Reproductive Health for Displaced Populations

February 1998 R ELIEF AND REHABILITATION NETWORK RRN 24 paper NETWORK Reproductive health for displaced populations

by Celia Palmer

Abstract

The provision of reproductive health (RH) concerns in emergencies, in reality the agenda services by humanitarian agencies to displaced has proved difficult to implement. Some aspects populations is relatively new. Until recently, the raise ethical and moral concerns to which needs of displaced people in emergency settings humanitarian agencies have different attitudes. were often ignored. During the eighties, attempts Bilateral agencies, non-governmental were made to address the problem, and in the organisations and donors are grappling with last few years increasing attention has been paid difficult decisions as to what services they should to these needs in emergency contexts. In provide and how to ensure services are safe and particular, recognition of the major threat posed effective. This is also happening in stable by STDs and AIDS and growing media attention settings. In the absence of good data on both to sexual violence among displaced populations needs and impact of RH service provision in has highlighted the importance of the RH agenda emergencies, much of the emphasis on safe in emergency settings. Alongside changes in RH provision falls to the judgement of field based provision in stable settings, the move to practitioners, with important implications for implement RH services for displaced populations training and appropriate resourcing at that level. was accelerated after the International In this paper available information about Conference on Population and Development in reproductive health among displaced populations 1994. The Conference set reproductive health is presented. Policies of a number of actors are within a rights framework and highlighted the also described and examples of current RH needs of displaced populations. programmes and the issues facing those attempting to implement them are explored. However, despite the increased recognition of RH

2 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ REPRODUCTIVE HEALTH for displaced populations ○○○○○○○○ training, research orprogrammedesign, implementationorevaluation. holders. TheNetworkCoordinator wouldappreciatereceivingdetailsoftheuse anyofthismaterialin Requests forthecommercial reproductionofRRNmaterialshouldbedirected to theODIascopyright Photocopies ofallorpart thispublicationmaybemadeprovidingthatthesource isacknowledged. © OverseasDevelopment Institute, London,1998. Price percopy:£5.00(excludingpostageandpacking) ISBN: Acknowledgements Comments receivedmaybeusedinfuture Newsletters. A copyofyourcommentswillbesenttotheauthor. Web site:www.oneworld.org/odi/rrn/ Email: [email protected] Fax: +44(0)1713931699 Tel: +44(0)1713931674/47/40 United Kingdom London SW1E5DP Stag Place Portland House DevelopmentOverseas Institute Network Relief andRehabilitation Please sendcommentsonthispaperto: unfailing patience. text. Finallyandmostofallthankstotheeditor,Laura Gibbons,forhersubstantialcontributionand particularly toKatewhoofferedhelpfuladditionalinformation andcommentonthefinaldraftof (formerly withMSI)whocontributedstatementson theiragencies'reproductivehealthpolicyand Pitroff, LouisianaLushandGabrielleRoss.Iamgrateful toKateBurnsofUNHCRandLyndall Sachs School ofHygieneandTropical Medicinewhogaveadviceandofferedsuggestions-Anthony Zwi,Rudi and withwhomthisdocumentwasoriginallytobewritten.MythanksalsogothosefromtheLondon I wouldliketothankCarolCollinsofOxfamforherwillingnessdiscussandshareviewsonthisfield those ofanyorganisation represented. of theauthoranddonotnecessarilyreflect Any viewsexpressedinthispaperarethose policies group. global reproductivehealthandpopulation and InesSmythasarepresentativeofthe central researchfundofLondonUniversity to workwhichwaspart-fundedbythe Medicine. Referenceismadeinthepaper the LondonSchoolofHygieneandTropical secondment totheHealthPolicyUnitat Office. Thisworkwasundertakenwhileon Registrar fundedbyNorthThamesRegional Celia PalmerisaPublicHealthSenior Notes ontheAuthor 0-85003-368-3 Contents ○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ 1. Introduction 4 Background to the paper 4 Historical Overview 5 2. What do we know about the RH status of displaced populations? 6 Pre-conflict context 6 Characteristics of displaced populations 8 Specific reproductive health concerns 8 3. Existing and proposed policies on RH for displaced populations 14 Current initiatives to develop reproductive health policies 14 Policies on specific areas of the reproductive health agenda 20 Difficulties in determining policy 20 4. Case studies of current RH services 23 Controlling STDs with Rwandans in Tanzania (1994) 23 Using reproductive health kits in Former Yugoslavia (Feb 1994-Jan 1995) 24 Coordinating reproductive health services for Rwandan refugees in Congo 24 Advocating reproductive health among Kenyan refugees in Somalia (1995-6) 25 Addressing violence among Burundian refugees in Tanzania (1996) 25 Maternal health education in Afghanistan 25 5. Issues affecting implementation of RH services 27 Deciding how to prioritise reproductive health services 27 Assessing the needs of the community 28 Ensuring a high quality of care 29 REPRODUCTIVE HEALTH for displaced populations 6. Conclusion 31

Appendix - signatories to the Interagency Field Manual and participants of the Inter-Agency Working Group 32 Glossary 33 Acronyms 33 Endnotes 34 Bibliography 35 Further Reading 38

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Introduction

1.1 Background to the paper The paper is targeted primarily at those working in the health sector with displaced populations, his paper seeks to give an overview of though not exclusively, as the nature of the reproductive health (RH) needs and service reproductive health agenda means that workers Tprovision in emergency settings and the from other sectors will also be involved. RH implications for those working with displaced service provision may range from education and populations. This first chapter defines counselling on sexual violence to condom reproductive health for the purposes of this paper. distribution to obstetrics, involving a range of Chapter 2 considers what is known about the professional competences. reproductive health status of displaced populations and highlights why these populations have Prevention of sexual violence may, for example particular needs. By displaced populations I refer involve the planners/logisticians in the appropriate to both refugee and internally displaced siting of latrines and water points when planning populations, (although there is evidence to show camps. Steps taken to ensure women-headed that IDPs tend to receive different levels of service households have equal access to food supplies may provision to refugees, not only in the area of RH). also be important, helping to minimise the role The advice contained in the paper also aims to sexual favours may play in their ability to obtain cover all phases of displacement from emergency food and other commodities. Community service to rehabilitation, only distinguishing particular NGOs can help empower women and young phases where these are relevant to the type of people through providing opportunities for income service provided. Current and proposed policies generating activities, which in turn enable them on the provision of reproductive health services to meet and talk together. Legal services will also in emergency settings are outlined in the third have a role to play in ensuring that perpetrators of Chapter with existing programmes illustrated by sexual violence are brought to justice. case study material in Chapter 4. Constraints to the implementation of these services are discussed Unfortunately, although awareness of RH in Chapter 5 and the final chapter summarises the concerns in emergency contexts has increased main conclusions of the paper and suggests considerably over the past few years, much of the possible ways forward. We hope, in this way, to information we have on reproductive health needs both inform aid workers who are new to this is anecdotal or of poor quality. This lack of data agenda and want to learn more about reproductive has led to considerable debate amongst policy health in these contexts. We also aim to clarify a makers and service providers as to the extent of number of key issues for those who are already the need in situations of competing demands for involved in service provision and are familiar with resources and as to the appropriateness and these debates. feasibility of providing safe services. There are a

REPRODUCTIVE HEALTH for displaced populations REPRODUCTIVE HEALTH number of reasons for this: (i) the difficulty of

4 collecting data in situations of insecurity where neglected. Evidence that women’s needs had been ○○○○○○○○ human resources are scarce and there may be rapid ignored to the detriment of their health and that population movements; (ii) the lack of priority of their children was beginning to accumulate. accorded to reproductive health; (iii) the lack of Refugee women were often not being registered importance attached to the collation of data; (iv) in camps; were not consulted when services were the perceived need for rapid responses and action. being planned; were not involved in food ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ This paper explores these and other barriers to RH distribution or targeted for income generating provision with a view to shedding light on some activities. This was despite the fact that women of the debates surrounding provision of these were often heads of households and in some important services. instances made up 30% of the populations of the refugee population (Eriksson et al, 1996). 1.2 Historical Overview At the ICPD conference, the particular problems What is Reproductive Health? The concept was of refugees and populations affected by conflict first developed in the late 1980s but did not gain were officially recognised. The document referred widespread acceptance until the International to, “migrants and displaced persons [who] in many Conference on Population and Development parts of the world have limited access to (ICPD) (Cairo, 1994). The document that arose reproductive healthcare and may face specific from this Conference argued for a move away from serious threats to their reproductive health and population control towards a more holistic view rights. Services must be sensitive to the needs of of women’s health. individual women and adolescents and responsive to their often powerless situation, with particular It recognised the role of men in reproduction and attention to those who are victims of sexual the importance of child survival and finally violence.” The Women’s Commission on Refugee advocated a shift in emphasis from providers to Women and Children were also already drawing beneficiaries, from population policies to attention to the issue of reproductive health individual rights. As such, it was initially greeted services to displaced populations (Wulf, 1994). with excitement and embraced by feminists, women’s advocates, and policy makers in In seeking to meet the objectives of the Cairo women’s health alike. conference, UNHCR and other international agencies brought the services shown in Box 1 The ICPD document defines reproductive health (below) under the RH umbrella - this paper also as, “a state of complete physical, mental and social takes these areas as constituting the principal. well-being and not merely the absence of disease or infirmity, in all matters relating to the

reproductive health system and to its functions and REPRODUCTIVE HEALTH for displaced populations processes. Reproductive health therefore implies Box No. 1 that people are able to have a satisfying and safe Reproductive health services for sex life and that they have the capability to refugee situations as recognised by reproduce and the freedom to decide if, when and the Inter-Agency Field Manual how often to do so”. • safe motherhood; This new approach links a variety of services • sexual and gender-based violence; previously offered by providers who traditionally worked apart. As a result, the developments • the prevention and care of sexually advocated by the Cairo conference necessitate not transmitted diseases (including HIV/ only a shift in attitudes but also involve structural AIDS); and organisational change that those working in • family planning and other reproductive conventional settings are also battling with. The health concerns (including advantages and disadvantages of the new approach gynaecological services and female as well as ways of dealing with them are still being genital mutilation). learned. Adolescent health and the involvement of Whilst this shift in emphasis to RH was occurring men are also highlighted as needing in the non-relief context, there was an increasing particular attention. recognition in relief circles that in emergencies, Source: Inter-Agency Field Manual, Geneva, 1995 women and their health needs were being

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What do we know about the RH status of displaced populations?

