitute is guaranteed a full, cost-free supply for at least six months. These guidelines include stipulations that breast milk substitutes are: § not used as a sales inducement; § used only for a limited target group of babies (i.e., for orphans in instances where wet nurses are not available); § used under controlled conditions (i.e., for therapeutic feeding; never in general distribution); and § accompanied by additional health care, diarrhoea treatment, water and fuel. In addition, the guidelines assert that feeding bottles and teats should not be provided by relief agencies except under strict supervision; and their use should otherwise be discouraged. These guidelines should be disseminated and followed by all agencies working in emergencies.

MYTH: General promotion of breastfeeding is enough. a TRUTH: Breastfeeding women NEED assistance; general promotion of breast-feeding is NOT enough. Most health practitioners have little knowledge of breastfeeding and lactation management. Women who are displaced or are in emergency situations are at increased risk of breastfeeding problems. They need help, not just motivational messages. Health workers may need to be trained to give practical help to women who have difficulty breastfeeding because of incorrect positioning, cracked nipples or engorgement (see Further Reading). A mother’s fear that she “may not have enough milk” is often a cause of early termination of breastfeeding. This (mis)perception may be intensified by the stress of an emergency situation. Health workers should encourage optimal breastfeeding behaviours, even if they require selective feeding of lactating women. Policies and services which undermine optimal feeding, such as giving food supplements to infants under six months and using bottles for Oral Rehydration Salts (ORS) delivery, should be avoided. 28

Checklist for Safe Motherhood Services

a In Emergency Phase: § Provision of delivery kits: UNICEF midwifery kits for health centres and clean delivery kits for home use § Identification of referral system for obstetric emergencies 4 One health centre for every 30,000-40,000 people 4 One operating theatre and staff for every 150,000 to 200,000 people 4 Skilled health care providers trained and functioning (one midwife for 20,000-30,000 people, one CHW/TBA for 2,000-3,000 people) 4 Community beliefs and practices relating to delivery are known 4 Refugee women are aware of service availability

a Antenatal Services are in place: § Record systems in place (clinic and home-based maternal records) § Maternal health assessment routinely conducted § Complications detected and managed § Clinical signs observed and recorded § Maternal nutrition maintained § Syphilis screening in pregnancy undertaken routinely § Educational activity related to antenatal care provision in place § Preventive medication given during antenatal services: iron folate for anaemia, Vitamin A, tetanus toxoid, others as indicated (malaria) § STD prevention and management undertaken § Materials available to implement antenatal care services

a Delivery services are in place: § Protocols for managing and referring complications in place and transport system functioning § Training and supervision of TBAs and midwives undertaken § Complications are detected and managed appropriately § Awareness of warning signs of complications in pregnancy is widespread § Standard protocols are used to manage deliveries § Medical facilities are adequately equipped § Breastfeeding is supported

a Postpartum services are in place: § Educational activities undertaken (especially family planning and breastfeeding) § Complications managed appropriately § Iron folate and Vitamin A provided § Newborn weighed and referred for under-five services (e.g., EPI, growth monitoring) Safe Motherhood 29 yes yes yes yes yes yes yes yes yes 5 or more 145 cm less than no no no no no no no no no 145 cm more than 12340 18-35 below 17 above 35

CHAPTER THREE *Source WHO, reproduced by permission.

Abnormal deliveries: Labour lasting more than 24 hours: Low birth weight (less than 2500 g): Age: Excess vaginal bleeding after delivery: Death of child during first week: Name Address Date of first visit Abortions: Oedema: Fits: Stillbirths: Height: Number of deliveries: Other health problems: (1) Mother’s health record Previous History

Chloroquine tablets Chloroquine

Further Readings

“Emergency Contraception: A Guide for Service Delivery”, WHO, Geneva, 1998.

“Emergency Contraception Pills: A Resource Packet for Health Care Providers and Programme Managers”, Consortium for Emergency Contraception, New York, 1997.

Heise, Lori L. “Violence Against Women: The Hidden Health Burden”, World Bank Discus- sion Papers, No. 255, The World Bank, Washington, DC, 1994.

“How To Guide: Community-based Response to Sexual Violence: Crisis Intervention Teams - Ngara, Tanzania”, UNHCR, Geneva, 1997.

“How To Guide: Developing a Team Ap- proach to Prevention and Response to Sexual Violence - Kigoma, Tanzania”, UNHCR, Geneva, 1998.

“Mental Health for Refugees”, WHO/UNHCR, Geneva, 1994.

“Security Guidelines for Women”, United Nations Security Coordination Office, United Nations, New York, 1995.

“Sexual Violence against Refugees: Guide- lines on Prevention and Response”, UNHCR, Geneva, 1995. Sexually Transmitted Diseases, Including HIV/AIDS 47

5CHAPTER FIVE The objectives of any activity in the area of sexually transmitted Sexually Transmitted diseases (STDs), including Human Diseases, Immunodeficiency Virus (HIV) and Including Acquired Immune Deficiency Syndrome HIV/AIDS (AIDS), should be to prevent and treat Contents: STDs, reduce the transmission n Introduction n Establishing STD/HIV/ of HIV/STD infections, and help AIDS Programmes care for those affected by AIDS. n Monitoring Also Included: n HIV Testing in Refugee Situations n Mother-to-Child Trans- mission and HIV and Infant Feeding n Formula for Calculating Condom Requirements n STD Treatment Based on Syndromic Case- Management Approach n Flow Chart on Suspected Symptomatic HIV Infections n Essential Drugs for Management of Opportunistic Infections for HIV/AIDS n Alternative Drugs for Treatment of STDs Based on Sensitivity Studies n Estimating Drug Requirements and Costs for Treatment of STDs 48

Sexually Transmitted Diseases, Including HIV/AIDS

Introduction infants acquire their HIV infection from their mothers during pregnancy, delivery or during STDs, including HIV/AIDS, spread fastest breastfeeding. When there is no intervention, where there is poverty, powerlessness and the risk of MTCT ranges from 15 to 25 per social instability. The disintegration of com- cent in industrialised countries and from 25 to munity and family life in refugee situations 45 per cent in developing countries. Trans- leads to the break-up of stable relationships mission is affected by a number of factors, not and the disruption of social norms governing all of which have been fully examined. These sexual behaviour. Women and children are factors include: frequently coerced into having sex to obtain § high viral-load level in the basic needs, such as shelter, security, food and money. In a refugee situation, popu- mother’s blood, lations that have different rates of HIV/AIDS § in cervio-vaginal secretions and, in prior to becoming refugees may be mixed. breast milk, decreased maternal Also many refugee situations are like large immune status, urban settings and may create conditions that § prolonged rupture of membranes increase the risk of HIV transmission. (greater than four hours), STDs, which are a major public health prob- § the mode of delivery, and lem in most parts of the world, were largely § neglected until the appearance of HIV/AIDS. intra-partum haemorrhage. Now, more attention is focused on conven- tional STDs (such as gonorrhoea, syphilis, Studies show an additional 7 to 22 per cent chlamydia, etc.). They are among the most risk of HIV transmission through breast- common, although undiagnosed, causes of ill- feeding. Late postnatal transmission after six ness in the world; and they have far-reaching months of age has been described in a health, social and economic consequences. number of studies. (See Annex 2 on MTCT STDs substantially increase the risk of HIV in- and HIV and Infant Feeding.) fection. Preventing and controlling STDs are key strategies in controlling the spread of HIV/ Interaction between refugee and local AIDS. populations is likely to occur. It is therefore vital to liaise with host countries to ensure The vast majority of HIV infections are sexu- that comparable services are provided to lo- ally transmitted. Between five and ten per cal populations. Failure to do so would not cent of HIV infections world-wide are esti- only be counterproductive in the effort to pre- mated to be transmitted through infected vent the spread of STDs and HIV, it could blood and blood products, though this per- also result in conflict between the two centage is decreasing as blood for transfu- populations. sions is more regularly tested for HIV. In refugee situations, it is essential to ensure that all Mandatory HIV testing of refugees is some- blood for transfusion is tested and that uni- times requested in the mistaken belief that versal precautions are enforced. this will help prevent HIV transmission. Under no circumstances should mandatory testing Mother-to-child transmission of HIV (MTCT), be pursued. Mandatory testing for HIV repre- also called “vertical transmission”, is the most sents a violation of human rights and has no common mode of HIV transmission in chil- public health justification. (See Annex 1 on dren. More than 90 per cent of HIV-infected HIV testing in refugee situations.) Sexually Transmitted Diseases, Including HIV/AIDS 49

Establishing STD/HIV/AIDS It will also be necessary to: CHAPTER FIVE Programmes § liaise with local health authorities to define a management protocol for STDs; As described in Chapter Two (Minimum Initial and Service Package [MISP]), three activities should § identify people in the refugee community be conducted prior to any assessment in any who have been trained in HIV/STD new refugee situation (including an emergency): prevention. § Guarantee availability of free condoms § Enforce universal precautions against Implementation HIV/AIDS transmission in health-care The situation analysis will indicate what STD settings and HIV/AIDS interventions are required and what is feasible. The following should be § Identify a person who will coordinate RH included as basic elements of response to activities. every refugee situation: universal precautions Comprehensive prevention, treatment and in health-care settings, safe blood transfusion, care services for STDs, including HIV/AIDS, access to condoms, access to STD care, infor- should be made available to refugees at the mation, education and communication (IEC) earliest opportunity. By taking the following activities, and comprehensive care for people steps, you will ensure that the services you with HIV/AIDS. provide are effective. Universal Precautions in Health-Care Settings Assessment Universal precautions are part of the MISP (Chapter Two) and are essential to prevent the Conduct a situation analysis as soon as possi- transmission of HIV from patient to patient, ble to help plan an appropriate and compre- health worker to patient and patient to health hensive prevention and treatment service. worker. Because people working under pres- The following information should be collected: sure are more likely to have work-related accidents and to cut corners in sterilisation tech- § the prevalence of STDs and HIV in the niques, infection-control measures adopted host and home country, region or area during crises must be practical to implement (this information is available from the and enforce. national AIDS programmes, UNAIDS and WHO); The guiding principle for the control of infection § by HIV and other diseases which may be trans- the location of specific risk areas within the mitted through blood, blood products and body refugee community (for example, where fluids is that all should be assumed to be po- sexual services are bought and sold, high tentially infectious. alcohol-consumption areas, bars), to be targeted as priorities for specific activities; and The minimum requirements for infection con- § the cultural and religious beliefs, attitudes, trol are as follows: and practices concerning sexuality, repro- § Facilities for frequent hand washing. ductive health, STDs and AIDS. This infor- Hands should be washed with soap and mation can be obtained through qualita- water, especially after contact with body tive research using focus groups, inter- fluids or wounds. views and, if possible, KABP (Knowledge, Attitudes, Behaviour and Practices) sur- § Availability of gloves for all procedures veys. involving contact with blood or other po- 50

tentially infected body fluids. Gloves § Treating injuries at work. In cases of should be discarded after each patient, or injury with a sharp instrument, the wound else washed or sterilised before re-use. should be washed thoroughly with soap Heavy-duty gloves should be worn when and water. Splashes of blood or other materials and sharp objects are taken for body fluid into the mouth or eyes should disposal. be rinsed thoroughly with water or saline respectively. Further procedures to be § Availability of protective clothing, such followed after an accidental exposure to as waterproof gowns or aprons. Masks blood have been developed by Médecins and eye shields should be worn where Sans Frontières (MSF). Prophylactic treat- there is a possibility of exposure to large ment against HIV transmission, known as amounts of blood. Post Exposure Therapy (PET), may be § Safe handling of sharp objects. Punc- warranted. ture-resistant containers for sharps disposal must be readily available, close at Guidelines containing information about poten- hand and out of the reach of children. tial risks in the environment, how to protect Sharp objects should never be thrown into against those risks, and what to do in case of ordinary waste bins or bags. accidents such as needle-stick injuries, cuts or blood splattering should be developed and dis- § Disposal of waste materials. People, tributed to field workers. It is equally important particularly small children, struggling to to provide clear information about what does survive will scavenge. It is therefore vital not constitute a risk. The guidelines should to make waste disposal safe. All medical indicate when it is appropriate to use protective waste materials should be burnt. Those clothing and why. Health workers should also items that still pose a threat, such as be given guidance on how to avoid unneces- sharp objects, should be buried in a deep sary injections and other procedures involving pit at least 10 metres from a water source. sharp instruments. Medical waste should not be disposed of in communal dumps. Access to Condoms § Cleaning, disinfecting and sterilising. If consistently and correctly used, condoms Pressure-steam sterilisers are recom- offer effective protection against STDs, includ- mended for cleaning medical instruments ing the sexual transmission of HIV. Since many between use on different patients. If sterili- refugees have already been exposed to this sation is not available, or for instruments message, there may be a demand for con- that are heat sensitive, instruments must doms in the early phases of a refugee situa- be cleaned and high-level disinfected tion. Condoms are contained in the MISP (See (HLD). HIV can be inactivated by boiling Chapter Two) and should be made freely avail- for 20 minutes or by soaking in chemical able for those who seek them. Take every op- solutions including a five per cent solution portunity to raise awareness and promote con- of chlorine bleach for 20 minutes or in a doms as a method of protection against STDs, two per cent glutaraldehyde solution for including HIV infection. The female condom is 20 minutes. not yet widely known; but, if available, it should § Proper handling of corpses. It is advis- be used as an additional method of protection. able for relief workers to wear gloves and cover any wounds on hands or arms when Procurement of good-quality condoms: handling corpses. The relief worker There are many brands of condoms on the should wash thoroughly with soap and market. If an agency does not have experience water afterwards. Special caution should in procuring condoms, it may be desirable to be taken with body fluids as they may be contact UNAIDS, UNFPA, UNHCR or WHO to potentially infectious. facilitate the purchase of bulk quantities of Sexually Transmitted Diseases, Including HIV/AIDS 51

good-quality condoms at low cost. Annex 3 fusion can be organised within the refugee set- CHAPTER FIVE shows how to calculate the number of con- tlement in major operations or should be doms required. Good-quality condoms are es- arranged with local health facilities following sential for the protection of the consumer and appropriate discussions with the Ministry of the credibility of the relief programme. Health. Should local health facilities be used, support to these structures must be assured by Condom distribution: To ensure ongoing the refugee programme. access in refugee situations, a system of distribution must be in place. The system should The likehood of becoming infected with HIV include the following: through transfusion of infected blood is well over 90 per cent. Measures to ensure the § Condoms and instructions for their use safety of blood transfusion in refugee situa- should be available on request in health tions are extremely important. facilities (especially where STDs are treated) and distribution centres (such as The main recommendations for preventing HIV food and non-food item distribution infection and other blood-borne diseases areas). Staff should be trained in the pro- through blood transfusion are to: motion, distribution and use of condoms. § Transfuse only previously tested blood § Promotional campaigns should be and only when clinically necessary. launched at football matches, mass ral- § Use blood substitutes, such as simple lies, dance parties, theatres, group dis- crystalloid (physiological saline solution cussions, etc., to promote the use of con- for intravenous administration) and col- doms and inform the public on how and loids whenever possible. where to obtain them. § Collect blood from donors identified as § Contacts between the refugee and local being least likely to transmit infectious populations are likely to occur. Therefore, agents in their blood. Selection of safe do- condoms must also be made available to nors can be promoted by giving clear in- the wider host community. This requires formation to potential donors on when it is liaison with groups involved in AIDS pre- appropriate or inappropriate to give blood vention and family-planning activities in and by using a blood-donor questionnaire. the area. Voluntary, non-remunerated blood donors § Once the situation has stabilised, health are safer sources than paid donors. Per- workers must decide whether or not to sonal information given by the donor must continue free distribution of condoms. The be treated as strictly confidential. introduction of some form of partial cost- § Provide reagents to perform HIV testing of recovery (social marketing) may be con- donated blood. Screening for HIV and sidered in situations where this is feasible other infectious agents should be carried and appropriate. When possible, the con- out using the most appropriate assays. dom-distribution network can be extended to community agents, shops, bars, youth § Develop clear policies and protocols/ and women’s groups, etc. Social market- guidelines concerning the appropriate use ing strategies in the host country or in the of blood for transfusion, the recruitment country of origin could be extended into and care of donors and the safe disposal the refugee situation. of waste products, such as blood bags, needles and syringes. Safe Blood Transfusion Blood transfusions must not be done if the fa- § Appoint an experienced person to be re- cilities for safe transfusion, including screening sponsible for refugee-specific blood trans- for HIV testing, do not exist. Safe blood transfusion services. 52

Access to STD Care § effective treatment based on observed Because the risk of HIV transmission is greatly syndromes increased in the presence of other STDs, early § importance of confidentiality establishment and integration of STD services within general health care services is a priority. § education for prevention/counselling STDs and their complications, such as infertil- focused on specific population groups ity and congenital syphilis, are a major cause § condom promotion and provision of ill health and are usually grossly under-reported. The prevention of STDs involves the § partner notification and management promotion of safer sex as well as early and ef- § monitoring fective case finding, advise on notification of partners and case management. STD Case Management. Treatment of symptomatic cases should be standardised STD services should be user-friendly, private on the basis of syndromes and not depend- and confidential. Special arrangements may ent on laboratory analysis. A treatment pro- be necessary to ensure that women and young tocol (consistent with national protocols) people feel comfortable using these services. based on syndromic case management In many societies, women will not seek treat- should be prepared and adopted. (See ment if the health professionals at the clinic are examples in Annexes 4 and 5.) The most ef- all male, particularly if a physical examination fective drugs should be used at the first en- is required. In these situations, female health counter. workers should provide services for women. Initial drug requirements should be based on Appropriate and effective case management available data from the country of origin or esti- involves the following: mated as indicated in Annex 8. Monitoring ac- § training health care providers tivities will then serve to review real needs. If § IEC efforts are effective, if services are user- providing guidelines for case manage- friendly and people from outside the camp are ment, including case definition and attending the health facilities, the need for management protocol drugs may increase rapidly. § consistent availability of appropriate drugs § Partners of patients with an STD are likely to consistent supply of condoms be infected themselves and should be treated. § monitoring Each patient should be provided with contact § slip(s) to be given to his/her sexual partner(s). identifying secondary or informal On the basis of these slips, partners should providers of STD care have access to the same treatment as the patient who presented first. The process should Training health care providers. Health care be confidential, voluntary and non-coercive providers, including volunteer workers, should and include all sexual partners of each STD receive training in prevention of STD/HIV/ patient. AIDS, be provided with information materials and serve as channels for the distribution of Applying a syndromic approach to STD case condoms. Professional health workers should management allows effective care for symp- be trained in the syndromic approach to STD tomatic cases without the need for laboratory management. support. The exception to this is systematic Health worker training should include the testing for syphilis in pregnant women. This following topics: type of testing is cost effective even in sites where the prevalence of syphillis in the gen- § syndrome recognition and diagnosis eral population is as low as one per cent. Sexually Transmitted Diseases, Including HIV/AIDS 53

Information, Education and § sensitising health workers to HIV-related CHAPTER FIVE Communication (IEC) illnesses and AIDS; Information, education and communication § developing a policy on the role of volun- activities are central to a successful HIV/ tary and confidential HIV tests (with AIDS and STD strategy in all situations. IEC related pre- and post-test counselling) for includes a variety of activities at different lev- clinical diagnosis (see Annex 1). If host els, from intensive person-to-person educa- countries offer voluntary counselling and tion to mass dissemination of information. testing services to the local population, ini- (For further information on IEC, refer to Ap- tiate discussions to determine the possi- pendix One.) bility of extending these services to refugee populations;

Comprehensive Care for People § adapting existing clinical and nursing with HIV/AIDS guidelines for case management of HIV- Comprehensive care for people with HIV-re- related illnesses in primary and secondary lated illnesses should be seen as a component care in refugee settings. This should of basic care in any refugee situation. This is include guidelines on discharge and refer- especially important when refugees come from ral of people with HIV-related problems, an area where HIV-related illnesses are a either for more sophisticated care or to major cause of morbidity and mortality. (The home-based care; WHO flow chart for suspected symptomatic § drawing up an essential drug list for care HIV infection for the purpose of clinical man- of HIV-related illnesses and establishing agement is provided in Annex 6.) mechanisms to ensure the procurement and supply of these drugs; The elements of comprehensive care include: § § training health care workers in the use of clinical management, involving early di- the clinical guidelines; agnosis of HIV-related illnesses, rational treatment and planning for follow-up care; § introducing counselling training for health § and lay workers and developing guide- supportive care to promote and maintain lines for counselling. This can be inte- hygiene and nutrition; grated into counselling for other problems § education of individuals and families on related to the refugee situation. It will be HIV prevention and care; helpful if staff involved in this activity are not subject to frequent rotation; § counselling to help individuals make § informed decisions on HIV testing, reduce including those people living with HIV/ stress and anxiety and promote safer sex; AIDS in training programmes; and § ensuring that HIV-related care is fully integrated into basic curative services and § social support, including information and that prevention components (such as sup- referral to support groups, welfare serv- ply of condoms) and STD treatment are ices and legal advice. provided; § A home-based care system, to which § developing community support for AIDS people with advanced HIV infection/AIDS- care by: related illnesses can be discharged from inpatient care, should be established early – exploring community potential for in refugee situations. stigma and discrimination; The introduction of comprehensive care for – exploring community capacities and HIV/AIDS in refugee situations involves: commitment; 54

– encouraging the development and training of self-help and other community-based support groups; and STD/HIV/AIDS Indicators – starting community-based care and a Indicators to be collected support activities, using the self-help from the health-facility level groups that have been established. § percentage of blood screened for HIV before transfusion and Monitoring per cent found positive for HIV Data on the number of STD and HIV/AIDS § incidence of STDs cases presenting for treatment or detected in § practice of universal precautions health services are essential for planning services and as indicators of trends in STD preva- a Indicators collected at the lence in the community. Always suspect un- community level der-reporting of STDs and HIV/AIDS. Manag- ers of health care programmes may want to § outlets for condoms distribution check for the presence of informal networks of § knowledge of correct condom treatment for STDs, such as in local markets. use § The following is a list of suggested indicators condom use for monitoring and evaluating HIV/AIDS and STD interventions in refugee situations: a Indicators concerning training and quality of care § training of health workers in syndromic case management § quality of STD case management

(Refer to Chapter Nine–Surveillance and Monitoring.) Sexually Transmitted Diseases, Including HIV/AIDS 55

CHAPTER FIVE

Checklist for STD/HIV/AIDS Programmes

From MISP q Guarantee availability of free condoms

q Enforce universal precautions aHIV/STD/AIDS situational analysis is undertaken aTrained people from refugee community are identified aInformation, education and communication programmes are in place aUniversal precautions in health settings are practiced aFree good-quality condoms are regularly available and accessible aSystem of condom distribution is in place aSafe blood transfusion services are in place, guidelines disseminated, HIV test kits available, staff trained aManagement protocols for STDs are defined and disseminated aDrugs for STD treatment are on hand aStaff are trained/retrained on syndromic case management aSystem for partner notification and treatment are instituted aVoluntary counselling and testing (VCT) services are in place (as appropriate) aHome-based care for people with AIDS is in place aCounselling and support services for people with HIV/AIDS are in place 56

HIV Testing in Refugee Situations

ANNEX 1 Available resources for HIV testing should be devoted, first and foremost, to ensuring a safe blood supply for transfusions. A voluntary HIV testing and counselling (VCT) programme HIV Testing is a lower priority in a refugee situation but should not be ruled out if resources are available in Refugee and if these services are available in the host country or were available in the country of Situations origin. HIV testing to diagnose HIV-related illness may be indicated, but only if two conditions are met: § consent, pre- and post-test counselling and confidentiality can be assured; and § a confirmatory testing procedure is undertaken as outlined in UNAIDS Policy on HIV Testing and Counselling. People known to be HIV infected or to have AIDS should remain within their communities or within the refugee settlements, where they should have equal access to all available care and support.