2.1 Pre-conflict context services there is unlikely, initially, to be a demand for them even if they are offered. Moreover, here is general consensus that populations different populations are accustomed to different affected by emergencies share some contraceptive methods. In the Democratic Tcommon attributes that can increase their Republic of the Congo (Former Zaire) in 1990, reproductive health needs but there may be while the practice of contraception was found to important differences in how communities respond be common in Kinshasa (dominated by the rhythm to their experiences. Little is known about the method), the use of modern contraceptives was impact of conflict on the perceptions, needs and limited. 15% of the ever pregnant women in the wants of women and men in these situations. survey also reported having induced abortion. The diverse pre-conflict contexts of these Both abortion and modern contraceptive methods populations will also result in differences in both were used as complementary fertility control need, and more particularly, demand for services. strategies (Shapiro, Tambashe, 1996). It is unlikely that the demand for family planning The cultural background of a particular population would be the same among a refugee population will also affect the acceptability of some from the Former Yugoslavia and an internally reproductive health services. Respect for women displaced population in Sudan for example. is often based upon traditional roles within Literacy rates, for example, may vary marriage and the family. Explicit rules for women substantially; low literacy rates can affect may involve restrictions of both movement and reproductive health in a number of ways: they may decision making. If facilities are dominated by be associated with early marriage, or the lack of male healthcare providers, some women will not knowledge about and utilisation of reproductive seek healthcare at all. For example, Burmese health services. Female illiteracy has also been refugee women in Bangladesh constantly shown to have detrimental effects on health and complained that they did not feel comfortable such as a failure to health seeking behaviour talking to or being examined by male doctors recognise early symptoms of infection and disease. (Hilsum, 1994). The movement of Afghan women Maternal mortality and morbidity rates vary refugees in Pakistan was severely restricted due substantially around the globe and some women to the rigidly imposed practice of Purdah; from entering conflict will already bear a huge burden marriage until the birth of her second child a in this area. woman could not attend the dispensary unless her The provision of services before an emergency husband accompanied her (Christensen H). Holck occurs will also affect demand for services later. and Cates found that Kampuchean refugees (WHO 1995) arriving at two different camps had very

REPRODUCTIVE HEALTH for displaced populations REPRODUCTIVE HEALTH Where there have been little or no contraceptive

6 Table 1: Demographic characteristics of selected refugee populations ○○○○○○○○

Percentage of total Females (x1000) Males (x1000)

population over 18 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Country of years of age years of age years of age Asylum 0-4 5-17 18+ 0-4 5-17 18+ Women Men yrs yrs yrs yrs yrs yrs

Algeria 11.4 24.5 44.9 9.7 23.2 15.4 34.9% 12.0%

Benin 4.1 15.6 19.3 3.9 14.8 12.7 27.4% 18.0%

Burundi 16.0 41.0 50.7 15.2 39.7 44.3 24.5% 21.4%

Cameroon 4.5 4.4 11.1 4.5 4.4 15.2 25.2% 34.5%

C.A.R. 3.9 7.3 9.4 3.8 6.3 8.2 24.2% 21.1%

Côte D'Ivoire 43.1 86.2 61.2 39.5 82.7 46.7 17.0% 13.0%

Djibouti 2.7 6.8 8.1 2.6 6.9 6.3 24.3% 18.9%

Ghana 9.5 23.4 29.2 10.3 22.4 16.9 26.1% 15.1%

Kenya 26.5 51.6 55.9 17.6 42.6 38.2 24.1% 16.4%

Mauritania 8.5 17.0 17.8 7.7 16.2 10.0 23.1% 13.0%

Bangladesh 13.5 20.6 24.7 13.2 20.1 24.1 21.3% 20.7%

Iran 173.7 309.5 307.6 183.8 342.1 424.0 17.7% 24.4%

Iraq 4.8 6.1 7.4 5.3 5.9 9.6 18.9% 24.6% REPRODUCTIVE HEALTH for displaced populations Nepal 539 16.0 20.3 6.0 16.6 21.3 23.6% 24.7%

Pakistan 136.7 137.2 285.1 121.5 121.7 253.2 27.0% 24.0%

Mexico 3.5 6.9 7.3 3.6 7.1 7.9 20.1% 21.8%

C.A.R.: Central African Republic Note: statistics dated 1 January 1995. Totals may not add up due to rounding. Countries selected on basis of a minimum sample of 30,000 refugees. Adapted from: The State of the World’s Refugees, 1995. In search of solutions. Annex II. Table 6. different fertility rates - ranging from 55 births in of use of traditional medicine may affect demand one camp per 1000 population to 13 births per for Western style health services while religious 1000 in the other. Those with lower rates had a beliefs may prevent potential users from using better nutritional status, higher socio-economic particular forms of contraception. The level of class, and came from urban areas. protection afforded a community or an individual in these circumstances will affect their Other factors include the use of traditional vulnerability to sexual and gender-based violence. medicine, religious beliefs, and the level of Normally, refugees have better access to protection protection the community is afforded. The level than IDPs but it cannot be assumed that a refugee

8 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ REPRODUCTIVE HEALTH for displaced populations ○○○○○○○○ chances ofbeingincontact withmenwhohave 1994; Amnesty, 1995). This willincreasewomen’s necessities forselfandfamily survival(Bissland, provide sexinexchangefor food,shelterorother of theirowncommunity. Theymaybeforced to country ofasylumandsometimesfrommembers both theopposingarmy, thearmedforcesin children. Theybecometargets ofviolencefrom toassuretheir ownsafetyandthatoftheir difficult women whoareontheirownmayfinditmore Despite inconclusivefigures,itistruetosaythat how tocook. the womenhadtobeorganised toteachthemen were youngSudanesemen(Anderson,1994)and Western Ethiopia90%oftherefugeepopulation Nepal andMexico,thereversewastrue.In 7), (page Table 1 approximately athirdofcountriesdescribedin outumbers thatofadultmen.Howeverin situations thepercentageofadultwomen 1995), inapproximatelytwothirdsofrefugee For example,accordingtoUNfigures(UNHCR, children willalsomakeupasimilarpercentage. This figureismisleadingasmentogetherwith populations (Cohen,1995; Forbes-Martin, 1994). constitute asmuch70-85%ofdisplaced It hasbeenassumedthatwomenandchildrenmay to serviceprovisionwillbenecessary. these distinctenvironmentsdifferent approaches back totheirhomesascircumstanceschange.In also bethereonatemporarybasisandmaymove the populationswhomtheyhavegonetohelpmay international staff withshorttermcontractsand settings, healthprovidersaremorelikelytobe that canbeprovided.Inmoreacuteemergency population islivingwillaffect thetypeofservices significantly. Thelevelofinsecurityinwhicha and needsofthesepopulationswillvary camps formanyyears.Thehealthstatus,priorities during flight,whileothershavebeenlivingin theeffectsstill suffering oftheirexperiences recently crossedaninternationalborderandare no meansahomogeneousgroup.Somehave Populations affected bycrisisorupheavalare Characteristicsofdisplaced 2.2 from theirhomecountrywhohadfledwiththem. by hostcountrymilitiaand/ormembersof origin, inothercasesrefugeeshavebeenattacked people vulnerabletoattackfromtheircountryof necessary. Sometimesthesiteofacampleaves alltheprotection camp automaticallyaffords populations namely Cameroon,Iran,Iraq, service provisionwill also makemothers tetanus fellbymorethanhalf. Thelackofhealth percentage ofpregnantwomen vaccinatedagainst reversed. Duringthewar inMozambiquethe humanitarian reliefinthis situation,thiscanbe services. However, withtheadventof reduction intheavailabilityandqualityof personnel, inthesecontexts,maycontributetoa of infrastructureandlosshealthservice hospital aresuddenlyunabletodoso.Breakdown passage ofprivatecarsandtrucksfortransportto transport: motherswhopreviouslyreliedonthe populations mayhavelittleaccesstoinformal evidence raisesanumberofissues.Displaced difficulties inevaluatingoutcomes,butanecdotal has beendoneinthisfield,partbecauseofthe mortality isdifficult todetermine.Littleresearch programmes inreducingmaternalmorbidityand refugee populations.Thesuccessofthese regarded asanessentialminimumpackagefor Maternal andchildhealthcarehasgenerallybeen Safe Motherhood Specific reproductive health 2.3 Figure 1opposite. such Key factorsaffecting thereproductivehealthof brewing (AchtaDjibrinne,1993). generating activitiessuchasprostitutionandbeer- Some womenareforcedtoresortillegalincome- collecting wildfruitsormakingsmallitemstosell. exception. Theyhaveoftentakenupcommerce, strategies, femaleheadsofhouseholdbeingno shown remarkablecreativityindevelopingcoping responsibility. Refugeegroupshavehereagain take onnewroleswithincreasedeconomic Women alonebecomehouseholdheadsandoften al, 1994). from 21%tobetween29%and40%(Erikssonet number offemaleheadedhouseholdsincreased 1992 tobetween60%and70%in1995.The share ofthepopulationincreasedfrom52%in elsewhere. AftertheRwandangenocidefemale killed ortoseekincomegeneratingactivities from theirspouses-whomayleavetofight,be exodus orshortperiodsofintensefighting,and families -splitintheconfusionthatensuesduring Womentheir from separated mayhavebeen STDs/HIV (ZwiandCabral,1991). ‘high risk’behavioursandthereforeofacquiring displaced communitiesaresummarisedin concerns Figure 1. Community factors affecting reproductive health status ○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○

vulnerable to other diseases that will impact on and ninety percent of these occur in the first 12 REPRODUCTIVE HEALTH for displaced populations their pregnancy. Malnutrition may be common and weeks. If many of the miscarriages reported can be harmful to the mother and the child. The occurred after this period then these figures could mere fact of living in high violence ituations has represent abnormally high rates. The reason also been shown to increase pregnancy proposed as to why rates may be high are poor complications (Zapata, 1992). nutrition, malaria complications and fatigue. In southern Sudan, high perceived rates of Miscarriage (spontaneous abortions) miscarriage were described by health service providers, key informants and the community alike NGOs working in Rwandan camps in Zaire (Palmer, C, forthcoming). STDs were frequently recorded that miscarriage rates were very high (De identified as the cause. This may well have been La Rosa, 1995). In Goma, a rate of 90 miscarriages the case as pregnant women with untreated per 1000 pregnancies was reported whilst data Syphilis of under two years duration transmit the from five camps in Bukavu suggested a rate of disease to their child1. Approximately half of the 139/1000 and in Hugo camp (in the Kivu region) pregnancies in mothers with primary or secondary the figures reached 163/1000. Whether these rates syphilis result in miscarriage, stillbirth, perinatal were indeed high is unknown as information is death or premature delivery (Over and Piot, 1997). required about the length of gestation and secondly the proportion of these miscarriages which were Infertility due to unsafe abortion is unknown. For example, Infertility levels may increase in some 15% of all pregnancies are thought to 9 spontaneously abort before 20 weeks of gestation circumstances due to the spread of sexually

10 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ REPRODUCTIVE HEALTH for displaced populations ○○○○○○○○ implicated (Simic, 1995). nutrients andthelackof ante-natalcarewere hydrocephalus. Maternal deficiency inspecific the malformationsincluded anencephalusand/or to thewar2.1%during it.Almostaquarterof congenital malformations rosefrom0.7%prior increase inlevelsofsmoking.Theincidence weight babieswasachangeinlifestylewithan alive. Akeycontributortotheincreaseinlowbirth difficulties encounteredinkeepingthesebabies steep incrementoflowbirthweightbabiesandthe of themostimportantunderlyingfactorswas Yugoslavia morethandoubledduringthewar. One other ways.Theperi-natalmortalityrateinFormer Pregnancy outcomesmaybeseriouslyaffected in Peri-natal mortality of pregnancy(page12). (Carballo etal,1996). See section ontermination abortions foreverypregnancygoingtoterm most ofthewaritaveragedmorethantwo abortion servicesroseduringtheconflictandfor Yugoslavia however, weknowthatdemandfor prevalence ofunsafeabortion.InFormer objective dataontheimpactofconflict detrimental effects ontheirhealth.Thereislittle continue torelyonunsafeabortionwith access toservicesmaybesopoorthatwomen trauma. Evenincountrieswhereabortionislegal, abortion manymoremaysuffer infectionor known. Inadditiontothemortalityfromunsafe availability ofservicessotheiraccuracyisnot service datawithadjustmentsforaccesstoand N, 1997).Estimatesareoftenbasedonhealth Asia, LatinAmericaandtheCaribbean(Sadiq, unsafe abortionofwhom69,000arefromAfrica, women areestimatedtodieayearasresultof or both(WHO/MSM/92.5).Globallyabout70,000 environment lackingminimummedicalstandards persons lackingthenecessaryskillsorinan for terminatinganunwantedpregnancyeitherby Unsafe abortionisdefinedbyWHOasaprocedure Unsafe abortions (Palmer, C,forthcoming). high prevalenceofsexuallytransmitteddiseases of pregnantwomenamongtheircommunitytothe was highandtheyattributedthesmallnumbers Sudan displacedpopulationsfeltthatinfertility displaced populations.However,southern in 1979). Currentlythereisnoformaldatafor burden ishigh(Westrom, 1975,Westrom etal problem insubSaharanAfricawheretheSTD treatment forthem.Thismaybeaparticular transmitted diseasesandthelackofavailable spread ofsexually transmitteddiseases. situations and isanotherfactorincreasing the new partners.Sexualviolence iscommoninthese themselves fromviolence and maythereforeseek women alonemaynotbe asabletoprotect of time.Inthissituationthey aremorevulnerable; women arewithouttheirpartners forlongperiods of conflictanddisplacementmaymeanthat The separationoffamiliesthatensuesasaresult and preventativeactivityoftenbeingomitted. for STDsisrarelyprovided,withcontacttracing soldiers aswellcivilians.Adequatetreatment numbersof overstretched havingtotreatlarge health facilitiesthatareavailablemaybecome destroyed byfightingorlooting.Moreoverthe primary healthcareunitsinMozambiquewere Liberia; between1975and1989about900 specifically beentargeted inMozambiqueand and maternalunitshaveforexamplebeen access toandavailabilityofhealthservices.Health war andsomenaturaldisasterswillalsoreduce The breakdownofinfrastructurethataccompanies Carael 1988). military recruitsbetween1981and1984(Piot Gonorrhoea continuouslyincreasedamong 1991). InRwandatheannualincidenceof geographical spreadoftheepidemic(Smallman, Amin’s armyhasbeenlinkedwiththe the virus.InUgandapatternofrecruitmentinto movement islikelytocontributethespreadof HIV thantheciviliansintheircountry, sotheir The militaryoftenhaveahigherprevalenceof money (Cossa,1994). displacement and3%reportedexchangingsexfor 8% ofwomenreportedsexualabuseduring estimated ratesfromnondisplacedpopulations. rates amongreturneeswerealmostdouble a highHIVrate returned homefromMalawi,whichhas refugees, rate beganrisingwhennearlytwomillion example ofMozambiqueisillustrative:theHIV of peoplefromhighandlowprevalenceareas.The movement ofpopulationswillresultinthemixing ‘devil’s alliance’(Mworozi,E,1993).Mass AIDS andcivilwarhavebeendescribedasa migration. disruption, psychologicalstressesandincreased displacement, militaryactivity, economic which populationsbecomehighrisk: describe lowintensitywarashavingfivewaysin of sexuallytransmitteddiseases.ZwiandCabral The conditionsofwarincreasetheriskspread STDs includingHIV/AIDS (Hulewicz, 1994).STDinfection Sexual and gender-based violence been ‘raped’ if their veil had been removed from ○○○○○○○○ their faces, not that they had been subjected to The breakdown of societal sanctions induced by forced sexual intercourse. war together with an increase in the number of armed people, and issues of control of food and Family planning

goods, make the community in general and women ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ in particular more vulnerable to sexual abuse. There is considerable anecdotal evidence to support Agressors may be soldiers living temporarily in arguments that fertility rates rise as a result of the area, deserters, or members of the opposing displacement as well as fall (Wulf, 1994). In force. During flight, there is evidence that women Sarajevo, the International Organisation for have been victimised by bandits, border guards, Migration (IOM) reported that the absolute army and resistance units. Yet the violence may number of deliveries fell from a yearly average of not end when they reach what they consider to be approximately 10,000 before the war to 2,000 a place of safety. during the conflict (IOM 1995). The IOM argue that this massive drop in birth rate could not be Perpetrators of sexual violence include guards and explained by population movement alone, but by administrators of the camps, military personnel a number of additional factors. First, most men of and fellow refugees or displaced people. Abuses military age were conscripted and sent out of the include not only outright rape and abduction, but city or away from home for long periods of time. also offers of protection and assistance in return Secondly, many people wanted to postpone for sexual favours. The structure of refugee camps pregnancy for fear of both physical insecurity and may further increase the potential for this violence the chance of additional displacement. to occur by locating water points far from populated areas and by the provision of communal In Pakistan, Afghan women refugees were latrines. reported to have high fertility rates. It was estimated that if current age-specific fertility rates Musse documented 192 sexual abuse cases against were continued, by the end of her childbearing refugees (mainly Somalis) over a four month life an average married woman would have had period in Kenyan refugee camps between February 13.6 children (Wulf, D, 1994). High fertility rates and June 1993 (Musse, forthcoming; International were coupled with high child mortality rates in Protection of Refugee Women). Nyakabwa and this population and most Afghan women refugees Lavoie describe the problems of single women in Pakistan were estimated to have lost at least refugees in Sudan and Djibouti. In Sudan, one live-born child (Miller, 1994). Ethiopian and Eritrean refugees were reported as using remarriage and prostitution as a means of Contradictions may exist within the same survival (Nyakabwa, 1995). A refugee survey population, for example, discussions with refugees REPRODUCTIVE HEALTH for displaced populations undertaken in 1983 found that 27% of mothers from Rwanda revealed that some wanted children who were single and heads of households had to replace lost family members while others felt resorted to prostitution to earn a living. In Djibouti, that conditions were too uncertain to have more arbitrary rape against Ethiopian and Somali children. A high prevalence of amenorrhoea may women occurred. Approximately 22-27% of also contribute to low fertility rates. One of the Burundi women, between the ages of 12-49, most common problems among women in Former reported experiencing sexual violence after Yugoslavia attending a womens’ therapy centre becoming a refugee (Nduna, 1997). This trauma during the war was amenorrhoea (Frljak, 1997). has both direct and indirect consequences. Direct Approximately seven months after the exodus of consequences may be a pregnancy or acquiring Rwandan refugees into Goma, according to a an STD. Indirect consequences include the report by the UNHCR reproductive health reaction of the women’s family who may consider coordinator, birth rates were found to be low (US that she has brought dishonour on them and she Committee for Refugees, 1996). One year after may be rejected by her family and even whole the exodus, however, they started to rise rapidly community. but still had not reached pre-disaster levels (US Committee for Refugees, 1997). These figures Care is needed when discussing sexual violence should be interpreted with caution as many women with women to ensure that social/cultural may deliver without contact with health services sensitivities are fully understood and terminology and the denominator in these contexts is very hard clear: female refugees in Bangladesh felt they had to estimate. 11