UNAIDS/WHO Position on Mandatory HIV Testing in Refugee Situations Mandatory HIV testing in refugee circumstances, with the single exception of testing blood for transfusion, is not justified. WHO and UNAIDS have determined that such testing should not be pursued as a matter of policy. a Identifying people with HIV/AIDS through mandatory testing does nothing to stop the spread of the virus. a Mandatory testing is a violation of human rights, and it leaves those who are identified as HIV-positive open to discrimination and persecution. a No negative HIV test can be assumed to have excluded the possibility of HIV infection in the person tested. There is a latent period of several weeks following infection, during which the HIV test can come up negative, but the person is still capable of transmitting the infection through unprotected sexual contact or blood. Occasionally, too, tests have shown false negative results. a A negative HIV test offers no assurance that the person tested will not be exposed to HIV and become infected soon thereafter. a A negative HIV test is, therefore, no reason to relax the universal precautions that health workers need to observe at all times; nor does a negative HIV test give any reason to feel that sterile procedures during medical interventions are any less important. In practice, every patient should be regarded as a potential carrier of HIV, Hepatitis B or other blood-borne infections, since testing removes none of the potential for transmitting these diseases. a UNHCR and International Organization on Migration (IOM) issued a joint policy in 1990 which strictly opposes the use of mandatory HIV screening, and any restrictions based on a refugee’s HIV status. Nevertheless, some States have adopted mandatory HIV testing for refugees and exclude those who test positive. Other States place restrictions on the admission of persons whom they know to be HIV positive or have AIDS. Although some countries have established waiver procedures, resettlement cases of refugees who are HIV positive or have AIDS are certain to be more complex than most resettlement cases. a Resettlement considerations of refugees living with HIV are difficult and must be given special attention to avoid placing these persons at greater risk for discrimination, refoulement, and institutionalisation. Sexually Transmitted Diseases, Including HIV/AIDS 57

CHAPTER FIVE Mother-to-Child Transmission and HIV and Infant Feeding ANNEX 2 Primary prevention of HIV in girls and women of reproductive age remains the most important component of any strategy or programme to prevent mother-to-child transmission (MTCT). Mother-to-Child Transmission and HIV For women who are HIV negative or of unknown status, breastfeeding should be protected, and Infant Feeding promoted and supported. (See Chapter Three-Safe Motherhood)

For HIV-infected pregnant women, the only interventions proven to reduce significantly MTCT of HIV are the use of antiretroviral therapy (ARV) and the avoidance of breastfeeding. Women who are known to be HIV positive should be counselled about the possibility of avoiding breastfeeding. They should consider using commercial infant formula, home- prepared formula, or a modified form of breastfeeding, such as expressing and heat treating their own breast milk. They could also breastfeed for a shorter time than usual, or find an HIV-negative wet nurse. However, most of these options are usually impractical. Studies are continuing on the effectiveness and service delivery implications of providing short-course ARV treatment which may represent a feasible intervention in some settings and for some circumstances.

In some settings, consideration could be given to providing HIV-positive mothers with breast milk substitutes and supporting its safe use. The supply of the substitute should be guaranteed for at least six months. The acquisition and distribution of breast-milk substitutes should be in compliance with the International Code of Marketing of Breast-milk Substitutes.

Considerable resources are required to prepare formula, whether commercial or home made. The mother needs water to clean equipment and prepare feeds; she needs adequate fuel to boil water to sterilise equipment and make feeds safe. She must do this six times a day, or prepare six feeds at one time and keep them cool for up to 24 hours to prevent spoilage.

This is not often practical when normal life is disrupted. If feeds cannot be mixed correctly, if equipment cannot be adequately cleaned and sterilised, or if prepared feeds cannot be stored to prevent spoilage, the risks of sickness and death to the infant may be greater than the risk of transmission of HIV through breastfeeding.

Bear in mind these considerations when counselling women. Health care providers should support women and, when possible, their families, in making the best decision on how to feed their infant given their particular circumstances. Breastfeeding may be the most appropriate and safest option.

For more information on HIV and Infant Feeding refer to the “HIV and Infant Feeding Packet” produced by UNAIDS, UNICEF and WHO, Geneva, 1998. Also refer to “Nutrition and HIV/ AIDS”, Sub-committee on Nutrition News, Number 17, WHO, Geneva, 1998. 58

ANNEX 3 Formula for Calculating Condom Requirements Formula for Calculating Condom needs can be calculated if you can estimate the following: Condom § Requirements The size of the target population (i.e., refugee population and adjoining areas). Roughly 20 per cent of this number represents the size of the sexually active male population. § The percentage of males using condoms. Results from previous knowledge, attitudes, behaviour and practices (KAPB) studies can be used when they exist. If they do not exist, plan from data provided by the most reliable source and adapt according to needs. § Plan for about 12 condoms per sexually active male per month. § Add to the above figure 20 per cent for wastage and loss.

a Example: A baseline calculation for procuring one month’s supply of condoms for an estimated refugee and adjoining population of 10,000 people, with 20 per cent of sexually active males using condoms, is as follows:

2,000 sexually active males 2,000 20/100 20 per cent using condoms x 0.2 = 400 12 condoms per month x 12.0 = 4,800 20% wastage/loss + 0.2 = 960 total condoms per month 4,800 total wastage/loss + 960 Estimated total needs for one month: 5,760 condoms

Condoms usually come in boxes of 144, called a gross. Quantities of follow-on supplies should be modified according to the field situation (demographic profiles in refugee camps may be very different from the normal demographic profile; use rates of condoms may also vary). To avoid shortages, make sure a three-month reserve supply is available. Sexually Transmitted Diseases, Including HIV/AIDS 59

CHAPTER FIVE

STD Treatment Based on Syndromic Approach ANNEX 4

STD Treatment Based on Syndromic Syndrome Treat For Approach

Urethral discharge Gonorrhoea and chlamydia

Genital ulcers Syphilis and chancroid

Vaginal discharge1 Gonorrhoea, chlamydia and trichomonas

Lower abdominal pain Gonorrhoea, chlamydia and anaerobes

Inguinal bubo as for chlamydia

Scrotal swelling Gonorrhoea and chlamydia

Neonatal eye discharge Neonate gonorrhoea and chlamydia

1. If a woman complains of vaginitis (itching)–treat for candidiasis. 60

ANNEX 5 Drugs for Treatment of STDs

Drugs for (Choice of drugs should be based on antibiotic sensitivity studies in a specific area) Treatment Treat For Drugs – Depending on Adult Dose (for uncomplicated of STDs Sensitivity Studies or early infections)

Gonorrhoea Ciprofloxacin1 500 mg - single dose - oral Spectinomycin 2 g - single dose - IM Cefixime 400 mg - single dose - oral Ceftriaxone 250 mg - single dose - IM Kanamycin 2 g - single dose - IM Sulfamethoxazole/Trimethoprim 400mg/80mg - 10 tabs once daily for 3 days

Chlamydia Doxycycline1 100 mg - twice daily for 7 days - oral Tetracycline1 500 mg - four times a day for 7 days - oral Erythromycin 500 mg - four times a day for 7 days - oral Sulfafurazole 500 mg - four times a say for 10 days - oral

Syphilis Benzathine penicillin G 2.4 MUs - single dose - IM Procaine penicillin G 1.2 MUs - daily for 10 days - IM Tetracycline(1,2) 500 mg - four times a day for 15 days - oral Doxycycline(1,2) 100 mg - twice daily for 15 days - oral Erythromycin2 500 mg - four times a day for 15 days - oral

Chancroid Erythromycin 500 mg - three times a day for 7 days - oral Ciprofloxacin1 500 mg - single dose - oral Ceftriaxone 250 mg - single dose - IM Spectinomycin 2 gm - single dose - IM Sulfamethoxazole/Trimethoprim 800mg/160mg - twice daily for 7 days - oral

Donovanosis Sulfamethoxazole/Trimethoprim 800mg/160mg - twice daily for 14 days - oral Doxycycline1 100 mg - twice daily for 7 days Tetracycline1 500 mg - four times a day for 7 days Chloramphenicol 500 mg - four times a day for 2 days

Trichomononas Metronidazole3 2 g - single dose - oral

Candidosis Nystatin pessaries 100,000 IU - twice intravaginally for 14 days Clotrimazole or miconazole pessaries 200 mg - once intravaginally for 3 days Miconazole 500 mg - intravaginally - single dose

Bacterial Metronidazole3 400-500 mg - twice a day for 7 days - oral vaginosis or 2 g - single dose - oral

1–Contraindicated in pregnancy 2–For persons allergic to penicillin, but may be less effective. Close follow up is necessary to ensure a cure. NOTE: Drugs for treatment of STDs are continuously revised. Health care providers should rely on the most 3–Contraindicated in first trimester of up-to-date recommendations. pregnancy

Based on: Management of STDs– WHO/GPA/TEM/94.1 and WHO Model Prescribing Information: Drugs Used in STDs and HIV Infections– WHO 1997 Sexually Transmitted Diseases, Including HIV/AIDS 61

ANNEX 6

Suspected Suspected Symptomatic HIV Infection (a) Symptomatic HIV Infections

1. Any cardinal WHO Flow Chart findings (b) yes no 2. Two or more characteristic findings? (c) yes

no CHAPTER FIVE

3. One 4. Two or more characteristic associated finding? (c) yes findings? (d) yes

5. Three or more 6. Any associated epidemiological findings? (d) yes risk factors? (e) yes

no no

7. Two 8. Positive lab test associated yes for HIV? findings? (d) no yes no Symptomatic: Symptomatic: not HIV related HIV infections

Annotations: a) The purpose is to help the health care than 1 month³ provider to recognize the patient with § Diarrhoea (continuous or intermittent) for more 1. Kaposi sarcoma is a cardinal symptomatic HIV infection, as an aid to than 1 month finding only when: (i) intraoral clinical management. HIV testing, when § Ulcers (genital or perianal) for more than 1 lesions are present; (ii) available and affordable, can be used to month lesions are generalised; or substantiate the clinical diagnosis. § Cough for more than 1 month³ (iii) lesions are rapidly b) Cardinal Findings: § Neurological complaints or findings4 progressive or invasive. § Kaposi sarcoma1 § Generalised lymphadenopathy (extrainguinal) § Pneumocystis carinii pneumonia § Drug reactions (previously not seen), e.g. to 2. If no other obvious cause of § Toxoplasma encephalitis thiacetazone or sulfonamides immunosuppression is § Oesophageal candidiasis § Skin infections (severe or recurrent), e.g. warts, evident. § Cytomegalovirus retinitis dermatophytes, folliculitis 3. The combination of fever, c) Characteristic Findings2: e) Epidemiological Risk Factors: weight loss and cough is § Oral thrush (in patient not taking antibiotics) § Present or past high-risk behaviour: characteristic of both § Hairy leukoplakia – drug injecting § Cryptococcal meningitis (may be a cardinal – multiple sex partners tuberculosis and AIDS. finding in Africa) – sex partner(s) with known AIDS or HIV 4. Neurological complaints or § Miliary, extrapulmonary or noncavitary infection findings associated with HIV pulmonary tuberculosis3 – sex partner(s) with known epidemiological risk § Herpes zoster, present or past, particularly factor or from an area with a high prevalence infection include seizures multidermatomal, age 50 years of HIV infection (especially focal), peripheral § Severe prurigo – males having penetrative sexual intercourse neuropathy (motor or § Kaposi sarcoma (other than as cardinal with males sensory), focal central motor finding) § Recent history of genital ulcer disease. § or sensory deficits, dementia High-grade B-cell extranodal lymphoma § History of transfusion after 1975 of unscreened and progressively worsening blood, plasma or clotting factor; or (even if d) Associated Findings²: headache. screened) from an area with a high prevalence of § Weight loss (recent unexplained) of more HIV infection. than 10% of baseline body weight, if § History of scarification, tattooing, ear Adapted from WHO/GPA/IDS/ assessable³ piercing or circumcision using non-sterile § Fever (continuous or intermittent) for more HCS/91.6 “Guidelines for the instruments. Clinical Management of HIV Infection in Adults”, December 1991. 62

WHO Essential Drugs HIV/AIDS ANNEX 7 Management

WHO Essential Drugs for HIV/AIDS Management Indications Drugs

Dehydration Oral Rehydration Salts

Diarrhoea Loperamide

Cotrimoxazole Bacterial Infections Amoxicillin Ciprofloxacin Ceftriaxone

Miconazole Fungal Infections Nystatin (oral and ointment) Ketoconazole1 1 Ketoconazole is expensive, therefore only limited supplies should be considered and only if Parasitic Infections Metronidazole (oral) there are enforceable criteria for its use. 2 The appropriate use of anti- Palliative Care and Pain depressant medicine should be Management Codeine considered in situations where clinical depression is diagnosed. 3 Given the possibility of overdose, Isoniazid tricyclics should perhaps be Tuberculosis Rifampicin prescribed only in 5 or less at a Pyrazinamide time and by a physician. Ethambutol 4 The use of anxiolytics (Diazepan - Benzodiazepine family) may also be considered for temporary Tricyclics3 Clinical Depression 2 management of severe anxiety Benzodiazepine Family4 reactions where respiration is not impaired (e.g., pneumocystis carinii pneumonia).

Sources: WHO Model Prescribing – Drugs used in HIV Infections, WHO/ EDM 1999. Standard treatments and essential drugs for HIV-related conditions WHO/DAP Dec. 1997. UNAIDS Technical Update “Access to drugs” October 1998. Sexually Transmitted Diseases, Including HIV/AIDS 63

CHAPTER FIVE

Sexually Transmitted Diseases: ANNEX 8

Example for estimating of drug requirements Sexually and costs for a population of 200,000 Transmitted Diseases

Cost per Total cost Treatment treatment in in Protocol US$ US$

Population 15-44 years 50% of total population 100 000

Expected % of STD (1) 5% 5 000

Expected % of genital 20% of (1) 1 000 benzathine benzyl- 0.24 ulcers penicillin 2.4 MU 1 dose plus erythromycin, 500mg plus 1.68 3/day x 7 days = 1.92 1 920

Expected % of urethal 50% of (1) 2 500 ciprofloxacin, 500mg x 1 1.72 discharge plus doxycyclin, 100mg plus 0.17 2/day x 7 days = 1.89 4 725

Expected % of cervicitis 5% of (1) 250 ciprofloxacin, 500mg plus doxycyclin, 100mg 2/day x 7 days 1.89 473

Expected % of vaginitis 25% of (1) 1 250 metronidazole, 2gr 0.04 plus nystatin 2p/day x 14 plus 0.50 days = 0.79 988

Condoms estimate 5 000 US$5.40 during STD management x 12 per = 60 000 144 pieces 2 250

TOTAL US$ 10,356 64

Further Readings On HIV testing and counselling “Counselling and HIV/AIDS” UNAIDS Technical Up- “Essential AIDS Information Resources”, WHO/ date, Geneva, 1997. AHRTAG, Geneva/London, 1994. “Guidelines for Blood Donor Counselling on Human “Guidelines for HIV Interventions in Emergency Set- Immunodeficiency Virus (HIV)” International Federa- tings”, UNHCR/ WHO/UNAIDS, Geneva, 1996. tion of Red Cross and Red Crescent Societies/WHO/ GPA Geneva 1994 (WHO/GPA/TCO/HCS/94.2) “Working with Young People: A Guide to Preventing HIV/AIDS and STDs”, Commonwealth Secretariat, “Policy of HIV Testing and Counselling” UNAIDS, WHO/UNICEF, London, 1996. UNAIDS/97.1 “Recommendations for the Selection and Use of HIV On universal precautions Antibody Tests”, WHO Weekly Epidemiological Record, No. 20:145-9, Geneva, 1997. “A Practical Guide to Infection Control: How to Use “Voluntary Counselling and Testing” UNAIDS Tech- Universal Precautions and Plan for Essential Sup- nical Update, Geneva,1999. plies”, WHO, Geneva, 1995. “Guidelines on Disinfection and Sterilisation”, On the management of STDs Médecins sans Frontières (MSF), Brussels, 1994. Adler, M., and S. Foster, J. Richens, and H. Slavin. “Guidelines on Procedures to be Followed after an Ac- “STD Infections: Guidelines for Prevention and Treat- cidental Exposure to Blood”, MSF, Brussels, 1997. ment”, ODA/DFID Occasional Paper, London 1996. “Management of Sexually Transmitted Diseases”, On access to condoms WHO, Geneva, 1994. “Prescribing Information: Drugs Used in Sexually “Managing Condom Supply Manual”, WHO, Geneva, Transmitted Diseases and HIV infection”, WHO, Ge- 1994. neva, 1995. “Specifications and Guidelines for Condom Procure- “Sexually transmitted diseases: policies and principles ment”, WHO, Geneva, 1995. for prevention and care” UNAIDS/WHO Geneva,1997. “The Female Condom: An information pack”, WHO/ “STD Case Management Workbooks” WHO/ UNAIDS, Geneva. GPTCO/PMT/95.18A, Geneva, 1995. “The Female Condom and AIDS” UNAIDS Point of “The public health approach to STD control” UNIADS View, Geneva, 1998. Technical Update, Geneva, 1998. “The Male Latex Condom” WHO/UNAIDS, Geneva, 1998. On comprehensive care “AIDS Home Care Handbook”, WHO, Geneva, 1993. On safe blood transfusion “Guidelines for the Clinical Management of HIV In- fection in Adults”, WHO, Geneva 1991. “Blood Needs in Disaster Situations: Practical Advice “Guidelines for the Clinical Management of HIV In- for Emergencies”, Transfusion International, No.59, fection in Children”, WHO, Geneva 1993. March 1993. “HIV/AIDS Counselling: A Key to Caring: Guidelines “Blood Safety” UNAIDS Point of View, Geneva for Policy Makers and Planners”, WHO, Geneva 1995. “Blood Safety” UNAIDS Technical Update, Geneva “Guide for Planning Operations for Refugees, Dis- On standard treatment and essential placed Persons and Returnees: from Emergency Re- drugs for HIV/AIDS management sponse to Solutions”, International Federation of Red “Access to drugs”, UNAIDS Technical Update, Cross and Red Crescent Societies, Geneva, 1993. Geneva, 1998. “Guidelines for the Appropriate Use of Blood”, WHO, “Standard treatments and essential drugs for HIV- Geneva, 1989. related conditions”, WHO/DAP, Geneva,1997. “Use of Blood Plasma Substitutes and Plasma in “WHO Model Prescribing – Drugs used in HIV Infec- Developing Countries”, WHO, Geneva, 1989. tions”, WHO/EDM, Geneva,1999. Family Planning 65

6CHAPTER SIX Family planning helps save women’s and Family children’s lives and preserves their health by Planning preventing untimely and unwanted pregnancies, Contents: reducing women’s exposure to the health risks of n Preliminary Considerations childbirth and abortion and giving women, who n Assessment of Needs n Implementation of Family are often the sole caregivers, more time to care for Planning Services n Examples of their children and themselves. Contraceptive Methods that May Be Provided in Refugee Settings All couples and individuals have the n Male Involvement in Family Planning right to decide freely and responsibly Programmes n Monitoring the number and spacing of their children and to have access to the information, education and means to do so. 66

Family Planning

Refugee women and men should be involved Protocols used to manage family planning in all aspects of family planning programmes; services in the country of origin may be differ- and the programmes should be conducted ent than those used in the host country. To the with full respect for the various religious and extent possible, host country protocols should ethical values and cultural backgrounds within be followed, although some negotiation may the refugee community. be necessary where differences exist.