12 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ REPRODUCTIVE HEALTH for displaced populations ○○○○○○○○ of thoseperformed inChile,Barbadosand Belize, Nearly alloftheseabortions, withtheexception intentionally aborted(Jacobson, Jodi,1990). one-quarter andonethirdof allpregnancieswere IPPF estimatesinthemid70s impliedthatbetween range from2.7-7.4million peryear. Figures from contraception. Estimatesofthenumberperformed fourth mostcommonlyusedmethodof In LatinAmericaterminationofpregnancyisthe mother. conditions itcanposeaconsiderablerisktothe procedure butifitisperformedinunsafe abortion (asitisalsoknown)arelativelysafe definitions ofphysicalhealthvary. Induced physical healthofthemotheralthough make someprovisionforthepreservationof pregnancy. Approximately60percentofcountries lifeasalegalbasisforstopping the mother’s the world.Mostcountriesrecogniseathreatto under certaincircumstancesalmosteverywherein Termination ofpregnancyorabortion islegal Termination ofpregnancy (TOP) difficulties inobtainingsupplies. contraception bythehealthprovidersand was attributedtothelowpriorityaccorded the warinYugoslavia wasfoundtobelow. This or continuingusers”.Contraceptiveusageduring for contraceptionparticularlyonbehalfofformer Rwandan campstherewas,“anincreasingdemand became availableinthecamps(Mulley, 1991).In embrace moderncontraceptiveserviceswhenthey refugees inHongKongwerealsoreportedto chose theinjectablecontraceptive.Vietnamese (D’Agnes, T, 1982;Potts,1980).95%ofacceptors of zerototwothirdsalleligiblewomen when serviceswereintroducedfromaprevalence Cambodian border, contraceptiveuseroserapidly camps. InKhaoIDangcampontheThai- contraception whenitbecameavailableinrefugee Some reportsnotedarapidriseintheuseof Figures forcontraceptiveuseareequallysporadic. population andthedurationofconflict. factors includingthehealthstatusofdisplaced mayrange of increaseordecreasedependingona It ispossiblethatfertilityrates is inconclusive. but the of familymembers, emergency duetopoorhealthstatusandseparation be alossinfertilitytheinitialstagesofan increase abovethepre-conflictlevels.Theremay and thereislittlefirmevidencethatfertilityrates movements limited bylackofage-specificdata.Refugeemass However, reportsonfertilityarefewandoften tend to be tend tobe from areasofhighfertility data thatisavailable North America. migrants fromtheseareasin Europe,Australiaand peninsula, alongthePersian Gulfandamongsome to EastAfrica,inSouthern partsoftheArabian still occursamongmanyethnic groups,fromWest the rightofsecurityperson.Thepractice attainable levelofphysicalandmentalhealth, human rightsincludingtherighttohighest UNICEF/UNFPA statementasaviolationof was condemnedbytheICPDandinajointWHO/ or otherinjurytothefemalegenitalorgans. FGM or totalremovaloftheexternalfemalegenitalia FGM comprisesallproceduresinvolvingpartial Bank, 1993).AccordingtoaWHOdefinition, million livingwomenintheworldtoday(World to havebeencarriedouton between85-114 Female GenitalMutiliation(FGM)isestimated Female genitalmutilation Other issues quantitative dataisyetavailable. have beenreportedtotakeplacebutno Elsewhere, asinRwandancamps,terminations 1% and4%ofthetime(Cate,1984;Tietze, 1960). act ofintercoursewillresultinpregnancybetween According toestimatesinmedicalstudiesasingle have contributedtotherequestsfortermination. amongst displacedpopulationsisalsolikelyto Welfare, 1995).The (Republic CommitteeforHealthandSocial abortions foreverypregnancytakentoterm was saidtoaveragemorethantwoinduced (Carballo, M,1996).Formostofthewarrate and reducedaccesstocontraceptiveservices was attributedtochangesinattitudesfertility the ratewasreportedtoincreasesignificantly. This where terminationwascommonpriortothewar, not theratesincrease.InFormerYugoslavia, information aboutunsafeabortionandwhetheror 1994). In developing countriesandonethirdinAfrica(WHO, 70,000 deathsworldwideofwhich69,000arein abortions, theseareestimatedtohaveresultedin Morrow, 1990).Ofapproximately20millionunsafe between 10and22legalabortions(Henshaw, between 26and31millionlegalabortions (Paxman etal,1993). In five unsafeabortionsleadstohospitalisation abortions (Bailyetal,1988). to three every of One complications ofabortionhadillegallyinduced under 18yearswhowerehospitalisedfor A studyinBoliviafoundthat39%ofwomenaged cause ofdeathamongwomenreproductiveage. are unsafeandtheirsequelaetheprincipal emergencies, wehavelittleformal increased 1987 worldwidetherewere incidence ofrape FGM is usually carried out by traditional Africa. Here adolescent fertility comprises ○○○○○○○○ practitioners using cutting tools ranging from a between 15 and 20 percent of total births in 11 piece of glass to scalpels or special knives. countries for which data are available. Teenage Instruments are often reused without sterilisation pregnancies are associated with significantly which is rarely available in these settings.3worse antenatal care, lower birth weights, earlier Anaesthetics and antiseptics are not used and weaning and especially during the second year of ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ various substances are used to stop bleeding. life, higher child mortality (Legrand, 1993). It is Unintended damage is often caused by septic argued that in some areas the deterioration of tribal conditions or the struggling of girls or women. It and rural traditions in the face of rapid is increasingly performed by trained medical urbanisation has led to the continuation of early personnel as this is thought to be more hygienic, childbearing in the absence of the traditional but medical participation is strongly condemned support for the young mother. Young people then by WHO. It is not known how emergency become spatially and psychologically cut off from situations affect the practice of FGM. Many their elders who were traditionally responsible for groups will have practised it prior to the conflict. passing on information (Barker, 1992). The impact Whether instability leads to an even stricter of emergencies on adolescents is likely to be enforcement of traditional cultural practices (as similar, with many taking on responsibility for for Afghan women in Pakistan) or it provides themselves and others which they were unlikely opportunities for change will probably vary to have in stable situations. However we need to significantly from place to place. learn more about this group in conflict situations. Existing demographic data is not very detailed but The health of adolescents suggests that there is great variability in the Adolescents have a special importance in relation number of adolescents in a refugee camp. For to reproductive health. High rates of childbearing example, under 17 year olds made up 47% of the among adolescents are common in some places refugees in camps in the Cote D’Ivoire but only and have been reported particularly in sub Saharan 24.5% of those in camps in Pakistan (See Table 1). REPRODUCTIVE HEALTH for displaced populations

13 ○○○○○○○○ 3 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○

Existing and proposed policies on RH for displaced populations

raditionally, adequate food, water, shelter Nafis Sadiq, UNFPA Executive Director, stated sanitation, and rapid immunisation against that, “UNFPA recognise that refugees and Tmeasles were considered as essential first internally displaced persons and persons in all steps in providing assistance to emergency- emergency situations have the same vital human affected populations. Where reproductive rights, including the right to reproductive health, healthcare delivery has been seen as a priority the as people in any community”. emphasis has been on maternal and child healthcare (MCH) (Sandler, 1987). Aspects of RH RH policy, as with the majority of policies in such as the treatment of STDs would be covered humanitarian situations tend however, to be by general outpatient services and the somewhat haphazard due both to the context in complications of abortion by hospital services. which assistance is provided, often insecure and rapidly evolving, but also because agencies often However, as discussed above, throughout the late have their own policies developed to suit their 80s and early 90s, due in part to the UN Decade particular mandate, principal funding sources and for Women and Safe Motherhood initiatives, their employees. There is no official accountability women began to be recognised as a significant to one body although some agencies often agree group among displaced populations whose needs voluntarily to take note of policies and guidelines had been ignored. Evidence was accumulating, for developed by others, such as the UNHCR or example, that family planning services were not WHO. These concerns are by no means unique to being made universally available to refugees2 the field of RH services, but have contributed to (anon, Lancet, 1993) and in 1992, the US the comparatively little attention dedicated until Department of Health and Human Services now to policy development. recommended that refugees should receive “counselling in family spacing, provision of 3.1 Current initiatives to develop contraceptives and education about breast feeding reproductive health policies and infant care”. In conjunction with a large number of NGOs and This chapter looks at existing and planned other interested parties, UNHCR and UNFPA provision of RH services in emergencies, focusing hosted an inter-agency symposium in June 1995. on the development of policy. Chapter 4 draws on One product of the symposium was the case study material to illustrate specific points and development of a field manual for reproductive Chapter 5 considers problems in implementation. health services in refugee settings (UNHCR, 1995) The provision of full reproductive health services (see also Box 5 on page 18). In addition, an Inter- in emergencies (see Box 3, page 16), is currently Agency Working Group (IAWG), consisting of backed by both UNHCR, UNFPA and WHO. Dr approximately 32 members and including NGOs, REPRODUCTIVE HEALTH for displaced populations REPRODUCTIVE HEALTH

14 donors, bilateral agencies, researchers and other Box No. 2 ○○○○○○○○ groups interested in working on reproductive health (see Appendix) was formed. The field The Minimum Initial Service manual is based on technical guidance provided Package (MISP) by WHO, who are also finalising managerial • prevention and management of the guidelines on reproductive health. These consequences of sexual violence ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ guidelines discuss the impact of all the different • prevention of the transmission of HIV/AIDS phases of displacement (from exodus to by enforcement of the respect for universal rehabilitation) on reproductive health status. precautions and guaranteeing the Despite the range and quality of organisations availability of free condoms signed up to the IAWG process, there has recently been some controversy as to the appropriateness • reduce excess maternal and neonatal of its guidance at field level and as to the evidence mortality by ensuring clean deliveries and on which it is basing some of its recommendations. establishing a referral system to manage Some of those concerns are discussed below, one obstetric emergencies. of the principal ones being that the tone and • planning for the provision of language of the manual suggest it would be more comprehensive RH into PHC. suitable for health programme managers. Yet the • identification of qualified human resources most recent draft of the manual states that, ‘the - specifically a RH Coordinator primary audience for the manual are field managers of health services’. The final version Source: Reproductive health for refugees: a field manual (1997). should be completed as this paper goes to print, in February 1998. One RH programme manager, to ensure that those who wish to have the treatment commenting on the draft manual, remarked that: as well as those who are prepared to offer it, are given the option to do so. “It is useful at the moment at the management level but it needs to be changed if it is for use at the field The field manual recommends the introduction of level. It is too technical. We need another manual full reproductive health services as soon as which is more practical.” (pers. comm. 1997) possible after the acute emergency phase. The recommended full services to be administered are Recognising the difficulties of providing all RH shown in Box No. 3. The following chapters of services, in the heat of an emergency, the current this paper refer to these services as forming the draft of the manual recommends the use of a basis of reproductive health services to conflict ‘minimum initial service package’ (MISP) see Box affected populations. 2 below, to be provided as soon as possible (UNHCR, 1995). This package has been Many non-governmental organisations are REPRODUCTIVE HEALTH for displaced populations developed for introduction without further needs working with UNHCR to produce common assessment on the grounds that there is enough guidelines in this area. However, some also have documented evidence for its justification. documents which clarify policy within their own organisations or which deal with particular areas While there appears to be general agreement by of the RH agenda. MSF, for example, in their book agencies operating in emergency settings on the called ‘Refugee Health’ (MSF, 1997) confirmed implementation of the MISP, there continue to be their commitment to the introduction of the MISP areas of concern. One in particular is the supply in emergency settings. Healthcare in the emergency of emergency contraception also known as the phase is seen as one of the top ten priorities, and 3 morning after pill (MSF 1997). Although this reproductive health is described as a special issue product has been described by the Food and Drug under this chapter. The authors state that ‘during Administration of America as ‘remarkably safe the emergency phase, resources should not be and effective when used as directed’, its diverted from dealing with the major killers. administration remains controversial as there is However, there are some aspects of reproductive debate as to whether or not its action constitutes health which must also be dealt with at this stage’. termination. The latest version of the inter-agency They then go on to outline the MISP as the field manual (December 1997) states that, standard services to implement. AIDS and ‘Cultural and religious beliefs may preclude some sexually transmitted diseases are given particular providers and women from using this treatment’. attention. In the ‘post’ emergency phase a full This is understandable but it will also be important range of reproductive health services are

16 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ REPRODUCTIVE HEALTH for displaced populations ○○○○○○○○ verbatim onthefollowingpages.(SeeBoxes4and5inparticular). A numberofpolicystatementsfromkeyactorsinthefieldRHdevelopmentarereproduced advocated. Source Reproductivehealthneedsofadolescents. Otherconcernssuchasthecareofunsafeabortions,andprevention/responsetoFGM. 6 Familyplanning 5 PreventionofsexuallytransmitteddiseasesincludingHIV/AIDs 4 Sexualandgender-based3 Violence SafeMotherhood 2 1 Box No.3 Material Support, andUN/IO/GO/NGO Coordination. Administration, Administration, Personnel Administration, Financial in theareaofProgram that facilitatesapro-active approachtoemergenciesbyreinforcing IRC’s systemsofreadiness to rapidassessments,planning, andresponse,IRChasanEmergencyPreparedness Programme location, circumstances, composition, andconditionsoftheaffectedpopulation. Inaddition of anemergencyresponsearedevelopedinconjunction withanassessmentofthenature, mitigate orinterruptthediseaseprocesses.Thespecific activitiesundertakeninthefirststages publichealthinterventions that In anemergencysetting,Consortiummembersemphasise communication; andpersonnelfinancialcommitments. strategies forservicedelivery;materialsandequipment, training;information,educationand and preventionofsexualviolence.Thequestionsaddress: servicesavailableandthoseneeded; motherhood, familyplanning;STD/HIV/AIDSprevention andtreatment;emergencyobstetrics; a coresetofneedsassessmentquestionsrelated tothefiveessentialtechnicalareas:safe conducting needsassessmentinordertodetermine appropriate servicemix.TheGuidecontains In responsetofieldrequests,theRHRConsortium hasdevelopedandtestedaguidefor phase. is clearthatbasicreproductivehealthservicescannotwaitforthestabilisation gender violence,STDtransmission,andmaternalmorbiditymortalityinemergencies,it Butas theinternationalcommunitybecomesmoreawareofproblemsrelatingto response. are neededimmediatelyandhealthservicesmustbeinplacewithindaysofanemergency water, TheConsortiumrecognisesthatfood, Health inRefugeeSituations. shelterandsanitation Agency Working GrouponReproductive Consortium membersplayakeyroleintheInter range ofactivitiesintheinstitutionalisationreproductivehealthforrefugees. Consortium membersplayacatalyticroleinthedevelopmentandimplementationofwide including advocacy, resource developmentandcoalitionbuilding.Individuallyasagroup, and delivery;theprovisionoftechnicalassistancetraining;orarangeotheractivities Each agencyhasatrackrecordinreproductivehealthdesign,implementation,monitoring to reproductivehealthservices. that refugeesanddisplacedpopulationsareanotoriouslyunder-served groupwhenitcomes for Refugees(RHR)Consortium.ThiswasinresponsetotheinternationalconsensusatICPD Commission forRefugeeWomen andChildrenjoinedforces tosetupTheReproductiveHealth Snow Research and Training (JSI),MarieStopesInternational (MSI)andtheWomen’s During theICPD(September1994),CARE,TheInternationalRescueCommittee(IRC),John Box No.4 : IAWG FieldManual,1997 (to beimplementedonceemergencyconditionshavestabilised) The ReproductiveHealthforRefugeesConsortium(RHR) (Lyndall Sachs,MarieStopesInternational) Full reproductivehealthagenda ○○○○○○○○ Aid budgets for refugee programmes remain static, with fierce competition for limited resources. For many agencies, reproductive health continues to be perceived as a low priority area. Yet, recent research indicates that once a refugee setting has stabilised, poor reproductive health is one of the leading causes of morbidity and mortality. Agencies which fail to acknowledge this are denying refugees a fundamental human right as embodied in a range of international law, the most recent of which is the Plan of Action from the International Conference on Population ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ and Development. Consortium members acknowledge that every refugee setting is unique and few programmes can simultaneously address all the reproductive health issues. Two constraints stand out: funding limitations, and differing community attitudes to reproductive health. MSI’s programme in Sri Lanka is a case in point. A needs assessment undertaken in 1995, indicated a huge gap in reproductive health provision among IDPs in four districts in the north and east of the country. Funding constraints compelled MSI to identify the two most needy areas, with the focus on family planning, prevention and treatment of RTIs and preventative health. In 1997, with additional funding obtained from the EU, and armed with its earlier experience, MSI was able to expand its programme to two additional sites, providing comprehensive family planning services, diagnosis and treatment of STDs, other gynaecological services, ante and post natal care, general health services and childhood immunisations. MSI recognised that approaches to programming for refugees’ reproductive needs may differ in order to meet their special needs. Yet, the end objective remains that interventions should result in knowledge, behavioural change or technical skills that will endure and have lasting advantages within the community. MSI’s experience has to date focussed on providing services to refugees in a development type situation. In recognition of this, the agency is currently exploring applying its model of local fund raising and cross subsidy between sites, areas and region. In it programmes in Sri Lanka, Pakistan and Nepal, refugees with means access services on a user pays basis, thereby freeing up funds for those who cannot afford to pay. Consortium members seek to address a specific range of health problems, and to meet the needs of identified client groups through the provision of quality client oriented services. The Guide to Needs Assessment and Evaluation clearly sets out a series of questions to assist agencies in ensuring quality of care. Drawing upon widely accepted frameworks for quality of care, MSI’s programmes offer information to clients, choice of methods for family planning, technical competence of service providers, inter personal relations between providers and clients, mechanisms for continued REPRODUCTIVE HEALTH for displaced populations care and an appropriate mix of services to address the needs of clients. MSI sets clearly defined project objectives and ensures that teams are properly trained in their respective competencies. Fundamental to the success of the programmes is the participation of the clients themselves in the quality and appropriateness of services. The past two years has seen a dramatic increase in awareness among policy makers, donors and the general public about the reproductive needs of refugees. The experience of Consortium members has shown that simple preventative programming in the initial phases of a refugee emergency can reap enormous benefits for the health and well being of refugees. As the body of experience grows, agencies will learn from each other how best to maximise these benefits. The RHR Consortium will continue its efforts to institutionalise reproductive health services in refugee and displaced settings through: • Advocacy for increased attention and action among policy makers, donors and service delivery groups; • Expanding the body of knowledge for the promotion of reproductive health in refugee settings; • Increasing the level of funding for reproductive health in refugee situations • Encouraging and facilitating research into and development of tools for implementation of reproductive health programmes. 17 Source: MSI, London. Lyndall Sachs now works for UNA in London. RHR can be contacted through Consortium members: American Refugee Committee, CARE, International Rescue Committee, John Snow, Marie Stopes and the Womens’ Commission. 17

18 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ REPRODUCTIVE HEALTH for displaced populations ○○○○○○○○ the differences. in fact—thecommonaltiesbetweenrefugeeandnon-refugeepopulationsarefargreaterthan on thismatter. ItistimetodemystifythedifferencesinundertakingRHrefugeesituations- technical recommendationsreproducedintheManualareconformitywithWHOpolicies All comprehensive reproductivehealthcareforpeopleinnotconflictordisplacement. guidelines fornon-refugeepopulations-thatistosayimplementationof The programmesoutlinedintheInter-Agency FieldManualreplicateinternationallyrecognised of therefugeesinconformitywithuniversallyrecognisedinternationalhumanrights. demands withfullrespectforthevariousreligiousandethicalvaluesculturalbackgrounds when feasible,andthattheseservicesshouldbe asserts thatappropriatereproductivehealthservicesmustandshouldbeintegratedintoPHC, principal concernsinarefugeeemergency, theguidingprincipleunderlyingallRHactivities While provisionofadequatefood,cleanwater, shelter, sanitation and PHC free andvoluntarychoice,tocomprehensiveinformationservicesforreproductivehealth...” persons inrefugeelikesituationshavethesamerightasotherstoaccess,onbasisof As statedbySadakoOgataandNafisSadikintheforewordtoManual”Refugees December 1995. version oftheInter-Agency FieldManualonReproductiveHealthinRefugeeSituations UN agenciesandNGOs.Theoutcomeofthemeetingwasissuingfield-test-draft on ReproductiveHealthinRefugeeSituationsheldGeneva,June1995attendedbyover50 refugee situations. A seriesofpreparatorymeetingsculminatedintheInter-Agency Symposium initiating any aspectofRH.Forexample, ifmanagementofSTDs isidentifiedasapriority, Careful planningisessential to ensure thatall theelementsofaprogrammeareinplacebefore Material andhumanresources requiredforeachcomponentareaofRHneed tobeassessed. refugee population,butwhich arefeasibleandpracticalforpartnerstoundertake andmaintain. Assessments mustbecarried outtoensurethatRHprogrammesnotonlymeet theneedsof broad programmaticguidancewhichneedstobe adaptedtoeachsituation. concerned. Working withnationalinstitutionsiscrucial.Thefield manualisaresourcewith the bestinterventionsforindividuals,communities andpopulationswithwhichtheyare context, andprioritisingamongcompetingdemands, themajorRHproblems—andselecting and experiencedstaffworkingcloselywiththecommunity ofrefugeesanalysingtheirown cannot prescribetheappropriatespecificRHprogrammes foreverysetting—ittakesdedicated before flightandthepoliciesservicesdelivered inhostcountries.A fieldmanualofitself refugees’ reproductivehealthneedsandpriorities, thetypeofservicesprovidedtorefugees sound. Eachrefugeesettinghastotakeintoconsideration amagnitudeoffactors-suchas,the settings asTanzania toThailandor Azerbaijan to Angola mustbeuser-friendly andtechnically manual designedtomeettheneedsofhealthcareprovidersandmanagersfromasdiverse wide posesacollectionofcomplexchallenges-astheydofornon-refugeesituations. A field Introducing orstrengtheningRHservicesthroughoutthevariousrefugeesituationsworld- promote theintroductionorstrengtheningof The commonobjectiveofthisinitiativeonReproductiveHealthinRefugeeSituationsisto efforts toaddresstheissueofreproductivehealthinrefugeesituations. (ICPD 7.11) FollowingtheCairoconferenceUNHCRandUNFPA spearheadedinternational access toRHcareandmayfacespecificseriousthreatstheirreproductivehealthrights of Plan Action states:“Migrantsanddisplacedpersonsinmanypartsoftheworldhavelimited the 1994ICPDwhere Attention toReproductiveHealthinRefugeeSituationsstemsfrom 5 Box No. From advocacy to action — The challenges challenges to ahead —The advocacy action From (Kate Burns,UNHCR) The challenge appropriate based on the refugees’ expressedneedsand basedontherefugees’

reproductive healthactivitiesin must remain ○○○○○○○○ then skills of staff in diagnosing and treating STDs needs to be assessed, skills upgraded as necessary, protocols for treatment of STDs must be prepared, drugs procured, prevention strategies developed and widely disseminated, and supervision and monitoring of treatment/ prevention practices routinely undertaken.