From the earliest stages of an operation, relief Most family planning methods are used by organisations should be able to respond to women. Women have the right to confidentiality refugees’ demand for contraceptives. As the and privacy about their choice of methods. But situation stabilises, a range of safe and effec- frequently men are the decision-makers within tive modern methods of family planning, the family unit. Where appropriate, men should approved by WHO, should be available. The be given appropriate information and encour- provision of family planning services requires aged to take an active role in the family planning appropriately trained staff and a reliable sup- decision-making process. This will help ensure ply of material and financial resources. that joint responsibility is taken for family planning decisions and will maximise acceptance of the programme within the community. Preliminary Considerations

The situation in the refugees’ country of origin Assessment of Needs will be an important factor influencing expectations, perceived needs and demand for family Background information on reproductive planning. Laws, infrastructure, religious and health (RH) in the country of origin should be ethical values and cultural backgrounds and available from pre-existing data. Sources for the training of health-care providers from the this information include UNAIDS, UNFPA, host country also have an important affect on WHO and other governmental and non-gov- the services that can be offered. Some women ernmental agencies that work in reproductive may want to continue using a contraceptive health and family planning. Headquarters and method that they used before displacement. regional offices should be able to provide this These women’s demands for continued family information to field operations. planning should be met as soon as possible. A review of the national or other (UNFPA, NGO, Given the risk of pregnancy and exposure to bilateral, etc.) family planning programmes of sexually transmitted diseases (STDs), in- the host country must be conducted to find ways cluding HIV, that often prevails in refugee and means for collaboration and to identify any situations, condoms should be available as differences in protocols which must be re- early as possible. (See Chapter Two – solved. If services are made available to refu- MISP.) Counselling services should also be gees, they should also be available to the sur- available. rounding local population on request.

Providing a full range of family planning serv- The following activities will help assess the ices will usually not be feasible until the situa- demand for family planning within a refugee tion has stabilised somewhat. A refugee situa- population: tion is considered “stabilised” when the crude § Carry out an investigation of attitudes mortality rate falls below one in 10,000 per held by the refugee population concern- day, when there are no major epidemics, and ing contraception. when the “settled” refugee population is not expected to repatriate or relocate within six § Assess attitudes and knowledge of months. providers from the refugee population, Family Planning 67

including those involving traditional information should be provided, allowing CHAPTER SIX methods. women and men to select freely a method that suits their needs. § Gather information on contraceptive prevalence by method in the country of High quality means that: origin. § § Verify in-country availability of supplies the needs of clients are assessed; and continuity of supplies. § an appropriate range of methods is § Determine if refugees can use existing provided; facilities in the host country. § complete and accurate information about all methods is offered, thus ensuring The support of community, social and religious informed choice; leaders should be sought before setting up family planning services. Without this support, § a mix of methods matches the needs of only those willing to risk community censure all potential clients; may use the services. For example, in some § providers have the necessary technical traditional cultures, talk of women’s reproduc- skills to offer the methods safely (i.e., tive rights may provoke opposition. But support providers screen women for medical may be given for an information, education and contraindications, assess STD/HIV risks, communication (IEC) campaign emphasising and can medically manage side effects); child spacing, safe motherhood and the health § of women. providers are trained in technically accurate and culturally appropriate counselling Discussions should be held with individual techniques and use them effectively; women (including leaders and traditional birth § services are convenient, accessible and attendants [TBAs]) and women’s organisations acceptable to clients; to obtain their advice on the location of service points, the timing of services at the health § follow-up care to ensure continuity of facilities and the level of privacy and confiden- services is provided; and tiality that will ensure maximum use. § an adequate logistics system ensures a continuity of supplies.

Implementation of Family Procurement of Contraceptives and Planning Services Logistics of Distribution To ensure an appropriate and effective family It is not possible to provide quality services planning programme, the following compo- unless an uninterrupted supply of contraceptives nents must be integrated, according to the is ensured and staff are appropriately trained. findings of the assessment: Local supply channels should be investigated. If these are inadequate, supplies should be obtained through reliable suppliers or with support High-Quality Family Planning from UNFPA, UNHCR or WHO. These agencies Services can facilitate the purchase of bulk quantities of good-quality contraceptives at low cost. All RH services should be of the highest quality possible. High-quality contraceptive care in- The following are the basic steps required to volves providing women and men with safe manage stocks of contraceptives: and appropriate methods to meet individuals’ and couples’ needs at every stage of their § Select contraceptives. Selection should reproductive lives. Accurate and complete be based on past use within the refugee 68

community, the providers’ skills, and con- made of qualified or experienced refugees or sideration for the laws, procedures and local staff. If lay workers are used for commu- practices of the host country. Negotiation nity-based distribution, they must be trained in maybe necessary to resolve any differ- appropriate skills and attitudes and must be ences. supervised. § Estimate quantities to be procured. Es- Those involved in providing family planning timates should initially be based on data services must show respect for the client’s from the country of origin and, later, on opinion and for the need for confidentiality. To data generated within the refugee situa- increase use, the provider may need to be of tion. the same sex and cultural background as the § Set up a system for record keeping. user and have strong communication skills. See section below on monitoring. To ensure administrative, technical and refer- § Set up procedures for efficiently man- ral support, there must be coordination and aging the procurement, distribution cooperation with the host country’s family plan- and inventory of contraceptives. Under- ning programme and with NGOs or UN agen- or over-supply may be avoided by careful cies, such as UNFPA. Such cooperation will organisation, primarily by appointing an also increase the chances of sustainability of individual who will assume this specific the refugee family planning programme. responsibility.

Planning Outlets and Opportunities Preparation of the information, for Family Planning Services education and communication (IEC) component Family planning delivery sites should be accessible and convenient. Ideally, family plan- Counselling should always be an integral part of ning services should be available at health family planning services. Appropriate, culturally centres, outreach health posts and through acceptable IEC materials help individuals and community-based distribution channels, when couples make free contraceptive choices. Infor- appropriate. Some groups, such as adoles- mation must include the benefits and con- cents, unmarried women and men, may need straints of different methods, and how to use special consideration so they feel comfortable them. (See Appendix One–The Essentials of using the services and so they can avoid the IEC Programmes.) risk of stigmatisation by the community. Con- traceptives should be available at the consultation point; the client should not be referred to a Preparation of an adequate training central pharmacy to obtain the selected programme for service providers method. In many situations, there will be trained provid- Counselling and family planning methods ers among the refugee population. These peo- should be systematically offered to refugees ple should be employed to the fullest extent after providing services related to post-abor- possible. All staff involved in providing family tion care, STDs or after childbirth. planning services must have adequate training on contraceptive methods and counselling, as indicated in the list below. This training should be supplemented by periodic refresher Human Resource Needs courses. On-the-job training and supervised Family planning programmes should be organ- practice are essential to ensure adequate per- ised and supervised by an experienced nurse, formance and must be integral components of midwife or doctor and maximum use should be the supervisory programme. Family Planning 69

The elements of an adequate training pro- said. In addition, providers should be CHAPTER SIX gramme for service providers include: taught strategies for effective counselling of clients about method choices in a lim- § Technical Competence ited time period. Providers should also be – description of methods (including trained to use visual and other support advantages and effectiveness) materials and to identify clients with special needs, such as those with a high risk – mode of action, side-effects, of STDs, post-abortion clients, breast- complications, danger signs feeding women, adolescents, etc. – appropriate groups of users and § Administrative Skills instructions for use or administration Many family planning providers must also – contraindications and drug interactions perform routine administrative and mana- – technical skills relating to the provision gerial tasks, such as record keeping, re- of each method (e.g., insertion of IUD ferrals and inventory control, and should or hormonal implant) therefore be trained in these activities. – follow-up and re-supply requirements, Training should emphasise not only the including ordering supplies specific skills necessary to carry out these functions, but also why they are important. – record keeping For methods that require specific techni- Plan protocols to be used during the cal skills–such as implants, IUDs, volun- family planning consultation tary sterilisation and the diaphragm–providers need hands-on training in method First contact involves: provision and close supervision. – registration and taking an individual RH history; § Interpersonal Skills – physical, gynaecological and pelvic – communication and counselling skills examination when indicated (for exam- – appropriate attitudes towards users and ple, to ascertain whether a woman is non-users and respect for their choices pregnant, to investigate unexplained vaginal bleeding, to determine the pres- – appropriate responses to rumours ence of an STD); and misconceptions – counselling regarding available methods – respect for dignity, privacy, and the user’s preferred choice accord- confidentiality ing to her/his STD/HIV risk; – understanding of the needs of specific – provision of the contraceptive method groups, such as adolescents, single supply, as indicated; women and men – counselling on when and how to use the § Communication Skills contraceptives; It is important for providers to be trained in – counselling on possible side effects and culturally sensitive, unbiased communica- reassurance that she/he can return to tion techniques that encourage open, in- the health facility at any time and teractive relationships with clients. Skills change methods; necessary for this kind of communication – scheduling a follow-up visit. include listening, clarifying, encouraging clients to speak, acknowledging client See Annex 2 for an example of the decision- feelings, and summarising what has been making process during a first visit. Annex 3 70

shows an example of a checklist used at a first Other barrier methods, such as spermicides visit to screen female refugees for contra- and female condoms, may be requested by indications against the use of various methods. refugees who are familiar with these methods Host-country checklists may exist for each from their country of origin. If requested, every method and should be used where appropriate. effort should be made to supply these methods.

For a new user, frequent follow-up (at one month, three months and six months) gives the Hormonal Contraceptives client opportunities to ask questions about use and any side-effects which she/he may have Oral Contraceptive Pills should include at least: experienced. As the user becomes familiar with § one combined oral contraceptive (COC): a method, he/she no longer needs frequent fol- ethinyl oestradiol < 0.035 mg and low-up visits. With some methods, such as pills, levonorgestrel 0.15 mg; condoms, and injectables, clients must make regular visits to obtain the contraceptives, so § one progestogen-only oral contraceptive follow-up is more automatic. Whatever the fre- (POP): levonorgestrel 0.03 mg or quency of follow-up visits, the user should be norethisterone 0.35 mg. assured of immediate access if she/he experi- Injectable Contraceptives could include depot- ences any difficulties. When arranging follow-up medroxyprogesterone acetate (DMPA, Depo- visits, providers must be sensitive to the literacy provera), one injection every three months, and numeracy of the client. norethisterone enatharem (NET-EN) one injection every 2 months, or Cyclofem, one injection per month. Trained health profession- Examples of Methods That May als should administer injectables. It is recom- Be Provided in Refugee mended that only one injectable method should be used to avoid confusion and misun- Settings derstanding over the schedule for reinjection.

Providers and users must be aware of the par- Supportive counselling and continued reassur- ticularities of each method, its effectiveness, ance during follow-up visits will help clients tol- safety, side effects. They should also know its erate common side effects, such as changed effect on the risk of STD transmission, its ap- patterns of menstrual bleeding. propriateness for breastfeeding women and the usual length of time between discontinua- See Chapter Four for details about the provi- tion of the method and return to normal fertility. sion of Emergency Contraceptive Pills (ECPs). Information on the common methods is pre- National policies and the demands of well- sented here. “In no cases should abortion be informed users should guide the use of ECPs promoted as a method of family planning” in refugee situations. (ICPD para 8.25).

Copper IUDs (Intra-Uterine Devices) Barrier Methods IUD insertion, like sterilisation and implants, In most refugee situations, the most important requires special training, facilities and equip- barrier method will be male latex condoms. Con- ment that must be in place before these meth- sistent and correct use of condoms can play the ods are provided. dual role of protection against STD and HIV infection and prevention of conception. They can Women known to be infected or at high risk for be used alone or in combination with another an STD, including HIV, should not have an IUD method to increase effectiveness. Only water- inserted. For nulliparous women, an IUD is not based lubricants should be used with condoms. the method of first choice. Family Planning 71

Natural Family Planning (NFP) of six or two silastic capsules containing the CHAPTER SIX Methods progestogen levonorgestrel. The capsules, inserted under the skin of the arm, slowly release Natural Family Planning methods include the the progestogen. These implants are effective basal body temperature method, the cervical for five years. They should only be inserted or mucus or ovulation method, the calendar removed by properly trained personnel. method and the sympto-thermal method. NFP is particularly appropriate for people who do not wish to use other methods for medical rea- Before using any long-term contraceptive sons or because of religious or personal be- within a refugee situation, service providers liefs. Counselling must be provided to both must be sure that the necessary facilities and partners when choosing these methods and skilled personnel exist in the country of origin when practising them. The methods require to reverse or remove the method, since refu- initial training and regular follow-up until confi- gees may return home at any time. If such dence is achieved in detecting fertility signs. facilities do not exist in the country of origin, the Teaching these methods to potential users is method should not be used. relatively time consuming, and requires separate sessions for those refugees who wish to use them. Voluntary Surgical Contraception Both male (vasectomy) and female sterilisation Breastfeeding are desirable methods of contraception for some clients. As a surgical method, sterilisation should Breastfeeding is effective as a contraceptive only be performed in safe conditions, with the method if a woman is exclusively breast- formal consent of the user and by trained per- feeding on demand her infant (no other food sonnel with the necessary equipment. Sterilisa- being given to the baby), she is not menstruat- tion should not be excluded especially if it is ing and her infant is less than six months old. If familiar to the refugees from their country of ori- any one this these three criteria are not met, gin and is allowed within the host country. then an additional method of contraception is advised.

Family planning methods recommended for breastfeeding mothers are: Male Involvement in Family § from delivery up to six weeks postpartum: Planning Programmes barrier methods, postpartum IUD insertion and sterilisation; Men must be involved in family planning pro- § grammes to increase recognition of other RH from six weeks to six months postpartum: issues, such as the prevention of STDs/HIV/ barrier methods, progestin-only methods AIDS, and to increase acceptance within the (pills, injectables, implants), IUDs, and community. Activities might include couples sterilisation; counselling, condom promotion, special § after six months postpartum: COCs and health facility times for men, peer-group ses- combined injectables, and natural family sions and social groups. Consideration of planning methods. men’s perspectives and motivation must be integral to programme activities. Contracep- tive use by men enables them to share the Hormonal Implants responsibility of family planning with their An implant is a long-lasting progestogen-only female partners. Some services may need to contraceptive. The most widely used types be specifically tailored to meet the needs of (Norplant and Norplant 2) consist, respectively, male users. 72

Monitoring Family Planning Indicators Providers should maintain a daily activity regis- ter and individual forms to help them record a Indicators to be collected information and offer effective follow-up. The at the health-facility level following information should be recorded: Contraceptive Prevalence Rate § date (CPR). CPR is the percentage of women who are using (or whose § user name–or, if required for partner is using) a method of confidentiality, only a number contraception at a given point in § user information (age, parity, address) time. § method selected (and brand name) a Indicators to be collected at § side effects experienced the community level § type of user (new, repeat, etc.) Community-based surveys could § reason for discontinuation–dropout or be carried out to assess the changed to other method knowledge, attitudes and practices of refugees concerning family § date of next visit (for follow-up). planning services.

Record-keeping forms should be simple and appropriate to the information gathered and to a Indicators concerning training staff literacy levels. All staff should receive and quality of care training in how to maintain appropriate records Regular skills training and and be informed of how the information being assessments. Health personnel collected will be useful to users and providers. implementing family planning programmes should be trained and their skills assessed regularly. An indicator of this competency should be monitored at least once a year. A possible indicator to assess the skills of family planning workers is the proportion of health workers appropriately implementing family planning services.

(Refer to Chapter Nine–Monitoring and Surveillance.) Family Planning 73

CHAPTER SIX Checklist for Establishing Technical and Managerial Family Planning Services Guidelines on Family Planning, aAssessment of attitudes of different WHO, Geneva groups undertaken aContraceptive prevalence in country of ¡ Barrier Methods and Spermicides: origin known Their Role in Family Planning Care, 1987. aFamily planning services sites established with participation of ¡ Natural Family Planning - A Guide for refugees Provision of Services, 1988. aContraceptives procured and logistics ¡ Norplant Contraceptive Implants: system in place Managerial and Technical Guidelines, 1990. aHealth and community workers trained in family planning service delivery ¡ Injectable Contraceptives: Their Role in Family Planning Care, 1991. aFamily planning record keeping system in place ¡ Guidelines for Community-based Distribution of Contraceptives, 1994. aInvolvement of male community undertaken ¡ Emergency Contraception: A Guide Service Delivery, 1998. ¡ Female Sterilisation: A Guide to the Provision of Services, 1992. Further Readings ¡ Technical and Managerial Guidelines for Vasectomy Services, 1988. “Pocket Guide for Family Planning Service ¡ Intrauterine Devices: Technical and Providers”, Blumenthal, P. et al. JHPIEGO, Managerial Guidelines for Services, Baltimore, MD, 1995. 1997.

“Contraceptive Logistic Guidelines for Refu- gee Settings”, Family Planning Logistics Man- WHO Brochures: What Health agement Project, John Snow, Inc., Arlington, Workers Need to Know VA, 1996. ¡ Natural Family Planning Hatcher, R. and W. Rinehart, R. Blackburn, ¡ Providing an Appropriate Contracep- and J. Geller. “The Essentials of Contraceptive tive Method Choice Technology”, a joint WHO/USAID publication, ¡ Female Sterilisation Population Information Program, Centre for Communication Programs, The Johns ¡ Vasectomy Hopkins School of Public Health, Baltimore, ¡ Breastfeeding and Child Spacing MD, 1997. ¡ IUDs “Improving Access to Quality Care in Family ¡ Injectable Contraceptives Planning: Medical Eligibility Criteria for Contra- ceptive Use”, WHO, Geneva, 1996.

“Medical and Service Delivery Guidelines for Family Planning”, WHO, IPPF, AVSC, Second Edition, 1997. 74

ANNEX 1

Appropriate Family Planning Methods at Different Stages in a Woman’s Reproductive Life

Appropriate Family Planning Methods at Different Stages in a Womans Reproductive Life

Breastfeeding women who Couples who wish to space birthsc wish to terminate Nonhormonal methods: child-bearing - IUDs Vasectomy - condoms Female steriliza- - diaphragm/cap tion - vaginal spermicides Implants Progesterone-only hormonal IUDs Adolescents Women who wish to methods: Combined oral delay their first birth - minipills contraceptives Implants - implants Condomsa Combined oral contra- - DMPA/NET-EN Vaginal spermicidesa ceptives Injectablesb Condomsa Diaphragm/cap Vaginal spermicidesa Natural family planninga Women not breastfeeding Perimenopausal who wish to space birthsd women Implants IUDs Combined oral contracep- Condomsa tives Diaphragm/cap Injectablesb Vaginal IUDs spermicidesa Condomsa a less than 90% effective Diaphragm/cap b return to fertility may be delayed after use of injectables Vaginal spermicidesa c exclusive breastfeeding alone has a significant Natural family planninga contraceptive effect if other criteria are also met: complete amenorrhea and a period of less than Source: “Providing an 6 months since delivery appropriate contraceptive d including post-abortion clients method choice”, WHO, 1993. Used by permission. Family Planning 75

ANNEX 2

Contraceptive Choice Decision Tree for Refugees Who Desire More Children

CHAPTER SIX NO ALL “NO” Does the client wish to adopt a contraceptive method to complement breastfeeding, or is she unlikely to return for services? Advise the client that she may be adequately protected from pregnancy but should return for contraception as soon one of the three criteria above is met. The client is adequately protected from pregnancy YES NO YES Discuss the suitability of barrier methods ONE OR MORE “YES” Is the client more than six weeks post partum? Is the client menstruating? Is the child given food supplements in addition to breastfeeding? Has the client been breastfeeding for more than six months? The client is not adequately protected from pregnancy and requires a complementary method. YES Discuss the suitability of: – IUDs – barrier methods – implants – minipills – DMPA/NET-EN Is the client breastfeeding? YES YES NO Discuss the suitability of: – implants – IUDs – DMPA/NET-EN planning Discuss the suitability of: – barrier method – natural family Does the client desire a method that does not require frequent use or resupply? NO NO contraceptives planning Is the client at risk of circulatory disease? Discuss the suitability of: – monthly injectables – combined oral – barrier methods – natural family Source: WHO, used by permission. 76

ANNEX 3

Family Planning Consultation Card *IUD (intra-uterine device) COC (combined oral contraceptive pill) POP (progesterone-only pill) INJ (injectable) Number: Desired: Signature Available methods Available Education: ooo oo oo o (–) o (–)oo+–++ o (–) + (–) -o (–) +oo–––– + + o + +o + – +o (–) + + oo + o + + ooo+––– + + o ooo+––– + + (–)oo–+++ (–)o (–) + – (–)oo+––– +oo+–++ + ooo–––– + + +oo–+++ + + (–) + + – + (–) NO YES IUD COC POP INJ* QUALIFICATION RECOMMENDED METHOD(S) METHOD RETAINED Living Children: heavy smokerobesity o o Date __ /__ Duration: Affluence: efficiency of oral contraceptives Births: 1. Nullipara 2. Post partum < 6 weeks 3. Post abortum < 6 weeks 4. Caesarean section < 6 months 5. Diabetes not under surveillance 6. of the following: Two years35 > age o 7. Hypermenorrhea/dysmenorrhea 8. Metrorrhagia 9. Medicinal treatment which could interfere with 1. Phlebitis, arterial thrombosis, embolism 2. Extra-uterine pregnancy 3. Upper genital infection 4. Recent liver disease (< 6 months) 1. conjunctiva (liver malfunction) Yellow 2. Cardiac valvular pathology 3. Blood pressure above 14/9 4. Mammary tumour 5. Phlebitis, important varicose veins 6. Pregnancy 7. Upper or lower genital infection NAME GYNAECOLOGICAL EXAMINATION Camp: Method(s) already used: Method desired: Pregnancies: Date: __ / A. ANAMNESIS B. HISTORY C. GENERAL AND Possible complementary exams: CONCLUSION: Address: Name: Age: Last menstrual period: Age of youngest living child: duration: Wishes to SPACE: Wishes to LIMIT: Family Planning 77

ANNEX 4

Calculating Contraceptive Requirements

Example of needs for one year in Two Camps: A and B When ordering contraceptives, always keep in mind the time it will take between the date of your order and actual receipt of the contraceptives (usually 2 to 3 months).