The Minimum Initial Service Package (MISP) (described in Box 2, page 15) is designed to ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ensure minimum services are available to refugee populations as soon as possible in an emergency situation. The MISP is not just a package of materials and equipment - but a series of activities undertaken by qualified staff - to meet certain objectives. The MISP can be implemented without any new needs assessment as there is sufficient documented evidence for its justification. Implicit within the MISP is the need to identify and put into place a referral service that can manage life-threatening RH emergencies. This is most often accomplished by strengthening and supporting national health facilities. The New Emergency Health Kit (NEHK 98), now being finalised under the auspices of WHO Action Programme on Essential Drugs, includes key reproductive health elements. This will ensure that, as soon as the kit arrives, health providers have the equipment, supplies and materials to undertake most aspects of the MISP.

Besides the material needs, reproductive health services require human resources. The Field Manual recommends that a Reproductive Health Coordinator be identified early on in the emergency. This person can take a lead role in assisting actors to implement RH services in a timely and appropriate manner and finding opportunities to mainstream RH into other allied sectors, such as community services, education and protection. Experiences in the Great Lakes and Kenya have proven the important role RH Co-ordinators can play in raising awareness of RH, assisting in refresher training of health care providers to ensure the necessary skills to undertake quality RH services and providing continuous technical assistance to all actors in this important field. It is important to remember that the majority of health workers working in refugee situations are trained healthcare providers from the refugee population, the host or neighbouring countries. We are not starting from scratch in introducing RH services in refugee situations as trained healthcare providers who provided these services prior to displacement can often be identified. They may need refresher training and certainly need supervision. REPRODUCTIVE HEALTH for displaced populations The future Much progress has been achieved since 1994. More than 150 RH projects in some 60 countries have been described in a database on who is doing what where. Technical assistance missions by various UN and NGO actors have been undertaken to strengthen RH activities in more than 15 countries. Over 10,000 copies of the Field Manual have been distributed. It has been field-tested by more than 100 health professionals representing 50 agencies in 18 countries. Results overall, expressed by field-testers, has been favourable to the manual and its contents. It is now being revised incorporating comments from the field as well as any new technical information, from sources such as WHO and UNAIDS. The final field manual will be ready in mid 1998. It is our expectation that the multitude of actors involved in meeting the health needs and well being of refugees and displaced populations are committed to providing comprehensive and high quality RH services, based on their abilities, to the populations they serve - through programmes which involve refugees in all aspects in a culturally sensitive manner.

Source: UNHCR, Geneva. Kate Burns, Senior Reproductive Health Officer, Programme and Technical Support Section.

20 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ REPRODUCTIVE HEALTH for displaced populations ○○○○○○○○ ask, as well asask, symptomatictreatmentofAIDS. together withcondomdistributiontothosewho actions 1-6arerecommendedforimplementation interventions (seeBox 6) intheemergency phase: indicating specifically forHIV/AIDS published in1995.MSFalsohaveapolicy settingswere for HIVinterventionsinemergency UNAIDS Guidelines Combined UNHCR,WHO, l Policies onspecificareas ofthe 3.2 thesituation isstableandthe emergency phase • programme shouldbeundertaken unless: the aboveandstatethat nofamilyplanning relocate overasixmonthperiod. MSFagreewith refugee populationisnotexpected torepatriateor are nomajorepidemicsandwhenthe‘settled’ rate fallsbelow1in10000perday, whenthere is saidtohaveoccurredwhenthecrudemortality the situationrequires‘stabilisation’.Stabilisation services forexample,theIAWG manualstates that services. Beforeintroducingfamilyplanning documents totheintroductionoffamilyplanning A numberof l Policy Paper. 2ndV October 1997.Vol.6 No3 Source: Protectionofthepatientagainst 10 Counsellingandsocialsupport 9 Promotionofsafersex 8 MedicalManagementof AIDS cases 7 Protectionofhealthworkers 6 ReductionofHIVtransmissionthrough 5 Reductionofinjections 4 Propersterilisation/disinfectionand 3 Safetransfusions,whentransfusionsare 2 Rationalindicationsforblood 1 Box No.6 is over; MSF priorityinterventionsfor reproductive healthagenda HIV/AIDS Family planning discrimination sexually transmitteddiseasescontrol proper disposalofmedicalwaste really necessary transfusions Blok,L.;Deguerry, M.;Sohier, N.MSFand HIV/AIDS programmes caveats rin- April1996.in ersion - exist in exist in general policy Medical News Medical priority AIDS clear.8. SeeBoxNo. roles andresponsibilitiesofserviceproviders statement onabortion,forexample,makesthe essential aidtoestablishingservices.TheICPD guidance establishedinstablecontextsisan populations isnotavailable,informationand Where guidelinesspecifictodisplaced l opposite7. inBox statement onthelatterwhichisreproduced WHO, UNICEFandUNFPA producedajoint genital mutilationinnondisplacedsettings. also beenissuedabouttheresponsetofemale sexual violenceagainstwomen.Statementshave guidelines onthepreventionofandresponseto Other specificguidanceincludesUNHCR l are abletoaccessit. populations thatneedandwantfamilyplanning A systemneedstobeinplacewhichensuresthat services wouldbeexcludedinallcircumstances. mentioned couldbeinterpretedsostringentlythat understandable inthesecontexts,thosealready six months.Althoughsomecaveatsare service providershouldbeavailableforatleast which continuitycanbeguaranteedie.thesame should beconsideredandfinallytheextentto programme byotherorganisations inthecamp MSF alsocounselthattheacceptabilityofsucha thereisademandforcontraceptionwithinthe • thenecessaryresourcesareavailable; • refugeesareexpectedtostayinthecampfor • fail toprovideevenbasicdata ontheageandsex 2) inthesecontexts.Registration systemsoften data tendsnottobewidely available(seeChapter healthcare andevaluateinterventions, butthis data areneededtoassessthe needforreproductive Biomedical, epidemiologicalandsocio-economic l makers aredescribedbelow. numerous. Someoftheissuesfacingpolicy- with regardtoreproductivehealthissuesare The problemsagenciesfaceindevelopingpolicy Difficulties indetermining policy 3.3 assessed. population andthisneedhasbeenthoroughly at leastsixmonths; Termination ofpregnancy Sexual andgender-basedviolence affect reproductive healthstatus data onhow emergenciespaucity ofgood ○○○○○○○○ Box No. 7 Joint WHO/UNICEF/UNFPA statement on Female Genital Mutilation. “All societies have norms of care and behaviour based on age, lifestyle, gender and social class. These ‘norms’, often referred to as traditional practices, originate either from social or ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ cultural objectives or from the empirical observations related to the well being of individuals or the society. Traditional practices may be beneficial, harmful or harmless. Traditional practices may have a harmful effect on health, and this is often the case in those relating to female children, relations between men and women, marriage and sexuality. In presenting this statement, the purpose is neither to critise or condemn. But it is unacceptable that the international community remain passive in the name of a distorted vision of multiculturalism. Human behaviours and cultural values, however senseless and destructive they may appear from the personal and cultural standpoint of others, have meaning and fulfill a function for those who practise them. However, culture is not static but it is in constant flux, adapting and reforming. People will change their behaviour when they understand the hazards and the indignity of harmful practices and when they realise that it is possible to give up harmful practices without giving up meaningful aspects of their culture.” Source: World Health Organisation,1996. Female Genital Mutilation: A Joint WHO/UNICEF/UNFPA Statement. Geneva: WHO. breakdown of the populations (De la Rosa, 1995). Box No. 8. In many places, the issue of registration is being addressed (pers. comm. K. Burns, UNHCR), even Common position of the if the data is not adequately used at field level. international community towards Some reproductive health issues such as unsafe abortion (TOP) abortion and female genital mutilation are sensitive and therefore difficult to document. “In no case should abortion be promoted as Others such as maternal mortality pose technical a method of family planning. All problems as the relative infrequency of a death Governments and relevant inter- means that large studies may need to be done at governmental and non-governmental considerable expense. organisations are urged to strengthen their commitment to women’s health, to deal with l lack of information about effectiveness of the health impact of unsafe abortion as a interventions major public health concern and to reduce the recourse to abortion through expanded

Effective reproductive health interventions can and improved family planning services. REPRODUCTIVE HEALTH for displaced populations make a significant impact on the health and health Prevention of unwanted pregnancies must status of populations in non-conflict settings: the always be given the highest priority and all use of the combined contraceptive pill to prevent attempts should be made to eliminate the pregnancy(Guillebaud, 1993), the use of condoms need for abortion. Women who have and the treatment of STD infections to reduce HIV unwanted pregnancies should have access transmission (Pinkerton, 1997: Grosskurth, 1997) to reliable information and compassionate and the immunisation of mothers against tetanus counselling. Any measures or changes (Jamison, 1993) are a few examples. The related to abortion within the health system effectiveness of these interventions is unlikely to can only be determined at the national or vary significantly in conflict contexts. Other local level according to the national services that are currently being provided are of legislative process. In circumstances in uncertain benefit. Regular prenatal care is needed which abortion is not against the law, such to help detect and manage some pregnancy-related abortion should be safe. In all cases women complications and for health education purposes. should have access to quality services for However, the most effective timing and content the management of complications arising of prenatal care is unknown (World Bank, 1994). from abortion. Post abortion counselling, The number of prenatal visits may not be important education and family planning services and as few as three may be enough where services should be offered promptly which will also are of high quality (Weinstein et al, 1993). help avoid repeat abortions.” Operational strategies to address issues of recent 21 Source: ICPD Programme of Action (1994) Paragraph 8.25

21 ○○○○○○○○ concern, such as the provision of counselling about the population are often available but rarely services to address gender violence, are also collated and distributed at field level. Data such relatively untested. Concerns about the as pre-conflict fertility rates, STD/HIV sero- effectiveness of counselling services have been prevalence, details of health service provision and explored more fully in a previous RRN Network the legality of abortion in both the country or