CHAPTER SIX 270 11 600 11 39 000 19 300 $70 170 ($) per year Total costs Total cycles ($) $5.40 per average 144 pieces Unit costs $60 per 100 $1.5 per vial $1.2 per IUD 864 000 225 IUDs Total 11 700 doses 11 19 300 cycles (both camps) (+20% wastage) (+10% wastage) (+10% wastage) 2 000 10 000 10 000 288 000 75 IUDs 50 000 Camp B 975 women 5 850 cycles 75 women or Population 1 500 women 450 women or or 3 900 doses 4 000 20 000 20 000 576 000 150 IUDs 100 000 Camp A Population 3 000 women 1 950 women 11 700 cycles 11 900 women or 150 women or or 7 800 doses Items CONDOMS group (males): 20% of Target population Users: 20% of the target group 12 condoms per user month CONTRACEPTIVES group Target (women 15-44 yrs): 20% of population Contraceptive Prevalence Rate: 15% 65% of the users prefer depoprovera (4 per year) 30% of the users prefer pills (13 cycles per year) 5% of the users prefer IUD 78 Other Reproductive Health Concerns 79

7CHAPTER SEVEN This Chapter does not include a discussion Other of all remaining reproductive health (RH) issues. Reproductive It deals with two particularly serious aspects Health Concerns of reproductive health: managing complications of spontaneous and Contents: n Post-Abortion Care 1 unsafe abortion, and eliminating the 4 Emergency Manage- ment of Post-Abortion practice of female genital mutilation and Complications 4 Post-Abortion Family caring for women who have undergone Planning 4 Links to Other RH this procedure. Services 4 Monitoring and Surveillance n Female Genital Mutilation 2 4 Scope and Definition 4 WHO classification 4 Prevention of Female Genital Mutilation in Refugee Situations 4 Care of Women with Female Genital Mutilation in Refugee Situations 4 Strategies to Eliminate Harmful Traditional Practices

1. This section draws heavily on WHO’s Clinical Management of Abortion Complications: A Practical Guide, WHO’s Complications of Abortion, Technical and Managerial Guidelines for Prevention and Treatment and the Post-abortion Care: A Reference Manual for Improving Quality of Care, Post-abortion Care Consortium 1995.

2. This section draws heavily upon “Female Genital Mutilation”, WHO Information Kit and the WHO Manage- ment of Pregnancy, Childbirth and the Postpartum Period in the Presence of Female Genital Mutilation. 80

Other Reproductive Health Concerns

Unsafe abortion contributes significantly to Introduction the morbidity and mortality of women of reproductive age throughout the world. WHO defines unsafe abortion as “a procedure for Complications of Spontaneous and terminating unwanted pregnancy either by Unsafe Abortion persons lacking the necessary skills or in an Health professionals should be able to recog- environment lacking minimal medical stand- nise and manage the complications of sponta- ards or both.” Every day, an estimated 55,000 neous and unsafe abortions, which are major unsafe abortions take place, resulting in the public health concerns as recognised in both deaths of 200 women daily. WHO reports that the International Conference on Population up to 13 per cent of pregnancy-related and Development (ICPD) in Cairo (1994) and deaths, world-wide, are due to unsafe abor- The Fourth World Conference on Women in tions. In some countries, deaths due to un- Beijing (1995). safe abortion may be responsible for up to 45 per cent of all maternal deaths. Furthermore, The following statement from the ICPD under- it has been estimated that for every death, pins the guidance offered in this Chapter: hundreds more women suffer chronic pain or disability. The most frequent complications are incomplete abortion, sepsis, haemor- “In no cases should abortion be promoted rhage, and intra-abdominal injury. Long-term as a method of family planning. All Gov- health problems include chronic pelvic in- flammatory disease, tubal blockage and sec- ernments and relevant intergovernmental ondary infertility. and non-governmental organisations are urged to strengthen their commitment to Spontaneous abortion or miscarriage can re- women’s health, to deal with the health im- sult in complications that require life-saving pact of unsafe abortion as a major public emergency care. health concern and to reduce the recourse to abortion through expanded and im- Female Genital Mutilation proved family planning services. Preven- Female genital mutilation comprises all pro- tion of unwanted pregnancy must always cedures that involve partial or total removal be given the highest priority and every at- of the female external genitalia and/or injury tempt should be made to eliminate the to the female genital organs for cultural or need for abortion. Women who have any other non-therapeutic reasons. Female unwanted pregnancies should have ready genital mutilation is widespread among refugee women who come from the cultures in access to reliable information and com- which it is practised. While it is not required passionate counselling....where abortion by any religion, it is a practice rooted in tradi- is not against the law, such abortion tions related to gender and power inequali- should be safe. In all cases, women should ties entrenched in a society’s political, social, have access to quality services for the cultural and economic structures. Many management of complications arising women and men believe that genital mutilation is necessary for women’s health, to from abortion. Post-abortion counselling, maintain virginity and to make them accept- education and family planning services able to their community. should be offered promptly, which will also help to avoid repeat abortions.” Care provided to women who have been subjected to female genital mutilation will be Cairo, ICPD, 1994, paragraph 8.25 improved if staff fully understand and are able Other Reproductive Health Concerns 81

to deal with its potential consequences. Health § supplies and equipment, CHAPTER SEVEN care workers should make it a priority to elimi- § conditions (cleanliness, space, privacy, nate harmful traditional practices, such as etc.) at the health facilities, female genital mutilation. § emergency transport system, and § capacity of referral facility. Post-Abortion Care for Where feasible, host-country health referral Managing Complications of facilities should be used and supported. Spontaneous and Unsafe Abortion Emergency Management of Post-abortion care (PAC) is the strategy to Post-Abortion Complications reduce death and suffering from the complications of unsafe and spontaneous abortion. The Women of reproductive age experiencing at elements of PAC are: least two out of three of the following symptoms should be considered as potential pa- § emergency management of incomplete tients with a threatened or incomplete abortion: abortion and potentially life-threatening complications § vaginal bleeding § post-abortion family planning counselling § cramping and/or lower abdominal pain and services § a possible history of amenorrhoea § making links between post-abortion (no menses for over one month) emergency services and other RH care services. The following steps should be taken to manage post-abortion complications: Since incomplete and/or septic abortions may threaten a woman’s life, health providers must Talk to the woman about her condition. be able to deal promptly with their conse- Any woman who presents with complications quences. As for obstetric emergencies, an ap- of unsafe abortion or miscarriage needs imme- propriate referral system should be estab- diate high-quality care. Health care workers lished and available 24 hours a day. (See should be aware that women seeking such Chapter Three.) care are under severe emotional stress in addition to physical discomfort. Privacy, confi- When planning for PAC, community needs and dentiality and consent for treatment should be perceptions, including women’s preferences for ensured. type and gender of PAC provider and location of services, must be solicited and considered. Conduct initial clinical assessment. Each refugee situation requires a protocol The initial assessment may reveal or suggest for managing post-abortion complications. the presence of an immediate life-threatening Refer to Table 1 for broad guidelines on the complication such as shock. Shock should be type of facility, the composition of staff and the addressed without delay in order to prevent types of emergency post-abortion care that death or keep the woman’s condition from may be available. Factors to consider in devel- worsening. oping the protocol are: § Managing shock: All health personnel § staff training, qualifications and should know the universal measures to supervision to achieve minimum treat shock: do not give fluids by mouth; standards, keep airway open; turn head and body to 82

one side and keep warm. Health centres uterine perforation, possibly as a result of should be equipped with IV fluids (saline, an attempted abortion. plasma substitutes or safe blood), sys- § Uterine evacuation: for removal of re- temic antibiotics and oxygen. tained products of conception. First and early second-trimester incomplete abor- Complete clinical assessment. tions can be treated by vacuum aspiration This consists of taking a thorough RH history, or dilatation and curettage (D&C). Vacuum performing careful physical and pelvic exami- aspiration, manual or electric, has been nations and, when necessary, obtaining ap- found to result in fewer complications than propriate laboratory tests. A complete as- D&C and causes less trauma to the patient. sessment will identify other possible compli- Health workers should refer incomplete cations (such as intra-abdominal injury, vagi- abortions in the middle- or late-second tri- nal bleeding [light to severe], infection/sepsis mester to a facility with surgical and full and pain) leading to an appropriate treatment emergency backup for treatment. plan. § Antibiotics: for infection or septic shock. These are common complications of in- Manage complications. complete abortion. Treatment with broad- Complications should be treated immediately spectrum antibiotics by IV or IM is indi- by qualified personnel. Prompt referral and cated. transfer may be needed if the woman requires § Management of pain: Appropriate pain treatment beyond the capability of the facility management ensures that the woman ex- where she is seen. Her condition will need to periences a minimum of anxiety and dis- be stabilised before she is transferred to a comfort. Women’s needs for pain man- higher-level referral service. The following agement will vary, depending on their treatments may be necessary: physical and emotional state. § Rest: in case of light to moderate bleed- § Prevention of tetanus: A tetanus vaccina- ing. tion should be given, as a woman may § Replacement of fluids: in case of shock have been exposed to tetanus and her vac- or severe vaginal bleeding, saline solu- cination history is likely to be uncertain. tion, plasma substitutes or safe blood. Laparotomy, surgery and uterine evacuation § Laparotomy/surgery: in case of suspi- should be undertaken by qualified and super- cion of an intra-abdominal injury. Intra- vised staff in appropriate and safe conditions, abdominal injury is commonly due to preferably in a host-country health facility. Other Reproductive Health Concerns 83

Table 1 CHAPTER SEVEN Minimum Standard for the Provision of Emergency Management of Post-abortion Complications By Level of Health Care Facility and Staff

Level Minimum Staff Emergency Care

Health Post/ Community Health ¡ Recognition of the signs and symptoms Clinic Workers, Traditional of the complications of spontaneous Birth Attendants and unsafe abortion and referral to (TBAs) facilities where stabilisation and/or treatment is available ·

Health Centre1 Health Workers All above activities plus: Nurses ¡ Diagnosis based on medical history Midwives and physical and pelvic examination General Practitioners ¡ Resuscitation/preparation for treatment or transfer ¡ Initiation of emergency treatments (antibiotic therapy, IV fluid replacement and oxytocics) ¡ Pain control, simple analgesia and sedation, and local anaesthesia ¡ Haematocrit/Haemoglobin testing

If trained staff, practising minimum safe standards, and appropriate equipment are available, above activities plus: ¡ Uterine evacuation during first trimester for uncomplicated case of incomplete abortion

Referral-Level Nurses Above activities plus: District Hospital Midwives ¡ Emergency uterine evacuation through (usually a host- General Practitioners second trimester country facility) Ob/Gyn Specialists ¡ Treatment of most post-abortion Surgeons complications ¡ Local and general anaesthesia ¡ Diagnosis and referral for severe complications (septicaemia, peritonitis, renal failure) ¡ Laparotomy ¡ Blood crossmatch, HIV testing and safe blood transfusions 1. A health centre in a refugee situation usually provides in-patient Tertiary-level Nurses Above activities plus: and outpatient services, has a ¡ basic laboratory and pharmacy, and Regional or Midwives Uterine evacuation as indicated for all is supervised by one or more National Hospital General Practitioners incomplete abortions medical doctors. Ob/Gyn Specialists ¡ Treatment of severe complications Surgeons (including bowel injury, severe sepsis, Taken from: “Complications of renal failure) Abortion, Technical and Managerial ¡ Treatment of bleeding/clotting disorders Guidelines for Prevention and Treatment”, WHO, 1995. 84

Post-Abortion Family Planning § Advice on proper nutrition Lack of access to adequate family planning § Advice on family planning methods services is a major contributor to the problem § Advice about antenatal care of unsafe abortion. Conversely, unwanted pregnancy and, in many cases, unsafe abor- § Links to under-five clinics for existing tion are prime indicators of the unmet need for children (if applicable) safe and effective family planning services. In § Referral for services following sexual most health systems, women treated for the violence complications of unsafe abortions rarely receive any counselling services to prevent sub- § Referral for counselling services follow- sequent unwanted pregnancies. Clearly, when ing diagnosis as HIV-positive. a woman receives care for post-abortion complications she should also receive comprehensive family planning counselling and services, if she so desires. At a minimum, all women Monitoring and Surveillance receiving PAC should understand: PAC services should be continuously re- § that the prompt return of ovulation can viewed. Managers of these services should result in pregnancy even before menses assess the level of use of these services, re- returns; and view all clients’ records, the availability and proper use of equipment and supplies, regu- § that there are safe contraceptive methods larly assess specific indicators of the quality of that can prevent pregnancy, and where care, identify changes or problems that occur, those methods can be obtained. provide feedback to staff, and intervene to cor- In addition, all staff providing PAC should know rect any problems identified. how to counsel and provide family planning services.

(Refer to Chapter Six for further details on family planning services.) Checklist for Post-abortion Care Links to Other Reproductive a Health Services Protocol for management of complications of unsafe and spontaneous abortions is developed and used Linking emergency PAC services with other RH services is essential and logical, yet in aStaff are trained to manage complica- much of the world these services remain dis- tions of unsafe and spontaneous tinctly separate. As a result, many women abortions have no access to RH care and suffer poor a overall health. Health facilities are equipped with appropriate materials It is important to identify the RH services that aProtocol for post-abortion family each woman may need and offer her as wide a planning and links with other RH range of services as possible, such as: services are developed and used § Treatment for reproductive tract aReporting and monitoring system to infections ensure quality of care are in place § Cervical and breast cancer screening and treatment (if applicable) Other Reproductive Health Concerns 85

Monitoring may include: direct observation of CHAPTER SEVEN staff at work; use of checklists (for example, to evaluate critical skills); examination of clinic WHO Classification records; and discussions with patients, staff and the community. a Type I: Excision of the prepuce with or without excision of part or all of the clitoris. a Type II: Excision of the clitoris to- Indicators to monitor gether with partial or total excision effectiveness of PAC of the labia minora. services a Type III: Excision of part or all of § Incidence of unsafe and the external genitalia and stitch- spontaneous abortions: The ing/narrowing of the vaginal open- incidence will indicate the ing (infibulation). magnitude of the problem and aType IV: Unclassified point to possible underlying causes. For instance, the § pricking, piercing or incision of incidence of unsafe abortion the clitoris and/or labia might indicate inadequate family § planning coverage for women stretching of the clitoris and/or who want to avoid or delay labia pregnancy. § introcision § § Quality of PAC services: The scraping (angurya cuts) or ability of staff to undertake all cutting (gishiri cuts) of the aspects of PAC should be vagina or surrounding tissue reviewed periodically through § introduction of corrosive direct observation of staff and/or substances or herbs into the review of medical records. vagina § any other procedure that falls under the definition of female genital mutilation

Female Genital Mutilation

Scope and Definition and women who have undergone female genital Female genital mutilation comprises all proce- mutilation live in 28 African countries, although dures that involve partial or total removal of the some live in Asia, and in other regions. female external genitalia and/or injury to the female genital organs for cultural or any other non- Approximately 15 per cent of women and girls therapeutic reasons. It is estimated that female subjected to female genital mutilation undergo genital mutilation has been performed on ap- infibulation. Most others undergo a clitori- proximately 130 million women and girls. About dectomy or excision. There is a high incidence two million girls risk being subjected to female of infibulation in Djibouti, Somalia and northern genital mutilation each year. Most of the girls Sudan, and a high rate of complications. 86

Infibulation is also reported in southern Egypt, Prevention of Female Genital Eritrea, Ethiopia, northern Kenya, Mali and Ni- Mutilation in Refugee Situations geria. RH programmes should include strategies to discourage female genital mutilation, emphasising the link between the practice and poor repro- Physical Consequences ductive, sexual and general health in women Female genital mutilation causes grave dam- and girls. It is vital to understand the reasons for age to girls and women and frequently results the practice before embarking on information in serious health consequences which may in- campaigns. Efforts to eliminate female genital clude an increased individual risk of mutilation can greatly be enhanced by enlisting bloodborne infections such as HIV. Some of the support of responsible community members. the effects are immediate; others become ap- parent only years later. Girls and women un- The “medicalisation” of female genital mutilation dergoing the more severe forms of mutilation (i.e., supporting health care professionals to per- are particularly likely to suffer serious and form female genital mutilation in health facilities long-lasting complications. Documentation under more hygienic conditions) is not accept- and studies are available on the nature of the able in the attempt to make this procedure physical short-term and long-term complica- “safer”. Medicalisation does not eliminate the tions described below, but there has been little harm caused by female genital mutilation and it study of the sexual or psychological effects of legitimises the procedure. Health workers em- the procedure or of the frequency with which ployed in refugee situations must be informed complications occur. The mortality rate of girls that their involvement in “medicalising” female and women undergoing genital mutilation is genital mutilation will not be tolerated under any unknown as few records are kept and deaths circumstances. Severe disciplinary measures, due to the practice are rarely reported. including possible termination of workers’ con- tracts, should be taken if they are found to be Usually the operation is performed on girls performing female genital mutilation. between four and ten years of age or younger, or, in some areas, adolescent girls. Village women, TBAs or male barbers generally per- Care of Women with Female Genital form the operation, usually without anaesthetics Mutilation in Refugee Situations or antiseptics. The effects on health depend on Women who have undergone female geni- the extent of the cutting, the skill of the operator, tal mutilation, particularly Type III, need the cleanliness of the tools and environment, special care, especially during pregnancy, and the physical condition of the girl. delivery and the postpartum period. When an infibulated woman gives birth, staff should The effects of the procedure last a lifetime and be aware of the following points: may threaten not only the woman’s reproductive health and well being, but also the health of § the formation of rigid scar tissue around her children. Health workers in refugee situa- the vaginal opening as a result of the muti- tions are seldom knowledgeable about the lation is likely to lead to delay in the sec- physical, psychological and social conse- ond stage of labour, which may endanger quences of female genital mutilation, nor are both the woman and the baby; and they always sensitive to the cultural beliefs that § extensive episiotomies may be needed to support the practice. allow for safe delivery.

Therefore, it is vital that field staff determine Women who have undergone infibulation need whether female genital mutilation is practised special care when using some forms of contra- within a refugee population and identify who is ceptive methods, such as the IUD, and in man- responsible for undertaking the procedure. aging the complications of unsafe and sponta- Other Reproductive Health Concerns 87

neous abortion. Sexually transmitted diseases § Promote, provide technical support to, CHAPTER SEVEN (STDs) are also more difficult to diagnose and and mobilise resources for national and women may be at a greater individual risk for local groups that will initiate community- bloodborne infections, including HIV. based activities aimed at eliminating harmful traditional practices. National committees to eliminate harmful tradi- Strategies to Eliminate Harmful tional practices exist in many countries Traditional Practices, including and their expertise should be tapped. Female Genital Mutilation § In Kenya, local NGOs running campaigns The issue of harmful traditional practices, in- aimed at eliminating female genital mutila- cluding female genital mutilation, should be tion discovered that refugees were more approached with great sensitivity. While there open to discussing the topic if it was in- are no hard and fast rules when working to pre- cluded in workshops that covered other vent and eliminate these practices, the follow- RH issues, such as STDs, HIV/AIDS and ing strategies and examples may provide safe motherhood, rather than if it was pre- some guidance to field workers: sented on its own. However, the campaign Experience has shown that the initial step in in refugee situations in Ethiopia began as addressing harmful traditional practices is pro- a stand-alone model and was very suc- viding education and information on such prac- cessful. Only later was it incorporated into tices, focusing on their negative conse- a larger RH programme. Clearly then, quences. However, action-oriented activities each programme must be tailored to the must follow initial awareness building. community it serves. § In some countries, alternative income- § Campaigns to eliminate these practices are generating activities should be devised for more likely to succeed and be accepted by those who earn money through harmful the target population when they initially em- practices. Traditional practitioners must phasise the harmful health consequences also be able to find other ways to secure rather than the legal or human rights as- the respect of their community. pects. Laws should be seen to be protective rather than punitive and designed to pre- § Videos provide an excellent means of vent harm to children. This aspect should demonstrating the harmful effects of some be emphasised at the community level so traditional practices. Videos depicting a that the law comes to be seen as providing female genital mutilation operation or a protection and support to the individual. woman who has not undergone female genital mutilation giving birth have proved § It is necessary to have a thorough understanding of the nature and extent of the to be very effective. particular practice, including its roots and § The use of drama and other cultural activi- social consequences. Health workers can ties, such as plays or songs, can also be acquire this knowledge through discus- an effective method of disseminating in- sions with the refugees, themselves. formation on the negative effects of harmful traditional practices. Radio, local pa- § Educate target populations (both men and pers, and mosques may also be used to women), such as religious leaders, traditional leaders (chiefs, tribal elders and help disseminate this information. political leaders), teachers, TBAs and § In the Sudan, some health workers focus other health workers, as well as the gen- mostly on men in their campaign to save eral refugee population (including women, girls from female genital mutilation. Men men and children) about the harmful are often the primary decision-makers in health consequences of these practices. It the family, though they are also generally is particularly important to educate young unaware of the exact nature and severity girls about these issues. of the procedure. 88

§ Health workers in Uganda support a “rite of Local NGOs, host communities, and the gov- passage” ceremony while trying to elimi- ernment, which may already have active cam- nate the harmful practices of female genital paigns in the country, could also be involved. mutilation. Programmes encourage the ceremonial aspects of the “coming of age” for young women, but eliminate the “cut- Monitoring and Supervision ting” part of the process. In Sierra Leone, female genital mutilation is part of an initia- Monitoring the change in female genital mutilation rite for women’s secret societies. tion practices in a community is very difficult. These societies can be very important for Programmes should monitor complications women’s self-empowerment, not only be- experienced by women during birth and inves- cause they provide a support network, but tigate any deaths that may be related to female because they also provide contacts for in- genital mutilation. Health care providers, both come-generating activities. While it is im- in health facilities and in the community, portant to encourage groups that empower should be supervised and monitored routinely women, it is equally important to encour- to ensure that they are not practising female age initiation ceremonies that do not re- genital mutilation. quire female genital mutilation. § The importance of educating girls and women cannot be overstated. The inci- Further Readings dence of harmful traditional practices, such as female genital mutilation and “Clinical Management of Abortion Complica- early childhood marriage, decreases as tions: A Practical Guide”, WHO, Geneva, 1994. female literacy increases. Therefore, pro- “Complications of Abortion: Technical and moting and supporting female education, Managerial Guidelines for Prevention and both the enrolment of girls in schools and Treatment”, WHO, Geneva, 1995. adult literacy, should be a priority. “Female Genital Mutilation: Findings from the § Growing immigrant populations in indus- Demographic and Health Surveys Program”, trialised countries have brought female Macro International Inc., Washington, DC, 1997. genital mutilation with them to countries “Female Genital Mutilation Information Kit” (in- where it had not been practised. UNHCR cludes Joint UNICEF, UNFPA and WHO discourages informing refugees, before re- Statement on female genital mutilation), WHO, settlement, of the criminalisation of the Geneva, 1994. practice in resettlement countries. Experi- “How To Guide: From Awareness to Action – ence has shown that if told prior to depar- Eradicating Female Genital Mutilation in Refu- ture, mass female genital mutilation opera- gee Camps in Eastern Ethiopia”, UNHCR, tions may be conducted in the country of Geneva, 1997. asylum before resettlement occurs. When “Management of Pregnancy, Childbirth and the refugees are resettled to countries that Postpartum Period in the Presence of Female have laws against female genital mutila- Genital Mutilation: A Report of a WHO Techni- tion, the authorities of the resettlement cal Consultation”, WHO, Geneva, 1998. country should be encouraged to inform “Policy Paper on Eradication of Harmful Tradi- refugees of these laws upon their arrival. tional Practices”, UNHCR, Geneva 1997. Field staff are advised to plan carefully their “Post-abortion Care: A Reference Manual for strategy for eliminating harmful traditional Improving Quality of Care”, Post-abortion Care practices in conjunction with the refugee com- Consortium, JHPIEGO Corporation: Balti- munity, implementing partners and any other more, MD, 1997. relevant UN organisations. It is important to “Post-abortion Family Planning: A Practical work with the refugee community to ensure Guide for Programmes Managers”, WHO, measures taken are as effective as possible. Geneva, 1997. Reproductive Health of Young People 89

8CHAPTER EIGHT Growing up is stressful and challenging in the best of times. For those young people living Reproductive Health of as refugees, the stresses are much greater. Young Their transition to adulthood is often People

made more difficult by the absence of Contents: the usual role models and the break- n Young People in Refugee Situations down of the social and cultural system n Principles in Working with Young People in which they live. They may have gone n Assessing the RH Needs of Young People through personal trauma themselves, including n Responding to the RH Needs of Young People armed conflict, violence, insecurity, sexual abuse, n Community-based harm to or loss of family members, disruption of Programmes n Monitoring and schooling or employment, of friendships, Supervision and of family and community support.