○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Paper (Summerfield, 1996). region and host country will be useful and could form a baseline to guide further assessments. The l deciding on the importance of needs RHR Consortium have developed a compendium assessment and on how needs can be of tools that could be used in these settings (add assessed quote). Traditionally the identification of needs in l deciding how services should be prioritised humanitarian emergencies and among displaced populations have taken the form of rapid In the face of competing priorities and diminishing assessments (Guha-Sapir, 1991). These humanitarian aid budgets (World Disasters Report, assessments often incorporate observation, the 1996), it is a difficult time to introduce new collation of health service data and discussion with services. Many still argue that reproductive health, community leaders. The delivery of appropriate or some aspects of it, should not be seen as a and effective reproductive health services priority in these contexts. However reproductive necessitates a more in depth understanding of health problems have been shown to contribute community knowledge, beliefs and attitudes. substantially to the global burden of disease and Qualitative data collection using, for example, there is evidence to suggest that some reproductive focus groups and in-depth interviews have proved health programmes represent some of the most useful (De la Rosa, 1995, IRC, 1997) as have rapid cost-effective interventions in the health sector in and participatory appraisal methodologies low-income countries (World Bank, 1993). Many (Palmer, 1998) but will not be adequate for all displaced populations come from regions with purposes. Certain reproductive health indicators high fertility and maternal mortality rates such as maternal mortality cannot be measured (exacerbated by poor prenatal and delivery care directly and a proxy measure of need will have to and unsafe abortion) and where STDs/HIV are a be used (Graham and Campbell, 1990). Such major cause of disability and death. However, to measures are being developed in stable settings date, priority among displaced populations have including the measurement of maternal deaths been given to other needs. through asking sisters of the woman who died and the measurement of a set of what have been called l ensuring that legal, religious and cultural ‘near miss’ indicators (Filippi et al, 1997). Policy- views of beneficiaries and service providers makers in humanitarian aid are therefore faced are respected with a situation where recommendations for Some areas of the reproductive health agenda, services and their measurement are constantly such as female genital mutilation and aspects of changing. contraceptive services are sensitive issues. Both Other aspects of the RH agenda are sensitive and beneficiaries and service providers will have appropriate skills and specific approaches will be different attitudes towards them depending on the needed to obtain the information required. One religious, cultural and socio-economic background from which they have come. These different views approach used to obtain sensitive information is the use of scenarios. Scenarios are hypothetical will need to be taken into consideration and stories of events that can be presented and then respected while ensuring that those who both need discussed, enabling sensitive topics to be and want services are able to access them. discussed in a less personal way3. More investment Dilemmas may arise when, for example, services to which a population are accustomed may be to develop further innovative methodologies for assessing need may have to be made. illegal in the host country to which they have fled. A vast amount of information on the community and its reproductive health status prior to exodus could and should be made available to providers working with displaced populations. Anthropological, health and socio-economic data REPRODUCTIVE HEALTH for displaced populations REPRODUCTIVE HEALTH

22 ○○○○○○○○ 4 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○

Case studies of current RH services

t is still rare to find programmes where the of formal policy guidelines up till now, have been full reproductive health agenda is being implemented. It is hoped that using examples of Iimplemented: in some cases existing services actual practice will help the reader to visualise (MCH and STD treatment) may simply be re- opportunities for appropriate provision. The packaged and termed reproductive health. A information below essentially covers work known database that is being developed on reproductive to the author, and as such it is recognised that it health in refugee situations cited approximately does not give a comprehensive picture. 150 programmes which were currently being run on reproductive health issues in refugee contexts, 4.1 Controlling STDs with Rwandans but this figure includes programmes which may in Tanzania (1994) provide only one aspect of reproductive health e.g. safe motherhood. Out of the 150, only one In Rwandan camps in Tanzania, AMREF programme was listed as comprehensively undertook a rapid 8-day assessment of the covering all the major aspects of reproductive prevalence of STDs in August 1994 (Mayaud, REPRODUCTIVE HEALTH for displaced populations health. Instead more piecemeal change is LSHTM/AMREF, 1997) soon after the arrival of occurring with agencies introducing one or two refugees between April and June 1994. aspects of the reproductive health agenda into their Prevalences of STDs were assessed from a survey existing programmes or different agencies may be of antenatal clinic attenders, men from outpatient providing one or other aspects of reproductive clinics and men from the community. All groups health within the same setting. reported frequent experience with STDs and engaging in risky behaviour prior to the survey. Much of the impetus for change has come from However, during the establishment of the camps the emergence and spread of HIV/AIDS and media sexual activity was said to be low. Over 50% of reporting of the occurrence of sexual violence antenatal attenders were infected with agents among displaced populations. Even before the causing vaginitis and 3% with Gonorrhoea. The ICPD conference in 1994 some change was prevalence of active Syphilis was 4% and among occurring. In 1991, for example, a prevention of male outpatient attenders this figure rose to 6.1%. HIV/AIDS programme initiated by MSF- Switzerland commenced in refugee camps in A mass education programme was initiated after northern Uganda this programme has been handed the assessment. This included the use of eight large over to an indigenous NGO (Madi Aids mobile exhibition boards bearing messages in the Community Initiative - MACI) and is still local Rwandan language with cartoons around the continuing. This chapter looks at some examples theme of HIV/AIDS/STDs. 400,000 STD/AIDs of these programmes, which despite the absence education leaflets were distributed. Health

24 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ REPRODUCTIVE HEALTH for displaced populations ○○○○○○○○ including suppliesforcervical screening,the incorporate otherneeds ofthecommunity held. Changesinthekits were recommendedto the kits.Two seminarson familyplanningwere leaflets inthelocallanguage fordistributionwith planning issues,MSIdevelopedandproduced information onreproductivehealthandfamily services. Inordertodisseminatepublic weighted towardstheprovisionoffamilyplanning and pregnancytesting.Itwasthereforeheavily condoms), abortion,gynaecologicalexamination contraception (oralcontraceptivepills,IUCDand education materialnecessaryforthefollowing:- contained supplies,equipmentandinformation/ phase ofdistribution(MSI1995).Theinitialkit September 1993andupdatedfollowingthefirst reproductive healthkit.Thekitwasdesignedin International (MSI)introducedthefirst In theFormerYugoslavia, MarieStopes Usingreproductive healthkitsin 4.2 transmission. an improvementinknowledgeaboutHIV of peoplereportingmultiplesexualpartnersand but therewasanoveralldecreaseinthenumber survey showedthatcondomusedidnotincrease follow upknowledge,attitudeandbehaviour ensure futurefertility.’ (Benjamin,J.A.,1996).A through themessage,‘treatSTDstoprotectand self-empowerment, ‘thefreedomtochoose,’ action wasfelttobeboththroughencouraging More effective strategies topromoteindividual while patientswaitedtobeseenin‘outpatients’. Trained counsellorsalsogaveeducationsessions one toencountersandgroupdiscussions. from therefugeecommunitytogivemessagesin Community Educators(ACEs)werealsorecruited the provisionofeducationandinformation.AIDS closely withCAREwhowereconcentratingon recommended drugs.Theprojectcollaborated and wouldnotrespondtopreviously it wasfoundthatsomeSTDswereresistantstrains inchangingprogrammeswhen was thedifficulty LSHTM/AMREF). Oneoftheproblemsthatarose rise (personalcommunicationP. Mayaud, STDs maynothavedecreasedbutneitherdidit but earlyresultssuggestthattheprevalenceof drugs. Fullevaluationresultsareexpectedsoon were equippedwithessentialsuppliesandSTD recommended STDtreatmentflowcharts.Clinics trained toprovidemedicalcareusingWHO organisationsworkers from13different were Jan 1995) Former1994- Yugoslavia(Feb by thepresenceof‘competent Rwandanrefugees was thepresenceoflocal capacity demonstrated Coordinator inafinalreport ontheprogramme users. Oneofthepoints notedbytheRH by thewomenespecially formerandcontinuing said tobeanincreasingdemandforcontraception services provided.Duringthemissiontherewas was oneofthemostpopularreproductivehealth and treatmentactivities.Ante-natalconsultation motherhood services,andSTD/HIVprevention Agencies providedfamilyplanningandsafe community workersandhealthcareproviders. communication (IEC)activitiesandtrainingof provision oftrainingininformation,educationand and staff capacityforimplementingactivities; reproductive healthindicators;areviewofNGO of areportingandmonitoringsystemfor planning; collectionofdataandthedevelopment surveys andstudiesonHIV/AIDSfamily and programmeconstraints;implementationof group discussions;identificationofpriorityneeds evaluation ofcommunityneedsthroughfocus programmes initiatedinthecampsincluded: implementing partnersinBukavu.The in Gomaandconsultationmeetingswereheldwith working groupswereestablishedineverycamp after theinitialinflux.Reproductivehealth 1995, throughJohnSnowInc.,somesevenmonths for GomaandBukavu,LakeKivuregioninearly A reproductivehealthcoordinatorwasappointed the DemocraticRepublicofCongo(FormerZaire). occurred inthecampsforRwandanrefugees comprehensive reproductivehealthservices agencies. Oneofthefirstattemptstointroduce advocated andsupportedtheworkofanumber reproductive healthcoordinatorwhohas initiated ithasoftenbeenthroughtheactionofa Where comprehensiveprogrammeshavebeen Coordinatingreproductive health 4.3 workers (DFID,1994). programme andthedifficultiesthiscausedforfield hostility ofsomethebeneficiariesto raised concernsbyteammembersaboutthe In May1994anevaluationoftheprogramme delivery in1993toone...in1994”(MSI,1995). rate haschangedfromtwoabortionstoevery of deliveriesremainconstanttheabortion/delivery “In Zeneca,...statisticsshowthatwhilethenumber treatment ofSTDs.MSI,forexamplereportedthat maintenance ofproblematicpregnanciesand Congo (Former Zaire) 1995-6 services for Rwandanrefugeesin working with NGOs on reproductive health for young people were organised on STDs, HIV/ ○○○○○○○○ activities.’ (De la Rosa 1995). AIDS, adolescent crises, school drop out, alcoholism and early marriage. Young people 4.4 Advocating reproductive health themselves were also trained to teach their peers. among Kenyan refugees in Somalia (1995-6) 4.5 Addressing violence among ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Burundian refugees in Tanzania In 1995, in the Somali camps in North-East Kenya. (1996) the National Council of Churches of Kenya (NCCK) was given the responsiblity of integrating The International Rescue Committee had been the missing aspects of reproductive healthcare into assisting Burundian refugees in South West services at Kakuma and Dadaab camps. The Tanzania since the first influx in 1993. A range of reproductive health coordinator found that safe reproductive health care services, including family motherhood services were already offered in the planning, counselling and contraceptive camps, treatment of STDs was available and a distribution, education on the prevention of STDs support programme for the survivors of sexual and safe motherhood initiatives were taking place violence existed. However, family planning within primary care services in Knembwa camp. services were only established in one camp and The refugees were estimated to have suffered a no preventive or education programme about high degree of sexual and gender-based violence AIDS/STDS was available. Training and both prior to their flight, during flight and within workshops were then initiated and where the camps. The ‘countering gender and sexual necessary supplies provided (Riungu, Mutua, violence project’ was initiated in October 1996. Mohamed, 1997). The aim of the project was to reduce violence and to minimise its consequences. The project was In the same camps, the NCCK also addressed the managed by two women one of whom was a issue of female genital mutilation with the Burundian refugee who was an elected community community. The details of the practice and its leader from the camp. Involving community origins were discussed with community leaders. members was seen to be crucial for the project to They reached some agreement that parts of the work. Elected refugee women representatives practice should be changed. One UN were therefore chosen to counsel and support those representative stated that who had experienced violence. These “among men there is still some opposition to the representaitives were involved in the assessment stopping of FGM. Some believe that the clitoris process which was undertaken at the beginning should be bled. They are prepared to reduce the of the project. The assessment included in-depth extent of the FGM but not to stop it altogether”. interviews, group discussions and a survey REPRODUCTIVE HEALTH for displaced populations (Nduna, 1997). Very high response rates were In addition, attempts were made to reach achieved and were attributed to involvement of adolescents. At first leaders were concerned about the community leaders and representatives. It was what the young people would be taught so they noted that ‘participatory methods ....make the attended the youth sessions. The importance of community desire change’. The results suggested preserving their fertility for the future of their that approximately 25% of the 3,803 Burundian family and clan was emphasised. Later more direct women between the ages of 12-49 in Knembwa contact with young people was achieved and had experienced some form of sexual gender specific needs were identified. A report on the violence. Survivors of violence reported to the project (Riungu and Barasa 1997) stated that, Women’s Representatives or members of the project team and a programme of assistance was “[young people] owned up to being sexually then offered (See Box 9 overleaf). active ,..informing us of the availability of cheap sex in the town.....[and that] exchange of sex for 4.6 Maternal health education in food was common”. Afghanistan In June 1995 a survey revealed minimal condom Health Unlimited, a British NGO has undertaken use among those who were sexually active. Those some pioneering work using health education who had used them did not know how to use them media projects (Health Unlimited, 1993). One properly. A group was trained specifically to direct project is taking place in Afghanistan with the their educative efforts toward the youth. Sessions 25 BBC Radio Pashto service using programmes with