Defining Children and Young People

a Children 0-18 years Convention on the Rights of the Child

a Adolescents 10-19 years UNFPA, WHO, UNICEF The definitions of children, adolescents and adults may change from culture to culture. Health workers must adapt a Youth 15-24 years the definitions they use to suit the specific refugee situation in which they are working. Whether an UNFPA, WHO, UNICEF adolescent has assumed the roles and responsibilities of a 10-24 an adult is also a reflection of the culture and the refugee Young People years situation. When working with young people, the cultural, UNFPA, WHO, UNICEF ethical and religious values of the refugee community must be respected. 90

Reproductive Health of Young People

Young people have special needs in all circum- homeland, one’s elders and one’s tradi- stances; and each age group within this popu- tional culture may create a situation in lation has different problems and requirements. which risky behaviour is less socially con- In refugee situations, where it is difficult enough trolled. Thus there is a greater risk of early to set up basic reproductive health (RH) serv- teen pregnancy, sexually transmitted dis- ices for the entire community, health providers eases (STDs), drug abuse, violence, etc. will also have to consider and address the spe- n Young people are not a homogeneous cial needs of young people. But young people group. Young women and young men face are tremendously flexible, resourceful and very different problems and opportunities. energetic. They can help each other through Young women are much more vulnerable peer counselling and peer education, and they to common RH problems and they invari- can provide care to others and assist health ably bear most of the consequences. Also, providers as volunteers. young people aged 10 to 14 years have different needs than those aged 16 to18 or 20 to 24. And different cultures have different Young People in Refugee expectations for youth in these different age Situations groups. For example, in some cultures, marriage is acceptable/expected for a 14- Young people often have an easier time adapt- year-old girl; in many other cultures, it is not. ing to a new situation than their parents do. n In many countries with high STD/HIV They learn how to “work the system” quickly. prevalence, the most vulnerable group In trying to understand their special circum- is young women. The AIDS epidemic is stances and meet their needs, it is helpful to exacerbating the health risks that young remember the following: women face. Their lack of power over their n Adolescence is a time for learning sexual and reproductive lives compounds about close relationships. In normal situ- the risks of unwanted pregnancy, unsafe ations, much of this information is gained abortion and STD/HIV infection, all of from peers and from role models in the which are likely to occur more frequently young person’s family and community. in refugee situations. These people may not be available in refugee settings. As respected adults in the Reproductive Health Needs of lives of young people, male and female Adolescents service providers may become important role models and should be aware of their The background characteristics of young peo- potential influence. ple, including their religion, cultural upbringing, place of origin (rural or urban), and level of edu- n Young people often lack a well-devel- cation will, to some extent, define their needs. oped future orientation. This can be re- However, basic RH needs include: inforced by refugee or displaced status. Projects that provide these young n information on sexuality and people with a reason to look to the future reproductive health may also help them consider the conse- n access to family planning services quences of unsafe sexual activity and the need to take responsibility for their actions. n prenatal and post-abortion care

n The behaviour of young people in refu- n safe delivery gee or displaced situations may not be n treatment of unsafe abortions subjected to the same kind of scrutiny as it would be under normal circum- n diagnosis and treatment of sexually stances. The separation from one’s transmitted diseases Reproductive Health of Young People 91

n protection from sexual abuse between health and community services CHAPTER EIGHT are necessary to ensure that young peo- n culturally appropriate psychosocial ple get the appropriate treatment for prob- counselling and/or mental health services lems which might be revealed through one n negotiating skills service but require additional assistance from another service (e.g., sexual violence or unsafe abortion).

Principles in Working with n Young people need privacy. The prob- Young People lems that bring them to a service provider often make them feel ashamed, embar- The primary principle in working effectively with rassed or confused. Though space may be young people is to promote their participation. at a premium in a refugee camp, it is im- Although this principle applies to the provision portant for providers to try to create the of RH services in adult populations, it is par- most private space possible in which to talk ticularly important for young people. As a group, to young people. young people often have a “culture” of their own, n Confidentiality must be guaranteed. with particular norms and values. They may not Service providers need to maintain confi- respond to services designed for adults. They dentiality in their dealings with young peo- are at a stage in life where they need to develop ple and be honest with them about their a sense of control over their bodies and their health problems. health. At the same time, since they are young and relatively inexperienced, they need guidance n In most cultures, the gender of the serv- that is both sensitive and reassuring. The best ice provider is important. A young per- way to encourage young people to participate is son should be referred to a provider of the to develop a partnership between them and the same sex. providers with proper regard for parental guidance and responsibilities. Services will be more accepted if they are tailored to the needs as identified by young people, themselves. RH Services for Young Other principles to remember: People Should: n Service providers must understand the cultural sensitivities surrounding the a be “user-friendly” provision of information and services to a young people. To the extent possible, com- have competent staff who munity leaders and parents should be in- are friendly, welcoming, and volved in developing programmes targeted non-judgmental at young people. Service providers with a promote trust and deep cultural knowledge (especially if the confidentiality provider is part of that culture) are more likely a be free or low cost to provide services acceptable to the community than those considered “outsiders”. a be easily accessible a n Programmes should identify and en- have flexible hours courage peer leadership and communi- a be located in attractive cation. Peers are usually perceived as safe facilities and trustworthy sources of information. a offer same-gender providers n It is essential to have links between health and community services. Links 92

Assessing the RH Needs of Responding to the RH Needs of Young People Young People

In the absence of information specific to the Young people need basic information about young people, providers must assume that sexuality and reproduction. They also need to many of the common problems cited above learn how to protect their reproductive health. may be worse in the refugee situation. The dis- In many refugee settlements, formal education ruption of health and education services and ends after primary school. Therefore, informa- general state of disorder imply a lack of pro- tion about reproductive health must be commu- tection and supervision, increased sexual vio- nicated in creative ways. Any organised activ- lence, and a greater need to exchange sex for ity for youth–sports, video showings, handicraft food, shelter, safe passage and protection. It “clubs”–may provide an opportunity for dissemi- is important to obtain information about a nating important health information to partici- young person’s history of STDs and pregnancy pants. status, unsafe abortion, rape and other forms of sexual abuse. Health care providers should It has been proven that sex education leads to also be aware of a young person’s knowledge safe behaviour and does not encourage earlier about and access to any form of contracep- or increased sexual activity. (See UNAIDS docu- tion, and his/her beliefs, attitudes, perceptions ment in Further Reading.) Therefore, young and values. people should be informed about STD/HIV/ AIDS and early pregnancy, and appropriate More specifically, it is important to gather infor- advice and supplies should be made available mation about: to them. Young people need to develop certain skills to be able to make informed, responsible n cultural norms related to sexual relation- decisions about their sexual behaviour. They ships and rites of passage into adulthood need to be able to resist pressure, be asser- (including harmful traditional practices, tive, negotiate, and resolve conflicts. They also such as female genital mutilation) need to know about contraceptives, such as condoms, and feel confident enough to use n current norms/practices/perceptions/atti- them. Peer counselling and peer education can tudes related to sex be very effective in strengthening these skills n typical patterns of adult authority over ado- and attitudes. lescent behaviour within the camp Young girls who do not attend school and who n services available to young people (and ap- are destined to marry immediately after the start plicable restrictions) and the degree to of menstruation may be particularly difficult to which the refugee community understands reach. However, their society may allow a com- this availability munity worker to visit the girls at home and dis- n perceptions of camp staff/service provid- cuss health matters relating to preparations for ers related to providing RH services to parenthood. young people Rape may be the reason an adolescent first ap- n young people’s perceptions of their RH proaches health services. Many victims of rape needs and sexual abuse are girls, but boys are also vulnerable to sexual violence. Young people who This information can be gathered through camp have been sexually abused need immediate records, interviews and focus group discussions health services and access to a safe environment. and possibly through simple survey techniques. (Some further guidance is found in Appendix In refugee situations, adolescent girls and boys One on IEC.) may be forced into selling sex simply to sur- Reproductive Health of Young People 93

vive. Refugee-community members should be needs assessment and planning of the pro- CHAPTER EIGHT involved in identifying ways to protect girls and grammes. Young people from all age groups women from sexual violence and coercion. One should be identified, as quickly as possible, to possible protective measure is to ensure that help design the programmes and eventually to women administer the distribution of food and take a leadership role. shelter. (See Chapter Four–Sexual Violence.) When an assessment of current needs and If an adolescent is pregnant, it is vital to pro- available resources has been made, the group vide her with good antenatal care, since young of service providers and young people who are women, especially those under 15 years of age, assembled to develop the programme can con- are prone to complications of pregnancy and sider the project objectives and develop the delivery. Many young pregnant women will re- corresponding activities. Planners should de- sort to unsafe abortion. They will need special fine simple mechanisms for collecting informa- care if complications from an unsafe abortion tion that can later be used to measure the develop. Information about family planning must project’s impact. That information will also be readily displayed and available to help keep guide any modifications made to the pro- unwanted pregnancies to a minimum. (See gramme. Young people should be involved in Chapter Six - Family Planning). evaluating and modifying the programme.

Adolescent boys engaging in homosexual in- RH services for young people are more ef- tercourse should be taught how to prevent STD/ fective and acceptable when they are linked HIV. However, IEC messages related to STDs to other activities or settings, for example rec- should not label this behaviour in a way that reation or work. Youth centres, developed in may stigmatise the boys (e.g., as homosexual), some refugee settlements, offer a place for but should refer to the behaviour as “men hav- young people to learn, play and receive health ing sex with men” or “same-gender sex”. services. In other refugee settings, young Psychological trauma resulting from refugee people have access to health services dur- experiences may make young people reluctant ing special hours, usually after school or af- to seek services related to their sexual health. ter work. Young people need their own physi- But they do need to know that these services cal spaces for social interaction. These may are available to them, that they will receive care be the best venues for providing health serv- and support if they want it, and that they will not ices. be judged or punished in any way. Information about the services could be displayed in places where young people gather or provided through other activities or social services. Monitoring and Supervision

Psychosocial support and counselling should RH programmes should be monitored to ensure be provided by trained counsellors whenever young people have access to health services needed, but particularly in cases of sexual and health care providers are caring for young abuse and unwanted pregnancy. people without stigmatising them. To be sure young people are attending health services and being targetted with health in- Community-Based Programmes formation, many RH indicators should be measured by age and sex break down. See Ideally, a person with experience in RH serv- Chapter Nine for select indicators for young ices for young people should participate in the people. 94

Further Readings

“A Picture of Health: A Review and Annotated Bibliography of the Health of Young People in Developing Countries”, WHO, Geneva, 1995.

“Action for Adolescent Health: Towards a Com- mon Agenda”, recommendations from WHO, UNFPA, and UNICEF, 1997.

“Coming of Age: From Facts to Action for Ado- lescent Sexual and Reproductive Health”, WHO/FRH/ADH/97.18, Geneva, 1997.

“Counselling Skills Training in Adolescent Sexu- ality and Reproductive Health: A Facilitator’s Guide”, WHO, Geneva, 1993.

“Refugee Children: Guidelines for Protection and Care”, UNHCR, Geneva, 1994.

“Technical Report of the WHO/UNFPA/UNICEF Study Group on Programming for Adolescent Health”, WHO, Geneva, 1997.

“The Impact of HIV and Sexual Health Educa- tion on the Sexual Behaviour of Young People: A Review Update”, UNAIDS, Geneva, 1998.

“Working with Young People in Sexual Health and HIV/AIDS: A Resource Pack”, AHRTAG, London, 1996. Surveillance and Monitoring 95

9CHAPTER NINE Surveillance and monitoring are basic Surveillance elements of programmes for both and comprehensive reproductive health Monitoring

(RH) and general health care. The person Contents: n A System Framework who coordinates RH activities should ensure n An Eight-Step Approach to Surveillance and timely and appropriate inclusion of RH data and Monitoring n Overview of Data indicators in the general health-reporting system. Sources n RH Indicators n Reference Rates and Ratios for RH Indicators n Sample Worksheet for Monthly RH Reporting

The Five Essential Components of a Monitoring System:

1 definition of essential data to collect, including case definitions1; 2 systematic collection of data; 3 organisation and analysis of data; 4 implementation of health interventions based on the data; and 5 re-evaluation of 1. A case definition is “a set of standard criteria for deciding whether a person has a particular disease or interventions. health related condition.” Criteria can be clinical, laboratory or epidemiologic. 96

Surveillance and Monitoring

The aims of monitoring are to: In this Manual, we use a simple framework for objectives and indicators. § identify high-risk groups; § Impact objectives target changes in mortality identify the most serious and/or the most and morbidity expected to result from pro- prevalent conditions; and gramme activities. § monitor the trends of these conditions Outcome objectives target changes in and the implementation and impact of knowledge, attitudes, behaviours, or in avail- interventions. ability of needed services or commodities that result from programme activities. They relate directly to the priority intervention (e.g., HIV/ STD prevention, child spacing), the target System Framework population (e.g., women of reproductive age), or those charged with caring for the target This Chapter explains how to develop a sys- population (such as health care workers and tem to collect and use essential RH data. family members). The system starts when a refugee situation Process objectives specify the actions occurs and no existing services are present. needed for programme implementation, and It is described in chronological order and in correspond to various activities (such as train- order of priority. The scheme can be ing, supply of drugs and equipment, and adapted and altered to respond to different health education) necessary to achieve the situations. intended outcomes and impact.

Most RH surveillance should be integrated Note that this Chapter presents mainly core into the overall health-information system impact and outcome objectives. Managers (HIS). During a refugee emergency, keep the can develop additional items (especially proc- HIS simple and limited to the most important ess objectives) according to the populations, causes of morbidity and mortality. Step 1 (of available resources, and working environ- the eight-step approach described below) ments. suggests the essential data relevant to repro- A selection of indicators is presented at the ductive health which staff should try to collect end of each chapter and the complete list of in the early phase. When more comprehen- suggested indicators is presented at the end sive services are available, other data can be of this chapter. The RH Coordinator should incorporated (as described in subsequent select one or more indicators based on pro- steps). gramme objectives. Before the indicator can be calculated, data will have to be collected Surveillance and monitoring of both health for the numerator and denominator. Standard status and service delivery involve defining measures should be used when possible for measurable programme objectives (what the comparison purposes, such as expressing programme will strive to achieve) and using some rates per 1,000 population. In some indicators to measure progress toward refugee settings, preliminary objectives may achieving those objectives. An indicator is a have to focus on setting up a system to collect measurement that, when compared to either a information on births and neonatal deaths, for standard or desired level of achievement, pro- example, before the indicator neonatal mortal- vides information regarding a health outcome ity rate can be calculated. Once the neonatal or a management process. Indicators are mortality rate is calculated, this indicator can measurements that can be repeated over time be followed monthly or for some specified time to track progress toward achievement of period, in order to monitor outcomes from the objectives. safe motherhood programme. Surveillance and Monitoring 97

The following is an example of the evaluation framework: CHAPTER NINE

PROCESSOUTCOME IMPACT

100% of community 100% of women with Maternal and health workers trained obstetric emergencies neonatal mortality and Objectives to recognise and refer are referred in a timely morbidity reduced by obstetric complica- manner and their ____%, in ____ year tions complications managed appropriately

% of health workers % of women with Reduction of neonatal Indicators able to recognise and obstetric emergencies mortality by ____%, refer obstetric who received appropri- in ____ year complications ate management

An Eight-Step Approach to 2. Define a System of Simple and Essential Data Collection Surveillance and Monitoring During programme design and implementation, programme planners should have estab- 1. Collect Basic Demographic Data lished measurable objectives. Based on these objectives, determine which indicators will be Collect the following RH-related data as soon used and what information is needed to calcu- as possible. late the indicators, and establish case definitions (such as those for live births and still- n Total population (by age and sex) births) so that indicator measurements are n Number of births clear. Next, determine the logical data flow, including time periods and reporting schedule. n Crude birth rate Identify people responsible for data collection, n Age and sex specific mortality rates including refugees (see Step 3 below). Finally, incorporate into the routine programme/camp n Number of women/men of reproductive age health-information forms, the data needed to n Number of pregnant women calculate the RH indicators. (See Sample worksheet for RH reporting–Annex 6.) n Number of lactating women Possible sources of data are: In addition to using information provided by refugee workers, estimates might be made us- n Daily birth or delivery reports. At mini- ing registrations, or through community-based mum, the reports must include age of the surveys (mortality, nutritional or household). mother, place of delivery, mode of delivery Information from the country of origin of the (vaginal, caesarean section), sex, birth refugees should also be obtained and used as outcome (live, stillbirth), and birth weight. estimates (for example, the Crude Birth Rate in If over- or under-reporting is suspected, the country of origin). cross check the information with the esti- 98

mated number of pregnant women or with 4. Implement Specific Reporting the agency responsible for distributing ra- Procedures tions. Experience has shown that several specific n Clinic-based log books or registries for areas of RH monitoring and surveillance have antenatal care, referrals, family plan- not been routinely conducted in refugee situa- ning, and STD syndromic case manage- tions. These include investigations of each ment as part of the out-patient log book. maternal death and reporting on cases of Women seeking care for the complica- sexual violence. tions of unsafe or spontaneous abortions should also be tracked through Investigating Maternal Mortality clinic and hospital-based registration/ Investigating the causes of maternal deaths log books. can help identify gaps in services and the need to improve referral procedures for obstetric n Health facility records, community report- complications. By reviewing cases, health care ing, cemetery records and referral facili- providers can strengthen their skills in identify- ties records outside the refugee situation. ing the early warning signs of obstetric emer- These should be used to track maternal gencies. Camp staff should investigate deaths and neonatal deaths. due to pregnancy (direct maternal mortality) and deaths of pregnant women caused by the Other sources of data include community effects of pregnancy on pre-existing conditions surveys, case investigations, laboratory re- (indirect maternal mortality). Both types of ports and community outreach-worker report- information are essential, since direct mortality ing. is often underestimated. The goal is to determine which deaths were caused by pregnancy or childbirth, or by complications or the management thereof, and how deaths can be pre- 3. Identify, Organise and Train vented in the future. Workers from the Refugee Community for Data Collection Points to be investigated include: Begin by identifying those refugees with mid- n time of onset of life-threatening illness; wifery skills and/or trained traditional birth attendants (TBAs), including those already n time of recognition of the problem and providing services, who can be trained to col- time of death; lect data. Otherwise, community members n timeliness of actions; will have to be recruited. Organise these workers (by geographical sector, for exam- n access to care, or logistics of referral; ple) and have them report to a key person and and place. Organising them this way will help n quality of medical care until death. gain access to and knowledge about the pregnant and lactating women in the popula- The information may come from grave watch- tion and provide a communication system to ers, hospital/health-post staff or from commu- help refer women with serious complications nity reports. Verbal autopsy, which has been related to pregnancy, delivery, the post- used in certain refugee situations, has proved partum period or spontaneous or unsafe relatively successful when medical records are abortion. Conduct training on the objectives unavailable. and flow of data collection, case definitions, completion and timely submission of collec- Reporting Rape/Sexual Violence tion forms, and on the use of the data to im- The person responsible for addressing sexual prove programmes. violence can devise an appropriate tracking Surveillance and Monitoring 99

system, in collaboration with camp authorities n Prepare and distribute summary reports to CHAPTER NINE and health care workers. Survivors of sexual all interested persons, agencies and host- violence may be seen in health facilities or country authorities, as indicated. reported by TBAs, community workers or other n Reassess programme objectives, indica- key informants. Since sexual violence is sensi- tors and interventions. Indicators can be tive and usually under-reported, note all reported evaluated in terms of their accuracy, com- cases or suspected cases. Confidentiality of sur- pleteness, relevance and timeliness. vivors must be ensured.

5. Analyse the Data 8. Improve Assessment Capability Analyse the data to address the problems and Surveillance Systems raised by the programme objectives. According to Need As disease incidences change, the situation n Calculate rates, ratios and proportions, stabilises and service provision becomes more and prepare tables, graphs and charts. comprehensive, the surveillance system may Compare these rates with expected need to be adapted. The system may need to values or reference rates. Trends are be expanded to include more conditions in the more important than point estimates. list of reportable illnesses. Programmes can n Prioritise the most important health prob- add or change indicators, or they can add lems as judged by cause-specific morbid- sources and methods of data collection. ity and mortality.

n Identify the subgroups at highest risk for health problems by person, place and time (such as by age and sex).

n Identify the factors potentially responsible for morbidity and mortality. For example, a List of Annexes high number of reported cases of genital ulcer disease among adolescent women Annex 1 RH Indicators for Early could indicate a need to target them for Phase syphilis prevention and treatment.

n Share data analysis with service providers Annex 2 RH Indicators in Stabilised and the community. Phase Annex 3 RH Reference Rates and 6. Implement Programmes Based on Ratios the Analysis Annex 4 Reference Rates and Ratios n Use the data to develop feasible, effective for RH Indicators and efficient strategies for achieving the programme objectives. Annex 5 Estimating Number of Pregnant Women in a n Implement the selected strategies and a Population system to monitor their progress. Annex 6 Worksheet for Monthly RH 7. Assess Programme Progress Reporting n Assess programme progress by confirm- Annex 7 Summary of RH Indicators ing whether programme objectives have been met. 100

ANNEX 1

RH Indicators for Early Phase supply” based on the number of potential Annexwomen (see Chapter 9, 5) exposures. 100 precautions. 100 pregnancy have access to clean 1000 10000 A case definition of Sexual Violence × × × × (numerator/denominator) Assumptions Total populationsupplies to carry out universal precautions system for supplies related to universal needs to be developed. Total population kits May have to estimate number of pregnant 100% of Supplies for Outcome Number of health facilities with adequate Measures the effectiveness of distribution Distribute Estimate of Outcome Number of condoms distributed in Measures whether condom supplies are : Distribute Estimate of Outcome Number of clean delivery kits distributedlate in women whether Measures Reduce the Incidence of Impact Number of incidents SV reported in Consider providing age and sex-specific Programme/Component Objectives IndicatorMINIMUM INITIAL SERVICE PACKAGE (MISP) – THESE INDICATORS ARE APPLICABLE TO BOTH THE EARLY AND STABLISED PHASES 1) Type SV prevention: Definition Data use, Remarks, Important incidence of reported SV from ___%to ___%. sexual violence the specified time period incidence rates. —————————— precautions against HIV/AIDStransmission. for ____% of pregnant women. clean delivery Number of camp service delivery points Each service must define “adequate Estimated number of pregnant women delivery kits. health facilities will have adequate universal sufficient clean delivery kits coverage of ——————————- 2) Universal precautions: supplies to carry out universal precautions4) Intra-partum care ——————————- 3) Condom distribution: supplies of condoms adequate forat least ___% of the total population. condom coverage ——————————- specified time period adequate. Surveillance and Monitoring 101

CHAPTER NINE ghts ANNEX 2/1

RH Indicators for Stabilised Phase Measures the health and nutritional status of pregnant in place. 1,000 100 also identify infants at higher risk who may need 100camp. a 100 as malaria or syphilis. 100 Assumes that: a) both indirect and direct maternal × × × × × (numerator/denominator) which are disseminated to health staff ——————————— Number of live births in the specified time period ——————————— period <1,500 gms in the specified time period women, and can help detect disease outbreaks in ——————————— period Number of infants 22 gestation weeks A general measure of pregnancy outcome. ——————————— in the specified time period policies. weight recorded) in the specified time weight recorded) in the specified time Total number of live births and stillbirthsnational on based stillbirth of definition Verify Total number of reported deaths maternal deaths. mortality events are investigated, to reduce under- reporting; b) a protocol for investigations is Neonatal Impact Number of live born infants who die Measures the overall health status of new-borns. percentage birth weight percentage Low birthLow Impact Number of live born infants weighing Measures the health status of pregnant women lowVery Impact Number of live born infants weighing Stillbirth Impact Investi- Process Number of reported maternal deaths Measures the programme’s capacity to identify all

The list of indicators provided in Annex 2 has been developed as a “master list”. It is the responsibility of the RH Coordinator to select from this list indicators that should be assessed in a given situation. The indicators selected should be based on the objectives of the RH programme in each situation. Targets set for each objective should be based on knowledge of the actual Reduce the neonatal mortality rateby ___%. mortality < 28 days of age in the specified time rate period Programme/Component Objectives IndicatorSAFE MOTHERHOOD Type1) Maternal and child health status: Definition Data use, Remarks, Important Assumptions Reduce the rate of live born infants 2) Maternal and child health status: Reduce the rate of live born infants weight3) Maternal and child health status: weighing <1,500 gms., from ___% <2,500 gms in the specified time period and the adequacy of antenatal care. Birth wei 4) Maternal and child health status: Reduce the number of infants born dead ratiofrom ___% to ___%.5) Maternal and child health status: 100% of reported maternal deaths or greater than 500g who are are investigated according toestablished guidelines, and the results gationare disseminated to health staff. deathsmaternal of which are investigated according to of established guidelines, and the resultsperiodtime specified the in dead born maternal deaths and to determine the risk factors deaths. those to contribute that May be elevated during outbreaks of diseases such ——————————— weighing <2,500 gms., from ___% to ___%.to ___%. Total number of live births (with birth special care. Total number of live births (with birth situation or information from country of origin where possible. 102 . ital asure of ANNEX 2/2

RH Indicators for Stabilised Phase 100 * This indicator is measured at the time of birth. 1000 100 100 100 * This indicator is measured at the time of birth. × × × × × (numerator/denominator) time period ——————————— Number of live births in the specified time period time periodNumber of live births in the specified time period specified time period who had been tested. being vaccinated with tetanus toxoid. ——————————— Number of live births in the specified time tested for syphilis in the specified systematic. Is only valid if all pregnant women are ——————————— Number of live births in the specified vaccination Syphilis Impact Number of pregnant women screened Measures how common syphilis infection is among taneousabortionsTetanus period. ——————————— Outcome Number of women delivering in the Measures whether women of reproductive age are womenwerewho women pregnant of Number There is a possible bias if syphilis testing not Coverage Outcome Number of women delivering in the Measures whether pregnant women are 100% of Coverage Outcome Number of women delivering in the Measures whether pregnant women are being The incidence Incidence Impact Number of unsafe and spontaneous Measures effectiveness of antenatal care in Programme/Component Objectives Indicator Type Definition Data use, Remarks, Important Assumptions pregnant women will be screened forsyphilis before delivery. of syphilis specified time period who had been screening screened for syphilis. tested for syphilis during the pregnancy 7) Antenatal care: 8) Antenatal care/STD prevention: Reduce the percentage of pregnantwomen who test positive for syphilisfrom ___% to ___%. infection among9) Antenatal care: for syphilis in the specified time periodof unsafe and spontaneous abortions pregnant women, and the potential for congen who tested positive for syphilisshould be less than ___% of unsafe pregnant syphilis. abortions before 22 weeks of gestation ——————————— and spon-10) Antenatal care: preventing early pregnancy loss. Also is me At least ___% of women delivering is adequately vaccinated with tetanustoxoid. coverage or below 500g in the specified time women’s general health. adequately vaccinated with tetanus * This indicator is measured at the time of birth toxoid Neonatal tetanus cases should also be reported. 6) Antenatal care: Trained personnel will attend to allpregnant women at least once. of antenatal care specified time period who had attended receiving minimal antenatal visits. antenatal services (at least once). Surveillance and Monitoring 103

CHAPTER NINE referral

ANNEX 2/3

RH Indicators for Stabilised Phase eclampsia, or haemorrhage. 100 100 Caesarean section rates will depend on the physical 1000 100 Trained health workers could include staff in facilities 100 × × × × × (numerator/denominator) ——————————— the specified time period is hereditary and will affect these rates). specified time period——————————— and obstetric care. emergencies in the specified time period periodtime category, per WHO guidelines.) time periodtime obstetric emergencies such as ruptured uterus, ——————————— Number of live births in the specified and hospitals, etc. (TBAs are not included in this ——————————— Total number of women with obstetric Outcome Number of women reproductive Measures whether women can identify danger signs Outcomebydelivered women of Number Measures access to emergency surgical obstetric of obstetric Knowledge complica-tions Caesarean Number of women reproductive age tions Number of live births in a specified Cause-specific rates can be calculated for various services cies 100% of Manage- Outcome Number of women with obstetric Measures the quality of obstetric care. Reduce the Incidence Impact Number of obstetric complications in the Measures the coverage and outcome of antenatal % of deliveries At least : A trained Coverage Outcome Number of women who deliver in the Measures whether trained health workers attend Programme/Component Objectives Indicator Type Definition Data use, Remarks, Important Assumptions can name at least two danger signsof obstetric complications. signs of obstetric signs of obstetric complications for proper care. ___% of women reproductive age of danger15) Intra-partum care: age who can name at least two dangerperformed by Caesarean section willbe at acceptable standards (depending of obstetric complications, which can facilitate sectionon the physical characteristics of percentage Caesarean section in the specifiedperiod time services. ——————————— refugee women).refugee indelivering women of Number characteristics of refugee women (e.g., pelvic size from ___% to ___%. complica- 13) Intra-partum care 14) Intra-partum care: health worker will attend at least___% of deliveries. of trained specified time period who are attended delivery deliveries. by a trained health worker incidence of obstetric complications 11) Intra-partum care: 12) Intra-partum care: women with obstetric emergencieswill be treated in a timely andappropriate manner. ment of obstetric emergencies who are treated in a emergen- timely and appropriate manner in the Case definitions for various obstetric emergencies specified time period need to be developed. 104

ANNEX 2/4

RH Indicators for Stabilised Phase among others. 100 100 quality of postpartum care. 100 incidence and type of obstetric complications, the × × × (numerator/denominator) Total number of women with complications due to abortions, in the period specified time period days___ within ——————————— Number of live births in the specifiedtime period percent of low birth weight births, the proportion Factors determining the timing of visit include: home deliveries, and the neonatal mortality rate, Outcome Number of women with complications Measures the quality of care for complications due Outcome Number of new-borns who receive BCG Measures the extent to which new-borns receive first Manage- Vaccination borns in new- 100% of At least ___% Coverage Outcomedeliveredhave who women of Number Measures whether women receive postpartum visits. : At least ___% Programme/Component Objectives Indicator Type Definition Data use, Remarks, Important Assumptions women with complications due tounsafe and spontaneous abortions willbe treated in a timely and appropriate complica-manner. ment of tions due timely and appropriate manner, in the specified time period due to abortions who are treated in a to unsafe and spontaneous abortion. to abortionsof new-borns will receive BCG andPolio vaccinations within first month ——————————— coverage for BCGbirthdaymonth first by Polio and ——————————— vaccinations early. It is also used as indicator of of life.of and Polio Number of live births during specified 17) Post partum care: of women will receive at least one postpartum visit within ___ days. of postpar- in the specified time period who have tum care received at least one postpartum visit Time period can be up to 42 days following delivery. 16) Intra-partum care: 18) Post partum care Surveillance and Monitoring 105

CHAPTER NINE

ANNEX 2/5

RH Indicators for Stabilised Phase Assumes that survivors have made the choice to take 100 services are defined and disseminated. 100 100actions. legal 100 × × × × (numerator/denominator) ——————————— Number of reported SV survivors in specified time period ——————————— specified time period specified time period prosecuting offenders. Number of reported SV survivors in a ——————————— Number of reported cases SV in a Assumes guidelines and procedures are defined for Outcome Number of identified SV offenders who Measures whether security forces can effectively Coverage Outcome Number of reported SV survivors who Measures whether SV survivors receives critical Timely Outcome Number of SV survivors who present forsurvivors Measures the ability of patients to access services Coverage Process Number of designated health workerstraining in Measures the number of health workers who can serving SV SV survivors ——————————— survivors Number of designated health workers : Prosecute at least Prosecu- Programme/Component Objectives IndicatorSEXUAL VIOLENCE Type1) SV response: Provide basic psychosocial andmedical services to 100% of reportedSV survivors. for SV of services Definition receive basic set of psychosocial & medical services in the specified time services. Data use, Remarks, Important Assumptions survivors period Assumes protocols for psychosocial and medical 2) SV response: ___% of SV survivors will present forcare within 3 days of an event. care for SV3) SV response care within 3 days of an event in the quickly, including emergency contraception. specified time period 4) SV response: All designated health workers aretrained to respond to SV survivors. of health worker trained (or retrained) within the past 2 years to provide services potentially service SV survivors. ___% of identified offenders in reportedin offenders identified of ___% tion of SVSV cases. are prosecuted in the specified time apprehend and prosecute offenders. offenders period “Designated health worker” is defined as those workers who will be providing a particular service. 106

ANNEX 2/6

RH Indicators for Stabilised Phase blood which tested positive could also be reported Assumes HIV test kits are available and used correctly. workers. 100 Assumes STD case management protocols and 100 1000 Optimally, age, sex and syndrome rates could be 100 Requires observation of skills as part supervision. 100 appropriate drugs in place. 100 List of potential outlets needs to be developed, but × × × × × × (numerator/denominator) ——————————— Number of blood samples drawn for transfusion in the specified time period ——————————— Total population calculated. Number of designated health workers appropriate drugs in place. precautions ——————————— Number of health workers Number of potential outlets with condoms Measures the effectiveness of condom distribution Number of potential outlets could include health facilities, bars, and outreach Outcome Number of health workers who Measures whether health workers comply with Training in Processworkershealth designated of Number Measures the extent of STD case management Quality ofQuality Outcome Number of patients with STDs assessed Measures the quality of STD case management. precautions ___% of Practice of 100% of Blood Outcome Number of blood samples drawn for Measures blood safety for transfusion. Condoms will be Outlets for Outcome Reduce the incidence Incidence Impact Number of cases STDs reported in Measures a programme’s potential impact on the blood drawn for transfusion will be screening transfusion that are screened for HIV All designated health workers will betrained (or retrained) to manage STD STD cases appropriately.case manage- trained to manage STD cases according training for health workers. to protocol ment ——————————— Programme/Component Objectives IndicatorSTDs including HIV/AIDS Type1) Safe blood provision: Definition Data use, Remarks, Important Assumptions according to protocol.4) STD control: ment Number of patients with STDs Requires observation of skills as part supervision. screened for HIV. for HIV in the specified time period of % 2) STD control: of STDs from ___% to ___%.3) STD control: of STDs___% of patients with STDs will beassessed, treated and counselled STD case manage- a specified time period and treated according to protocol ——————————— 5) Universal precautions: Assumes STD case management protocols and health workers will carry out universal incidence of STDs. precautions. universal6) Condom use: available for distribution in 100% of demonstrate use of universalpotential outlets. condoms universal precautions. available for distribution distribution systems. ——————————— Surveillance and Monitoring 107

CHAPTER NINE

ANNEX 2/7

RH Indicators for Stabilised Phase 100 100 × × (numerator/denominator) Number of persons in target population with a non-regular partner, within ——————————— Number of persons in target population who report having had intercourse with a non-regular partner, within specified time period preventive effecs, and can non-regular Condom Outcome Number of persons in target population Measures the impact of a community-education Knowledge Outcome Number of persons in target population Measures the impact of a community-education and correct condom describe how to use it correctly and will be able Programme/Component Objectives Indicator Type Definition Data use, Remarks, Important Assumptions 8) Condom use: ___% of persons in target populationwill report condom use at last with use intercourse with a non-regular partner. partners reporting condom use at last intercourse programme about on behaviour specified time period 7) Condom use: ___% of persons in target populationwill recognise a condom, know its of function who recognise a condom, know its programme about condom use on knowledge. preventive effects, to describe how use it correctly. use ——————————— 108

ANNEX 2/8

RH Indicators for Stabilised Phase in setting this target. 100 100 100 100 × × × × (numerator/denominator) family planning services Number of sexually active refugees able Measures knowledge of family planning in the targeted for family planning messages Number of service delivery points ——————————— Number of health workers who provide (CPR) Number of women reproductive age Knowledge of the CPR in country origin will assist planning Number of sexually active refugees All contraceptive Contra- Outcome Number of service delivery points which Measures effectiveness of contraceptive supply At least ___% Community Outcome All health workers Coverage Outcome Number of health workers who provide Measures extent of family planning training provided At least ___% Contracep- Outcome Number of women reproductive age Measures what per cent of women is using Programme/Component Objectives IndicatorFAMILY PLANNING Type1) Family planning: of women reproductive age will usea method of contraception. tive preva- Definition using any method of contraception lence rate contraception. ——————————— Data use, Remarks, Important Assumptions 3) Family planning: of sexually active refugees willknowledgeappropriate demonstrate about family planning. concerning knowledge4) Family planning: service delivery points will maintain planninga minimum of 3 months’ supply to site major messages about familyeach of combined oral contraceptive family ceptivepills, progestin-only and injectables. population and is based on the major messages supply maintain a minimum of 3 months’ supply ——————————— distribution system. of each of combined oral contraceptive ——————————— pills, progestin-only and injectables given during awareness activities. 2) Family planning: who provide family planning serviceswill be trained (or retrained) to providefamily of appropriate family planning services. planning training family planning services and who were trained (or retrained) in the past 2 years to health workers. to provide family planning services Surveillance and Monitoring 109

CHAPTER NINE

ANNEX 2/9

RH Indicators for Stabilised Phase 1,000 Need to define age group for young people relevant 100 behaviour. 100 100 100supervision. of × × × × × (numerator/denominator) reporting condom use at last intercourse programme about condom use on young people’s Total number of young people to local situation. periodtime to local situation. surveyed Number of live births in the specified Need to define age group for young women relevant services at health facility during specific time period. people ——————————— people Condomuse among Outcome Number of sexually active young people Measures the impact of a community-education Young Impact Number of live births to young women Measures how common births are among young Contracep- Outcome Number of sexually active young people Measures what per cent of sexually active young servicesfor youngperiod time ——————————— Requires observation of skills performance as part people. Number of young people seeking percentage young surveyed Reduce Incidence Impact Number of reported cases of STDs Measures a programme’s potential impact on the ___% of youngof ___% of Quality Outcomearewho people young of Number Measures the quality of reproductive health services Reduce the percentage women in the specified time period women. Programme/Component Objectives IndicatorREPRODUCTIVE HEALTH OF YOUNG PEOPLE Type1) Young people and STDs: the incidence of STDs among youngpeople from ___‰ to ___‰. of STDs Definitionyoung in specifiedthe in people young among incidence of STDs among young people. time period Data use, Remarks, Important Assumptions 4) Young people and STDs/HIV: At least ___% of sexually active young people will report condom use at last young ——————————— intercourse. people Number of sexually active young people 2) Young people and safe motherhood: of all births that occur to young women birth3) Young people and family planning: At least ___% of sexually active youngpeople will use a method of tive preva- ——————————— who use a method of contraception lence rate people are using contraception. ——————————— 5) Quality of care: people receiving adequate careaccording to protocol. reproductive health assessed, treated and counselledpeople. young for according to protocol during specified from ___% to ___%. contraception among Number of sexually active young people 110

ANNEX 3 RH Reference Rates and Ratios

RH Reference The figures shown here have been collected from various sources and cover Rates and different periods. They are intended to give estimates of what may be expected in Ratios some populations. These figures are not to be used as definitive baseline rates or as rates to be achieved. They merely indicate the possible range and may assist with resource planning and with targeting specific programmes.

Abortions 10-15% of all pregnancies may spontaneously abort before 20 weeks gestation 90% of these will occur during the first three months 15-20% of all spontaneous abortions that occur require medical interventions

Hypertensive 5-20% of all pregnancies will develop HDP Disorder of Pregnancy 5-25% of all primigravida pregnancies will develop HDP (HDP) or Pre-eclampsia

Labour and 15% of all pregnancies will require some type of Delivery intervention at delivery Complications 3-7% of all pregnancies will require a Caesarean section 10-15% of all women will have some degree of cephalo- pelvic disproportion (higher in poorer socio- economic populations) 10% of deliveries will involve a primary postpartum haemorrhage (within 24 hours of delivery) Data Sources 0.1-1.0% of deliveries will involve a secondary postpartum haemorrhage (occurring 24 hours or more after WHO Collaborating Centre in delivery) Perinatal Care and Health Services Research in Maternal and Child 0.1-0.4% deliveries will result in uterine rupture Health, Pregnancy and Infant Health 0.25-2.4% of all deliveries will result in some type of birth Branches, Division of Reproductive trauma to the baby Health, NCCDPHP, Centers for Diseases Control and Prevention, 1.5% of all births will have a congenital malformation Atlanta, GA., 30333 USA (does not include cardiac malformations diagnosed later in neonatal period). Sing, S. and Wulf, P., Estimated Levels of Induced Abortion in Six Latin 31% of these malformations will result in death. American Countries, International Family Planning Perspectives, 1994, 20 (1): 4-13. Surveillance and Monitoring 111

CHAPTER NINE Reference Rates and Ratios for RH Indicators

Regional Indicators ANNEX 4

Reference Indicator Sub-Saharan South East Industrial (1) Rates and Africa Asia and Countries Ratios for Pacific RH Indicators Safe Motherhood

Crude birth rate (per 1000 population) 44 26 13

Neonatal Mortality Rate (per 1000 live births) 53 36 5

Perinatal Mortality Rate (per 1000 live births) 83 51 8

Maternal mortality ratio (per 100,000 live births) 971 447 31

Infant mortality rate (per 1000 live births) 97 50 14

Coverage of Antenatal Care (%) 63 65 95

Low birth weight percentage (per 100 live births) 16 15 6

Births attended by trained health personnel (%) 42 53 99

Institutional Deliveries (% of live births) 20 41 98

Unsafe Abortion (1000 women 15-49) 26 15 1

Anaemia in Pregnant Women (%) 52 57 18

Coverage of Tetanus vaccination (Preg. Women) 46 49 –

STDs, including HIV/AIDS

STD Incidence Rate (per 1,000 population) 254 160 77

AIDS cases (per 100,000) 94 80 27

Family planning

Contraceptive prevalence rate 15.9 53.2 70.5

Others

Reference – UNDP Human Development Report - 1997 and World Health Report 1996

(1) Complete this table with country-specific information either from host or country of origin. 112

Estimating Number of Pregnant Women in the Population If Total Population is 100 000 ANNEX 5

Estimating If CBR is (per 1,000 population) 55 45 35 25 Number of Pregnant a) Estimated number of live births in the year 5500 4500 3500 2500 Women in a b) Estimated live births expected per months (a/12) 458 375 292 208 Population c) Estimated number of pregnancies that end in stillbirths or miscarriages (estimated at 15 per cent of live births = a × 0.15) 825 675 525 375

d) Estimated pregnancies expected in the year (a + c) 6325 5175 4025 2875

e) Estimated number of women pregnant in a given month (70 % of d)* 4400 3600 2800 2000

f) Estimated % of total population who are pregnant at a given period 4.4 3.6 2.8 2

* this is a weighted estimate of full-term pregnancies plus those pregnancies that terminate early Surveillance and Monitoring 113

CHAPTER NINE Sample Worksheet for Monthly Reproductive Health Reporting ANNEX 6/1

Month: Sample Worksheet Total Pop: for Monthly Camp Name: Pop of Reproductive Women 15-49: Health Agency: Reporting

1 – Safe Motherhood – Ante-natal Care <19 years >19 years Total

1a: Number of antenatal visits - First Time

1b: Number of antenatal visits - Repeat

1c: Total antenatal visits

1d: Number of women treated for complications of abortions

1e: Number of pregnant women screened for syphilis

1f: Number of pregnant women screened for syphilis testing positive

Indicators rates – Antenatal coverage: estimated (1a/2e ) [This is an estimate – see 2j below] – Incidence of complications of unsafe and spontaneous abortion (1d/2e) – Coverage of syphilis screening (1e/2e) [This is an estimate – see 2l below] – Prevalence of syphilis infection in pregnant women (1f/1e)

2 – Safe Motherhood – Delivery hospital h.centre home total 2a: Number of births attended by trained staff 2b: Number of births NOT assisted by trained staff 2c: Number of births 2d: Number of stillbirths 2e: Number of livebirths 2f: Number of low birth weight (<2500 gms) 2g: Number of livebirths who die <28 days (neonatal deaths) 2h: Number of obstetric emergencies managed 2i: Number of maternal deaths Number of women giving birth this period who received 2j: Antenatal care services (1-3 Visits) 2k: Adequate Tetanus Toxoid Vaccination 2l: Screened for Syphilis 114

Indicators Rates

– Crude Birth Rate (2e/total population × 1000)

ANNEX 6/2 – Neonatal Mortality Rate (2g/2e × 1000)

Worksheet – Low Birth Weight Rate (2f/2e × 100) for Monthly × Reproductive – Stillbirth Rate (2d/2e 1000) Health – Births attended by trained personnel (2a/2e × 100) Reporting – Coverage of antenatal care (2j/2e × 100)

– Coverage of syphilis screening (2l/2e × 100)

– Incidence of obstetric complications (2h/2e × 1000)

3 – Safe Motherhood – Post-natal Care No.

3a: Number of women visiting post-natal care services (within 6 wks of birth)

Indicator – Post-Natal Care Coverage Rate – (3a/2e × 100)

4 – Sexual Violence No.

4a: Number of cases of sexual violence reported

4b: Number of cases receiving medical care with 3 days

Indicators

Incidence of sexual violence (4a/total population × 10 000)

Timely care for survivors of sexual violence (4b/4a × 100)

5 – STDs including HIV/AIDS No. 5a: Number of units of blood transfused 5b: Number of units of blood for transfusion tested for HIV 5c: Number condoms distributed 5d: Number of cases treated for STDs (total by age, sex and syndrome) Syndromic Case Management Male Female Total – urethral discharge – genital ulcers – vaginal discharge

Total Surveillance and Monitoring 115

CHAPTER NINE STD/HIV Indicators Rate

– Blood screening for HIV (5b/5a × 100)

– Condom coverage (estimate – 5c/ total population × 1000) ANNEX 6/3

– Incidence of STDs (total – 5d/ total population × 1000) Worksheet for Monthly – (STD incident rates could also be calculated by sex, age and syndrome) Reproductive Health Reporting

6 – Family Planning No.

6a: Number of users of modern methods of family planning

By Method Registered beginning New acceptors Total end of month of month this month

COCs

Injectible

POPs

IUDs

TOTAL

Indicator - Contraceptive Prevalence Rate (6a/WRA × 100)

7 – Training

Type of Training in RH Type of Health Worker Number a. b. c. 116

Summary of Reproductive Health Indicators

ANNEX 7 Name of Refugee Situation Year: Population – Total Summary of Reproductive Number of Camps Reporting

Health JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC ALL Indicators Indicators -Safe Motherhood Antenatal coverage: estimated Incid.of complic.of unsafe/spont.abort. per 1000 livebirths Coverage of syphilis screening: estimated Prevalence of syphilis infection in pregnant women Crude Birth Rate Neonatal Mortality Rate per 1000 live births Low Birth Weight Rate Stillbirth Rate Births attended by trained personnel Coverage of antenatal care Coverage of syphilis screening Incidence of obstetric complications Post-Natal Care Coverage Rate

Indicators – Sexual Violence Incidence of sexual violence Timely care for survivors of sexual violence

Indicators – HIV/AIDS/STDs Blood screening for HIV Condom coverage; estimated (per 1000 pop) Incidence of STDs (total – per 1000 pop)

Indicators – Family Planning Contraceptive Prevalence Rate Surveillance and Monitoring 117

Last, J.M. A Dictionary of Epidemiology, CHAPTER NINE Further Readings Oxford University Press, New York, 1883. Berg, C., I. Daniel, and D. Mora. “Guidelines “Mother-baby Package”, WHO, Geneva, 1994. for Maternal Mortality Epidemiological Surveil- lance”, Pan American Health Organization, “Primary Health Care Management Advance- Washington, DC, 1996. ment Programme” (modules include Assess- Bryce, J. and J.B. Roungou, P. Nguyen-Dinh, ing Information Needs, Assessing Health J.F. Naimoli, and J.G. Breman. “Evaluation of Worker Activities, Morbidity and Mortality Sur- National Malaria Control Programmes in Af- veillance, Monitoring and Evaluating, Assess- rica”, Bulletin of the World Health Organiza- ing Service Quality, Management Quality, Cost tion, Vol. 72, Geneva, 1994. Analysis and Other Relevant Topics; includes managers’ guides and computer pro- Gosling, Louisa and Mike Edwards. “A Practi- grammes), Aga Khan Foundation, USA, 1993. cal Guide to Assessment, Monitoring, Review and Evaluation”, Development Manual 5, Save “Safe Motherhood Needs Assessment Part VI: the Children Fund, London. Maternal Death Review Guidelines”, WHO, Field-test Draft, Geneva, 1997. “Guidelines for Evaluating Surveillance Sys- tems”, Morbidity and Mortality Weekly Report, Teutsch, Steven M. and R. Elliott Churchill. Vol. 37, Centers for Disease Control and Pre- Principles and Practice of Public Health Sur- vention, Atlanta, GA, 1995. veillance, Oxford University Press, New York. “Guidelines for Monitoring Availability and Use Toole, M.J. and R.M. Malikki. “Famine of Obstetric Services”, UNICEF/UNFPA/ Affected, Refugee and Displaced Populations: WHO. Recommendations for Public Health Issues”, Hakewill, P.A. and A. Moren. “Monitoring and Morbidity and Mortality Weekly Report, Evaluation of Relief Programmes”, Tropical Vol. 41, 1992. Doctor, 1991. Toole, M.J. and R.J. Waldman. “Prevention of Hausman, Benson and Koert Ritmeijer. “Sur- Excess Mortality in Refugee and Displaced veillance in Emergency Situations”, MSF Medi- Populations in Developed Countries”, Journal cal Department, Amsterdam, 1993. of the American Medical Association, 1990. 118 Information, Education and Communication (IEC) Programmes 119

a1APPENDIX One Information, Education Information, Education and and Communication Communi- cation (IEC) (IEC) Programmes Programmes

Contents: n Essentials of IEC The essentials of IEC and assess the knowledge of different populations about various issues, products and be- n Counselling and the Role of the Counsellor Information, education and communication haviours. Channels might include interpersonal n (IEC) combines strategies, approaches and communication (such as individual discus- Steps in Developing sions, counselling sessions or group discus- Materials for an IEC methods that enable individuals, families, Activity groups, organisations and communities to sions and community meetings and events) or n Undertaking a play active roles in achieving, protecting and mass media communication (such as radio, tel- evision and other forms of one-way communi- Reproductive Health sustaining their own health. Embodied in IEC (RH) Needs Assessment cation, such as brochures, leaflets and posters, is the process of learning that empowers n visual and audio visual presentations and Field tools for people to make decisions, modify behaviours Conducting RH and change social conditions. Activities are some forms of electronic communication). Needs Assessments developed based upon needs assessments, Good communication between users and pro- n Links to Providing sound educational principles, and periodic viders of any service is essential; but it is es- Services, Support and Follow-up evaluation using a clear set of goals and ob- pecially important when providing RH serv- jectives. IEC activities should never be devel- ices, given the sensitive nature of some of the oped or implemented independently from a issues that are addressed (such as sexual broader reproductive health programme that violence, female genital mutilation, and pro- is being designed and executed in the country. viding contraceptives to adolescents). Ac- IEC activities not only need to have an appro- cordingly, IEC approaches must be carefully priate context in which they are shaped, but it and appropriately designed and selected. is crucial that health services providers be prepared to respond to any demand that may Although good “one-to-one” communication at be created as a result of effective IEC activi- the point of service provision is essential for ties. The influence of underlying social, cul- transmitting information and building trust with tural, economic and environmental conditions the client, communication with other individu- on health are also taken into consideration in als and groups within the community is also the IEC processes. Identifying and promoting vital. It is through such communication net- specific behaviours that are desirable are usu- works that service providers can obtain infor- ally the objectives of IEC efforts. Behaviours mation about users’ needs, priorities and con- are usually affected by many factors including cerns. Such informal information gathering is the most urgent needs of the target population the first step in assessing needs (which can and the risks people perceive in continuing be supplemented by other more formal their current behaviours or in changing to dif- means – see section below). It also helps ferent behaviours. providers better understand the specific setting and context in which they are working, Health information can be communicated which will be useful in the later development through many channels to increase awareness of IEC approaches, messages and materials. 120

These types of conversations, or passing on much as words. It is often through such body information by “word-of-mouth”, has been language that we express our attitudes shown to be one of the most effective commu- towards an issue, a person or a person’s nication channels for acquiring knowledge behaviour. Service providers must become and promoting desired changes in behaviour. skilled in interpreting the body language of Evidence of this is the speed with which ru- users as this may assist them in understand- mours spread and the force of their impact. ing users’ needs and concerns more fully. Field staff should not ignore these informal Service providers must also be aware of their opportunities to educate the public through own body language and the signals they may casual conversation with people in the com- be unknowingly sending to users (e.g., move- munity. ments or expressions that indicate fatigue, boredom, fear, frustration, indecision). It is Once a refugee situation stabilises, it becomes important that the attitude conveyed by the appropriate to consider the development of service provider be compassionate and non- more elaborate and formal IEC strategies. This judgmental. requires serious thought and significant alloca- tion of time and resources. The steps involved in the development of IEC are outlined here, Service Users but this is not intended to be an exhaustive Good communication skills are necessary to guide. More in-depth information and details ensure that good-quality services are provided can be found in the items listed in Further and that service users are satisfied. It is Reading. Whatever materials and formal programmes are developed, it is important to ensure that the different aspects are coordinated, and that the content of any messages and the media used to convey those Good communication skills messages are complementary. It is also vital to could include the following: ensure that people are provided with the necessary support and resources to act in the a effective, “active” listening in manner advised. which the provider gives small verbal or non-verbal feedback Communication that indicates to the client that (s)he is being heard and Communication can be both verbal and non- understood; verbal. a rephrasing what the client has In verbal communication, the tone of voice said to make sure it is correctly can communicate feelings and emotions that understood; are as significant as the words being spoken. a asking open-ended questions, Accordingly, it is important to choose words asking the client to answer that do not offend in any way and that are eas- questions with more than one ily understood. One should avoid using trigger word answers; words, jargon, medical or other sophisticated terms. The use of particular languages may be a making eye contact; important in reaching all sections of a commu- a providing complete attention; nity (women may speak fewer languages than men, for example). a not being curt or showing a condescending attitude toward In non-verbal communication, body position, the client. gestures and facial expression, often referred to as “body language”, can communicate as Information, Education and Communication (IEC) Programmes 121

through communication that trust and rapport can also serve as role models for desired APPENDIX One are established between the provider and user behaviours and actions. of a service. Emotional support and the com- ¡ Provide these individuals with very clear in- munication of concern and understanding by formation about what your intentions are, health staff are often as crucial in providing what you plan to do, and how they can con- quality services as is clinical care. If there is a tribute as partners. Be specific about what strong provider-user relationship established they will gain from working with you and al- in this way, it becomes easier to move towards lowing you access to the community. open dialogue on more sensitive aspects of ¡ reproductive health. Provide them with input about your plans before you proceed, and secure their will- ingness to participate and to support your Other Individuals and Community efforts. Groups Beyond communication with service users, it is Counselling necessary to open a dialogue with influential individuals and groups within the community. Counselling is a key component of an IEC pro- Such individuals and groups will need to be gramme. In the best of circumstances, a good identified as early as possible. The nature and counsellor is compassionate and non-judg- intention of services should be explained to mental, is aware of verbal and non-verbal com- them and their concerns and priorities discov- munication skills, is knowledgeable concern- ered and understood. This will not only help ing RH issues, and is respectful of the needs make the services more appropriate to the cli- and rights of the users. In a refugee situation, entele being served, but it will help garner fam- there is often a poor counsellor-to-client ratio, ily and community support for the client in the emergencies are common and the local envi- reproductive health behaviour being promoted. ronment is not conducive to counselling. The following are some pointers for identifying However, at a minimum, counsellors should such individuals and groups: strive to ensure that every service user has the right to the following: ¡ Familiarise yourself with the community with the help of someone who lives in the ¡ environment of the refugees and who pro- Information: to learn about the benefits vides them with some service, advice or and availability of the services. protection. ¡ Access: to obtain services regardless of ¡ Identify individuals who are most impor- gender, creed, colour, marital status or lo- tant in the social structure of the commu- cation. nity with which you are working. They can ¡ Choice: to understand and be able to ap- be existing formal leaders (elected or apply all pertinent information to be able to pointed), but, more often than not, they make an informed choice, ask questions are informal leaders. This can be done by freely, and be answered in an honest, asking many people in the community. As clear and comprehensive manner. certain individuals are named repeatedly, ¡ Safety: a safe and effective service. it will become clear that they are the true ¡ leaders. Privacy: to have a private environment during counselling or services. ¡ Identify individuals who have some influ- ¡ ence within the community, people whose Confidentiality: to be assured that any per- opinions are respected. They will make sonal information will remain confidential. suggestions about how to approach peo- ¡ Dignity: to be treated with courtesy, con- ple and work with them effectively. They sideration and attentiveness. 122

¡ Comfort: to feel comfortable when receiving services. Undertaking a Needs Assessment ¡ Continuity: to receive services and supplies for as long as needed. Be careful never to assume that you know ¡ Opinion: to express views on the services what refugees need or want in their lives or offered. from your projects.

To plan effective interventions, you must find out what refugees think and know about various issues, including their ideas about: what Although the GATHER method of causes sickness and disease and what main- counselling may appear simplistic, tains health, health care, traditional medicine, it is complete and thorough: and reproductive health. It is important to build a relationship of trust and mutual respect in or- G reet users der to get accurate and complete information about sensitive issues such as sexual and A sk users about themselves reproductive matters. T ell users about the service(s) It is usually necessary to use multiple methods available in undertaking a thorough needs assessment. Focus groups, individual interviews or Knowl- H elp users choose the service(s) edge, Attitude, Behaviour and Practice (KABP) they wish to use surveys can be valuable ways to gather information and help develop systems, activities, E xplain how to use the service(s) materials or messages to support RH interven- R eturn for follow-up tions. Only after there is an accurate picture of the refugee community’s knowledge, attitudes, behaviours, expectations and aspirations surrounding reproductive health can you determine what programme and messages might be best suited to its needs. The Role of the Counsellor RH interventions and IEC activities and materi- The counsellor’s role is to provide accurate als should be based on relevant research con- and complete information to help the user ducted through the use of quantitative (how make her/his own decision about which, if any, many) and qualitative (what, why and how) part of the services (s)he will use. The role of methods. Research and discussions should be the counsellor is not to offer advice or decide seen as an integral and ongoing part of plan- on the service to be used. For example, the ning and implementation. counsellor will explain the available family planning methods, their side effects and for whom they are considered most suitable. The Quantitative: user then makes a decision, based on the in- ¡ Use available incidence or prevalence formation given, about which method she/he rates of targeted problems. wishes to use. ¡ Knowledge, Attitude, Behaviour and Prac- Effective counselling requires understanding tice (KABP) Surveys use a series of one’s own values and not unduly influencing closed- and open-ended questions to de- the user’s by imposing, promoting or display- termine what people in a community ing them, particularly in cases where the pro- know, think, believe or do in relation to vider’s and the user’s values are different. their reproductive health. Findings are Information, Education and Communication (IEC) Programmes 123

presented in the form of percentages of what people are thinking about certain top- APPENDIX One people who think or do a certain thing. ics, or why they engage in a particular ac- These surveys require many respondents tivity. that are randomly selected from the community. Interviewers are needed to imple- Field Tools for Conducting RH ment the survey and they must be trained. Needs Assessments This is generally considered an expensive and time-consuming method. Also, this The Reproductive Health for Refugees Con- 1 kind of survey does not usually gather in- sortium has field-tested and finalised five RH formation about what inhibits or promotes needs assessment tools. These are certain behaviours, since those factors n Refugee Leader Questions may arise from the context in which people live and not from their knowledge and n Group Discussion Questions attitudes. n Survey for Analysis by Computer

n Survey for Analysis by Hand Qualitative: n Health Facility Questionnaire and Check- ¡ Individual interviews allow the researcher list to get deeper insights into a person’s thoughts and feelings. Using an interview The purpose of these tools is to assist relief guide, interviewer and respondent talk at workers in refugee/displaced person settings length about the respondent’s feelings in gathering information to assess attitudes about a specific service or issue. If trust is toward RH practices and local medical prac- established and confidentiality ensured, tices/policies, the extent of needed services the interviewer can often get very valuable and the degree to which current services pro- information about the interviewee and the vide what is needed. community, information that might not It is important to note that not all tools will be otherwise be revealed. appropriate for all refugee situations. The ¡ Focus Groups are in-depth discussions, order in which the tools are used may also usually of one to two hours in length, with a vary. In general, refugee leaders are consulted small group of people. Members of the Fo- before any information is gathered from the cus Group should have something in com- larger population. This is often followed by mon with each other (age, sex, and experi- group discussions, key informant interviews ence) in the expectation that this will make and facilities review. In some situations, a sur- it easier for them to talk together. They are vey may be conducted but this is often depend- representatives of the target group in that ent upon resources, time, skills of available they are deliberately chosen. The intention staff and whether or not the level of effort is to make sure different groups within the required by a quantitative survey is warranted. community are represented within the Fo- A clear needs assessment objective will help cus Group, or that several Focus Groups field workers decide which tools are appropri- are held with members drawn from various ate for their particular situation. sectors within the community. Discussions The RHR Consortium comprises American Refugee Committee, are lead by a facilitator who follows a pre- The information provided by the tools must be CARE, Center for Population pared guide that allows for probing into the reviewed in the context of the broader objec- and Family Health, Columbia thoughts and feelings of group members. tive of the needs assessment. Any tool used University’s Mailman School of This method is often considered cost-effec- should be adapted to the local situation and Public Health, The International tive, as many people are gathered together resources available. Judgement is required by Rescue Committee, JSI Research and Training Institute, at one time to express their opinions. Find- those applying the tools. In many cases, other Marie Stopes International and ings are presented in the form of comments resources may exist to support the needs the Women’s Commission for or extracts from interviews, which illustrate assessment and these should be used. Exam- Refugee Women and Children. 124

ples of additional strategies for collecting in- n Develop the IEC activities and involve as formation include: camp registration records many other partners as possible. After (information on women’s ages, marital status, their successful implementation, you and sometimes pregnancy); clinic, health should be able to have a significant impact centre and/or traditional birth attendant on achieving the behavioural objectives. records; in-depth interviews with representa- n Identify potential barriers and ways of tives from UNHCR, UNFPA, Ministry of overcoming them. Health and NGO staff; camp health coordinating committees and NGO logistics officers; n Identify potential partners, resources, and and structured observation at different times other forms of support for your activities of the day and night in the refugee commu- and gain their sustained commitment. nity. n Establish an evaluation plan. The indicators should determine the level of achievement of the behavioural objectives. Steps in Developing IEC Having such specific indicators makes evalu- Activities ating and monitoring the progress and impact of the activities much easier. Additionally, The information gathered through the needs process indicators could be established to assessment provides the framework for the track to what extent and how well the planned development of suitable IEC activities. Any ac- activities have been carried out. tivities and materials must always be culturally sensitive and appropriate. These are the major steps you should follow when designing an IEC IEC Messages activity: n Develop IEC messages. A good message ¡ Conduct a needs assessment. is short, accurate and relevant. It will ¡ Set the goal. This is a broad statement of make, at the most, 3 points. It should be what you would like to see accomplished disseminated in the language of the target with the target audience in the end. audience and should use vocabulary appropriate for that audience. The message n Establish behavioural objectives that will tone may be humorous, didactic, authori- contribute to achieving the goal. tative, rational or emotionally appealing. It may be intended as a one-time appeal or as repetitive reinforcement. It is often necessary to develop several versions of a message depending on the audience to An objective must be SMART: whom it is directed. For example, differing information about contraceptive services S pecific (what and who) will be relevant to women who already M have three or four children already, from easurable (something you can see, that which would be appropriate for ado- hear or touch – usually expressed lescents who are just beginning to be with an action verb) sexually active. Their needs and priorities A rea specific (where) are different, so the IEC materials used with each group must also differ. Find out R ealistic (achievable) if materials already exist in the host coun- T ime-bound (when) try or country of origin, and if appropriate, use these instead of developing new ones. Information, Education and Communication (IEC) Programmes 125

n Pre-testing, by trying out the materials of any message will, in reality, be context-spe- APPENDIX One with small groups from your larger target cific; often a group of messages will be decided audience, is an essential part of develop- upon, rather than just one. ing messages and educational materials. It is through pre-testing that you will en- Sexual Violence: sure that people understand the message as intended. Pre-testing may need to be n The importance for women to seek repeated frequently until you are sure your medical care as soon as possible information is being conveyed as desired. n Where to go for counselling if it is available n Determine suitable methods and channels of action and communication. Once the tar- n How to prevent it, particularly in col- get audience is identified and researched laboration with others in the community and the key messages have been chosen, it is time to decide which media and combi- Safe Motherhood: nations of information channels will reach the target group. Both formal and informal n The reasons why it is important for groups can be targeted. Different channels women to seek prenatal care do different jobs. Each has its own n The need to and how to identify obstetric strengths and weaknesses, depending the complications and refer immediately role it will take in the communication pro- n gramme. The choice of messages and me- The reasons it is important to breastfeed dia will be influenced by many factors: cost; exclusively and the importance of literacy levels; artistic style within the com- maternal nutrition munity; familiarity with, and extent of pen- etration of a particular medium for both Sexually Transmitted Diseases service providers and users; and availabil- (STDs)/HIV/AIDS: ity of the medium in the target population’s n How to use condoms and how to dispose community. of them safely

The development and refinement of messages n How HIV is and is not transmitted and the choice of the communication channel or medium are inseparable. Very different n Means of prevention messages will be developed for different me- n Common signs and symptoms dia, for example radio, stories, poems, songs, posters or flip charts, for the nature of the n Where to receive counselling medium affects what messages can be suc- n Where to receive treatment cessfully used. The skills of those using the n materials must also be considered. It may be Where to go for support services necessary to provide training to those staff n Why it is important to inform and involve expected to use the materials. For example, it all sexual partners is important to recognise that placing a picture or poster on a clinic wall at which people may Family Planning: or may not look is quite different from using a series of pictures in the form of a flip chart as n How and where to obtain reproductive an educational tool in a group setting. health services, including contraceptive supplies The following are some suggestions for key n Where to get information or counselling messages on technical topics that may be shared. These are presented as examples n How adequate birth spacing contributes only and are shown out of context. The choice to healthy families 126

Reproductive Health of Young Further Readings People: n How young people can protect them- “A Tool Box for Building Health Communica- selves through safe sex tion Capacity”, Healthcom, Academy for Edu- cational Development, Washington, DC, 1995. n Delay and patience is a positive value and that there are other ways to have Debus M. Methodological Review: A Hand- fun book for Excellence in Focus Group Research, n Young people need to take responsibility Washington, DC, Academy for Educational for their own health Development, 1988.

n High-risk behaviours may result in long “Developing Health and Family Planning Print term, unwanted consequences Materials for Low-Literate Audiences: A Guide”, Program for Appropriate Technology in Health, Seattle, PATH, 1989. Links to Providing Services, Support and Follow-up “Developing Health Promotion and Education Initiatives in Reproductive Health: A Frame- For IEC of any kind to be effective it must be work for Action Planning”, WHO, RHR, linked with the availability of support and re- Geneva, 1998. sources so target audiences can act in the manner which is being recommended. It is “Facts for Life”, UNESCO/UNICEF/WHO. therefore essential that the content of any IEC “Guide to Planning Health Promotion for AIDS programme accurately reflect the nature and Prevention and Control”, WHO AIDS Series 5, quality of the services provided. Logistical sup- Geneva, WHO, 1989. port must be adequate to ensure the necessary supplies (material and human) are con- “Refugee Reproductive Health Needs Assess- sistently available and adequate training ment Field Tools”, RHR Consortium, 1997. should be provided to health workers to support inter-personal communication and com- “Tools for Project Evaluation: A Guide for munity follow-up. People must be able to act Evaluating AIDS Prevention Interventions”, on the advice contained in the IEC messages Family Health International , AIDSTECH/Fam- and materials. ily Health International, Durham, NC, 1992. Legal Considerations 127

a2APPENDIX Two Legal Considerations: Legal Considera- Refugee Rights Related to tions: Reproductive Health Refugee Rights Related to Reproductive contained in international human rights decla- Health Reproductive Health Rights rations and treaties. These principles apply to Based on International and all persons, including refugees, without dis- Human Rights Instruments crimination.

Refugees are entitled to the protections out- n The right to the highest attainable lined in the 1951 Convention relating to the standard of physical and mental Status of Refugees, and its 1967 Protocol, as health well as in other relevant international human rights declarations and treaties, including: Sexual and reproductive health are essential elements of the right to health, as n the Universal Declaration of Human Rights, they cannot be separated from men and women’s overall well-being and their right n the Covenant on Civil and Political to the “enjoyment of the highest attain- Rights, able standard of physical and mental n the Covenant on Economic, Social and health”. International human rights law Cultural Rights, and recognises that health represents an important factor in the realisation of the n the Convention on the Elimination of All Forms of Discrimination Against Women. right to an adequate standard of living, including adequate food, clothing, hous- Reproductive rights embrace many of the ing, water and sanitation. States parties human rights recognised in these documents. to the Conventions in which this right is Other, more recent, documents, particularly described are obliged to take measures the 1994 Cairo Programme of Action of the that ensure “the reduction of the stillbirth- United Nations International Conference on rate and of infant mortality and the Population and Development (ICPD) and the healthy development of the child”, and Beijing Platform for Action of the 1995 World “the creation of conditions which would Conference on Women, reflect broad interna- assure to all medical service and medical tional consensus on the issue of reproductive attention in the event of sickness”. rights. Reproductive health (RH) care may also be safeguarded by national laws, which n The right to the survival and extend government responsibility for such development of the child care beyond international obligations. The policies of the host country should guide the States parties to the Conventions are implementation of RH care in refugee situa- obliged to ensure, to the maximum extent tions and humanitarian actors should familiar- possible, the survival and development of ise themselves with these policies. the child. In this context, the threat to women’s lives posed by the lack of RH The following is a brief overview of basic prin- care affects the health and development ciples related to reproductive health that are of children. 128

n Obligation on States to take meas- n The right of men and women of ures to abolish traditional practices marriageable age to marry and found prejudicial to the health of children a family States shall take all effective and appro- The World Health Organization recom- priate measures with a view to abolishing mends that the minimum age for girls to traditional practices prejudicial to the marry should be 18 years. health of children. These include the practices of female genital mutilation and n The betrothal and the marriage of a early childhood marriage, which not only child, as defined by national legisla- harm girls, but may also adversely affect tion, is specifically prohibited their future offspring. Early maternity is often an immediate result of early childhood marriage and n The right of equal access to can have adverse effects on the physical health care development of the mother and her child. States parties to the Conventions shall take all appropriate measures to elimi- n The rights of the family special nate discrimination against women in protection the field of health care to ensure, on a basis of equality of men and women, ac- The family, as the natural and fundamen- cess to health care services, including tal group unit of society, is entitled to the those relating to family planning. widest possible protection and assistance, particularly for its establishment and while it is responsible for the care n The equal right to reproductive and education of dependent children. choice

Men and women have the same rights to n Special rights in relation to mother- decide freely and responsibly on the hood and childhood number and spacing of their children and These are special provisions for pre- and to have access to the information, educa- postnatal health care for women and chil- tion and means to enable them to exer- dren. cise these rights.

n The right to enjoy the benefits of n The right to education scientific progress Everyone has the right to education. In Everyone has the right to enjoy the ben- particular, women have equal rights with efits of scientific progress and its applica- men to specific educational information tions, which should also be interpreted to to help ensure the health and well-being encompass reproductive health. of their families, including information and advice on family planning. The best interest of the child shall be the guiding principle of those responsible for his/her Pregnancy education and guidance; that responsibility lies in the first place with the parents. There are special rights pertaining to pregnant Adequate information and counselling and lactating women articulated in interna- are critical to enabling refugees to make tional documents (see above). The issue of informed choices about their reproduc- termination of pregnancy, however, is highly tive health. controversial. In most countries, national laws Legal Considerations 129

and policies regulate the termination of preg- (Refer to UNHCR Guidelines on Preventing APPENDIX Two nancies. Where the matter is regulated, due and Responding to Sexual Violence against regard must be paid to the laws and policies of Refugees, specifically Chapter 4, “Legal the host country. In many countries where Aspects of Sexual Violence”. These guide- abortion is normally highly restricted, it is none- lines provide a clear and comprehensive theless permitted under certain conditions analysis of the legal framework governing the when a pregnancy results from rape, incest, or prevention of sexual violence in the refugee threatens the life of the woman. context.)

Sexual Violence Cairo Programme of Action of the 1994 United Nations International Sexual violence against refugees is a global Conference on Population and problem and constitutes a violation of human Development (ICPD) rights as enshrined in international declarations and treaties: Although not legally binding, the Cairo ICPD Programme of Action is an important step in n The right to life, liberty and security of recognising reproductive rights internationally. person It represents the political consensus of 184 nations. n The right to freedom from torture and cruel, inhuman or degrading treatment The ICPD Programme provides for individuals and punishment to decide freely and responsibly the number, n Children’s right to freedom from all spacing and timing of their children and to have forms of physical or mental violence the information and means to do so. It also includes the right of all to make decisions con- The Geneva Conventions and their Protocols, cerning reproduction free of discrimination, which are among the foundations of interna- coercion and violence. tional humanitarian law, also apply to refugees, returnees and internally displaced persons in Furthermore, it expresses the right of men times of armed conflict. These laws offer pro- and women to be informed and to have ac- tection to all civilians, particularly women and cess to safe, effective, affordable and accept- children, against various forms of sexual vio- able methods of family planning of their lence, including mutilation, forced prostitution, choice, as well as other methods of their sexual abuse and rape. choice for regulation of fertility which are not against the law. Regional human rights laws applicable in Europe, the Americas and Africa similarly protect the rights to personal dignity and integrity and prohibit degrading treatment or punish- The Beijing Platform for Action of ment and violence against women. the 1995 World Conference on Women National laws also usually protect against sexual violence. The government on whose Also not legally binding, it nonetheless repre- territory the sexual attack occurred is responsi- sents international consensus in endorsing ble for taking diligent remedial measures, many of the commitments made in the ICPD including conducting a thorough investigation Programme of Action and specifies action to into the crime, identifying and prosecuting be taken by States, international bodies, do- those responsible, and protecting victims from nors, non-governmental organisations and reprisals. others. 130

Further Readings Cook, Rebecca J. “Human Rights and Repro- ductive Self-Determination”, 44 AM U. L. Rev., 975, 1995.

“Guidelines on Refugee Women” and “Guide- lines on Refugee Children”, UNHCR, Geneva.

“Promoting Reproductive Rights: A Global Mandate”, Center for Reproductive Health Law and Policy (CRLP), New York.

“Rights Awareness Training Programme”, UNHCR, Geneva, 1997.

“Sexual Violence against Refugees: Guide- lines on Prevention and Response”, UNHCR, Geneva, 1996.

“Women of the World: Laws and Policies Affecting Their Reproductive Lives: Anglophone Africa”, CRLP and International Federation of Women Lawyers (Kenya Chapter), New York, 1997. Glossary of Terms 131

a3APPENDIX Three Glossary of Glossary Terms of Terms

antenatal care coverage reported on women who are currently Percentage of women attended at least once married or in union, which should be stated during pregnancy by skilled health personnel accordingly. because of their pregnancy. crude birth rate (CBR) birth weight The number of live births in a given period The first weight of the fetus or newborn per 1,000 people in the same period. Usually obtained after birth. This weight is best expressed per year. measured within the first hour of life before significant postnatal weight loss occurs. crude death rate (CDR) The number of deaths per 1,000 people in a case given year. A person in the population or study group identified as having a specific health problem deliveries attended by skilled health or disease of interest. personnel Percentage of deliveries attended by skilled case definition health personnel irrespective of outcome A set of standard criteria for deciding (live birth or fetal death). whether a person has a particular disease or health-related problem. Criteria can be skilled health personnel or skilled clinical, laboratory or epidemiologic. attendant Doctors (specialist or non- specialist), and/or persons with midwifery case-fatality rate (CFR) skills who can diagnose and manage The probability of death among diagnosed obstetrical complications as well as cases of a specific health problem or normal deliveries. (Traditional birth disease. The CFR is defined as number of attendants, trained or untrained, are not deaths due to the disease in a specified time included.) period divided by the number of cases of the disease during the same period. person with midwifery skills A person who has successfully completed the cause-specific death rate prescribed course in midwifery and is able The number of deaths attributable to a to give the necessary supervision, care specific disease in a given population in a and advice to women during pregnancy, given time period (usually expressed per labour and the postpartum period. This 100,000 persons per year). person is also able to conduct deliveries alone, to provide lifesaving obstetric care, contraceptive prevalence rate (CPR) and to care for the newborn and the infant. Percentage of women of reproductive age who are using (or whose partner is using) a epidemiology contraceptive method at a given point in The study of the patterns of human disease, time. In practice the CPR is generally health and behaviours. 132

fetal death (deadborn fetus) indirect obstetric death Those deaths Death prior to the complete expulsion or resulting from previously existing disease extraction from its mother of a product of or disease that developed during preg- conception, irrespective of the duration of nancy and which was not directly the pregnancy. The death is indicated by the fact result of obstetric conditions, but which that after such separation, the fetus does not was aggravated by the physiologic effects breathe or show any other evidence of life, of pregnancy. such as beating of the heart, pulsation of the umbilical cord, or definite movement of maternal mortality rate voluntary muscles. The number of maternal deaths per 100,000 women of reproductive age (15-49). incidence rate (IR) The number of new cases of a health problem or disease in a specified time that occurs in a maternal mortality ratio population at risk of the disease in the same The number of maternal deaths per time period. The rate is expressed per 100, 100,000 live births during the same time 1,000, 10,000 or 100,000. period. live birth neonatal mortality rate The complete expulsion or extraction from its Number of deaths in the neonatal period mother of a product of conception, irrespec- during a given time period per 1,000 live tive of the duration of the pregnancy, which births during the same time period. after such separation, breathes or shows other evidence of life, such as beating of the neonatal period heart, pulsation of the umbilical cord, or Commences at birth and ends 28 completed definite movement of voluntary muscles, days after birth. Neonatal deaths (deaths whether or not the umbilical cord has been among live births during the first 28 com- cut or the placenta is attached. Each product pleted days of life) may be subdivided into of such a birth is considered liveborn. early neonatal deaths, occurring during the first seven days of life, and late neonatal low birth weight deaths, occurring after the seventh day but Less than 2,500 g (up to and including before 28 completed days of life. 2,499 g). maternal death perinatal period The death of a women while pregnant or Commences at 22 completed weeks within 42 days of termination of pregnancy, (154 days) of gestation (when birth weight is irrespective of the duration and the site of the normally 500 g) and ends seven completed pregnancy, from any cause related to or days after birth. aggravated by the pregnancy or its management, but not from accidental or incidental perinatal mortality rate causes. Maternal death is subdivided into Number of deaths in the perinatal period two groups: during a specified period of time per 1,000 total births (live births plus fetal deaths) direct obstetric death Those deaths during the same period of time. resulting from obstetric complications of the pregnant state (pregnancy, labour post-neonatal mortality rate and puerperium), from interventions, Number of deaths after 28 days up to, but omissions, incorrect treatment, or from a not including, one year of age during a given chain of events resulting from any of the time period per 1,000 live births during the above. same period. Glossary of Terms 133

pre-term spontaneous abortion or miscarriage APPENDIX Three Less than 37 completed weeks (less than A fetal death in early pregnancy. At what 259 days) of gestation. Pre-term births are gestational age (point in pregnancy) a also referred to as premature births. miscarriage becomes a stillbirth for reporting purposes depends on the country’s policy. prevalence rate The proportion of the population that has the stillbirth health problem or disease under study. The A fetal death in late pregnancy. At what prevalence rate is expressed as the number gestational age (point in pregnancy) a of existing cases of the disease at a specified miscarriage becomes a stillbirth for reporting point in time in the total population. The ratio purposes depends on the country’s policy. is expressed per 100, 1,000, 10,000 or 100,000. surveillance A dynamic process in which data on the proportion occurrence and distribution of health or A fraction where the numerator is a subset of disease in a population is collected, organ- the denominator. ised, analysed and disseminated. random sampling A method of selecting a sample whereby each total fertility rate element in the population has an equal chance The number of children who would be born (probability) of being selected for the sample. per woman, if the woman was to live to the end of her child-bearing years and bear rate children at each age in accordance with A measure of the frequency of some event in prevailing age-specific fertility rates. a defined population at a specified time. In a rate, the numerator is a subset of the unsafe abortion denominator. The rate is expressed per 100, “A procedure for terminating unwanted 1,000, 10,000 or 100,000. pregnancy either by persons lacking the necessary skills or in an environment ratio lacking minimal medical standards or both” A measure of the frequency of one group of (WHO). events relative to the frequency of a different group of events (e.g., maternal mortality ratio vital statistics is the number of maternal deaths per 100,000 Data collected from continuous or periodic live births). The ratio is expressed per 100, recording or registration of all “vital events”, 1,000, 10,000 or 100,000. such as births, deaths, marriages and divorces. relative risk A measure of the incidence of a condition in women of reproductive age (or women of those exposed to a particular factor in relation childbearing age) to the incidence of that condition in those not Refers to all women aged 15 to 49 years so exposed. (WHO). 134 a4 Reference Reference Addresses Addresses

Contact addresses from which you can IPAS obtain cited reference documents and Box 999 other information Carrboro, NC 27510 USA Fax: 1 919 929 0258 E-mail: [email protected] AEDES 34, rue Joseph II JSI Research and Training Institute B-1040 Brussels, Belgium 1616 North Fort Myers Drive Fax: 32 3 319 09 38 Arlington, VA 22209 USA Fax: 703 528 7480 Appropriate Health Resources & Technologies Action Group - AHRTAG Macmillian Farrington Point Houndmills, Basingstoke 29-35 Farrington Road Hampshire RG21 6XS UK Fax: 44 1256 814 642 London, EC1M 3JB UK Fax: 44 171 242 0041 Médecins sans Frontières International E-mail: [email protected] (MSF) 39, rue de la Tourelle Centers for Disease Control and B-1040 Brussels, Belgium Prevention Fax: 32 2 280 1881 International Emergency and Refugee Website: www.msf.org Health Branch Mailstop F-48, 4770 Buford Highway Oxford University Press Atlanta, Georgia 30341 USA Walton Street, Oxford OX2 6DP UK Fax: 770 488 7829 Fax: 44 1865 267 782 E-mail: [email protected] Population Information Program Website: www.cdc.gov The Johns Hopkins School of Public Health International Federation of the Red Cross 111 Market Street, Suite 310 and Red Crescent Societies Baltimore, Maryland 21202 USA 17, chemin des Crets, Case postale 372 Fax: 410 659 6266 1211 Geneva, Switzerland E-mail: [email protected] Fax: 41 22 730 0395 Reproductive Health for Refugees Website: www.ifrc.org Consortium (RHR Consortium) Contact: The Women’s Commission for International Planned Parenthood Federation Refugee Women and Children Regent’s College Inner Circle 122 East 42nd Street - 12th Floor London NW1 4NS UK New York, NY 10168 USA Fax: 44 171 487 7950 Fax: 212 551 3186 Website: www.ippf.org E-mail: [email protected] Reference Addresses 135

Save the Children Fund UK UNHCR - Centre for Documentation for APPENDIX Four 17 Grove Lane Refugees London SE5 8RD UK Case postale 2500 Fax: 44 171 703 2278 1211 Geneva 2 Switzerland Fax: 41 22 739 73 67 Teaching Aids at Low Cost - TALC E-mail: [email protected] PO Box 49 St Albans Website: www.unhcr.org Herts AL1 5TX UK Fax: 44 1727 846 852 UNICEF Three United Nations Plaza UNAIDS, Information Centre New York, NY 10017 USA 1211 Geneva 27, Switzerland Fax: 212 824 6464 Fax: 41 22 791 4187 Website:www.unicef.org E-mail: [email protected] World Health Organization UNFPA - Contact local country offices or Distribution and Sales 220 East 42nd Street 1211 Geneva 27 Switzerland New York, NY 10017 USA E-mail: [email protected] Fax: 212 297 4915 World Health Organization or Department of Reproductive Health and Research UNFPA Emergency Relief Office 1211 Geneva 27 Switzerland 9 Chemin des Anemones Fax: 41 22 791 41 89 1219 Geneva, Switzerland E-mail: [email protected] Fax: 41 22 979 9049 Website: www.who.org E-mail: [email protected] Website: www.unfpa.org World Bank 1818 H Street N.W. Washington, DC 20433 USA Fax: 202 477 6391 Website: www.worldbank.org Action Contre la Faim African Medical and Research Foundation American Refugee Committee CARE Centre for Research on the Epidemiology of Disasters Centro de Capacitación en Ecología y Salud para Campesinos Center for Population and Family Health – Columbia University Mailman School of Public Health Family Health International International Centre for Migration and Health International Federation of the Red Cross and Red Crescent Societies Ipas International Planned Parenthood Federation International Rescue Committee International Organization for Migration JSI Research and Training Institute London School of Hygiene and Tropical Medicine Marie Stopes International Médecins du Monde Médecins sans Frontières MERLIN (Medical Emergency Relief International) Population Council Save the Children Fund UK United Nations Children’s Fund United Nations High Commissioner for Refugees United Nations Joint Programme on AIDS United Nations Fund for Population Activities U.S. Agency for International Development U.S. Centers for Disease Control and Prevention U.S. Department of Health and Human Services U.S. Department of State Women’s Commission for Refugee Women and Children World Association of Girl Guides and Girl Scouts World Health Organization