25 ○○○○○○○○ drama, song and comedy to bring health messages Box No. 9 alive. Early results, as assessed by a follow up survey, showed significant changes in attitudes and IRC Burundian refugee project for practices in mother and child health. During the victims of gender violence project, local warlords used the radio to negotiate

○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ a ceasefire to facilitate a mass communication 1 Counselling in how to continue to live in campaign. More recently in Cambodia, similar the community techniques have been used to educate women 2 Medical examinations for trauma, STDs about birth spacing. including HIV and pregnancy 3 Material support such as soap and clothes for the most needy 4 Referral to camp management through social workers to apply for family separation in cases where women fear continued domestic violence 5 Referral to the camp police to investigate in cases where the woman wants to seek prosecution 6 Open invitation to return as often as they want to discuss the incident or their feelings.

Source: IRC (1997) Pain too deep for tears. Assessing the prevalence of sexual gender violence among Burundian refugees in Tanzania. REPRODUCTIVE HEALTH for displaced populations REPRODUCTIVE HEALTH

26 ○○○○○○○○ 5 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○

Issues affecting implementation of RH services

‘ oucement, doucement, je suis 5.1 Deciding how to prioritise pressée’ reproductive health services

AsD discussed previously, the concept of One of the first problems the advocates of such reproductive health is a new one, and despite the service provision and RH coordinators have however, is in persuading field colleagues of the rhetoric and activity at an international level, field workers in humanitarian contexts may have little importance of RH. Service providers often underestimate the significance of reproductive knowledge of the agenda. This is not surprising in some ways as what policy there is has, for the health to the populations with which they work. most part, been developed from the top, with little This may be because specific needs assessments, involvement of representatives of international where appropriate questions are asked, are not field workers or of the communities (Palmer, C, undertaken, perpetuating the perception that demand for such services from displaced

forthcoming). One reason for this is the fact that REPRODUCTIVE HEALTH for displaced populations humanitarian aid workers are a mobile workforce, populations is low. Unless the right questions are often only remaining for a short time in the field, asked, programme decisions will continue to be making it difficult to involve them at policy level. made on incorrect assumptions. One programme Representatives of both the communities affected manager responsible for southern Sudan said: to date and the host countries also appear to have “I .. see if we can make them [displaced had little opportunity to influence policy. Perhaps populations] aware before it (AIDS) hits them… as a result, some humanitarian agencies have been then it may have minimal damage but ... they all slow to take forward the new agenda because of want to have children.... . We realise its a problem concerns about prioritisation of the issues and and its a priority but... maybe there are more quality of care. pressing health needs, more immediate health problems for the populations”. Some of the difficulties facing policy makers in the field of reproductive health have already been and another said, outlined in the Chapters above, but other issues “At the moment reproductive health is not a face those implementing programmes. At a local priority...abortion is not a problem, they already level these difficulties revolve around answering have good child spacing, ...violence is not the following key questions: (i) how to prioritise occurring in Sudan as the women are treasured.” reproductive health; (ii) how to obtain an understanding of the needs of the community; and Yet in research recently undertaken in southern (iii) how to ensure high quality services. These Sudan with Oxfam, a number of beneficiaries were issues are discussed in more detail below. not happy to have so many children;

28 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ REPRODUCTIVE HEALTH for displaced populations ○○○○○○○○ condoms and contraceptivesupplies.In orderto were facedwithdelays intheprovisionof agenda. InFormerZaire(Congo) serviceproviders interventions withinthe reproductivehealth necessary forfieldworkers toprioritise Depending ontheavailable resourcesitmaybe ICPD conference. regarded asarefusalofrightsendorsedatthe provide serviceswherethereisneedwouldbe RH fieldworker).However, anoutrightrefusalto methods inordertoreducefertility(pers.comm. coercion ofwomentocommencefamilyplanning about thepossibleabuses,forexample, Other serviceprovidershavebeenconcerned were introduced(Riungu,Muta,Mohamed,1997). community leadersiffamilyplanningservices security andfelttheremaybeabacklashfrom refugee campsinKenyawereworriedabout Coordinator, Nairobi).HealthworkersinSomali to avoidcontroversy(pers.comm.,NGOMedical some thinkitbettertoignoreanissueandtherefore whom theyareworking,andrightlyorwrongly, cultural andreligiousbeliefsofthepeoplewith Health providersmayfeelconcernedabout mongering andtheft”. visitors, infidelity, abuseofherhusband,rumour sex withherhusband,improper ways ofreceiving funds, misconduct,ifthewomanrefuses tohave reasons“The for beatingare mismanagementof and violenceinthehomewasverycommon, make youpregnant infourmonthstime”. don’t allowmentogoand‘stealoutside’theywill their husbandhecangoand‘stealoutside’Ifyou only fourmonthsold.Whilekeepingawayfrom somewomenconceiveeveniftheirbabyis “...but practice, child spacingwasalsoeasierintheorythan because ofthis.Somealsotry withawire”. drinking it.TheyalsotakeOmo.Peopledie and chloroquine injectionsbybreaking glassand man otherthantheirhusband.Theytakeherbs if theyare very youngoriftheyare pregnant bya “Some peopledon’t wanttobepregnantespecially induced abortionintheircommunities: many womentalkedabouttheoccurrenceof divorce youandleaveyourchildren”. isbecausethe mennow having fewchildren not goodtohavetoomany. Anotherreason for become thievesandtheydon’t listentoyousoits I don’t wantmanyasifyouhavetheymay 8 7 6 5 was struckhowever, indicating thatthemethods the communitydesirechange. Acautionarynote was ingivingthecommunity controlandmaking (discussed above)andfound thattheiradvantage used thesemethodsinassessing genderviolence commitment ofthecommunityconcerned.IRC they increasetheinvolvementandtherefore advantages ofthesemethodsassessmentarethat will befamiliartocommunitymembers.The be availableassometechniques(describedearlier) undertake theseassessments.Localcapacitymay need toensuretheirstaffhavetheskills are asrobustpossible.Serviceproviderswill need tobemadeavailableensuretheresults analysis. Bothfinancialandhumanresourceswill methods themselvesandthetimeneededfor assessments areoftentimeconsuming,bothinthe reproductive health.First,morein-depthneeds seeking tofulfilltheCodeinrelation issues willfaceinternationalfieldworkersin diminished byouraidprogrammes.’Anumberof ensure thatthisroleissupportedandnot women indisasterpronecommunitiesandwill approach, werecognisethecrucialroleplayedby to meetthoseneeds....inimplementingthis victims andthelocalcapacitiesalreadyinplace thorough assessmentoftheneedsdisaster we willbasetheprovisionofreliefaidupona 1994). TheCodestatesthat,‘whereverpossible, response programmes(RRN,NetworkPaper7, Code ofConductforNGOsworkingindisaster Many NGOshavealreadysigneduptothe1994 Assessing theneedsof 5.2 legal andculturalconstraints. feasibility ofdeliverywithinagiventimescale, beneficiaries, theavailabilityofresources, account ofthefollowingfactors:-views reproductive healthprogrammeswhichtakes have drawnupcriteriaforprioritisinginternational resources. ResearchersatColumbiaUniversity needed toensureappropriateandefficient useof sophisticated prioritisationmechanismsmaybe (see followingsection).Howevermore first stepindecidingwhatservicestoimplement 1995). Collectingdataaboutneedwasanessential set accordingtothesepriorities.(DelaRosa, and thenranked.Goalsobjectiveswere health serviceswerescoredineachoftheseareas community andfeasibility. Thereproductive severity, prevalence,acceptabilitytothe in theircampsbyusingfourcriteria.Thesewere: address theseconstraints,NGOsprioritisedneeds community should only be used if programmes to address the others and in some circumstances pragmatic ○○○○○○○○ issues of concern to the community are developed choices will have to be made. In the former Zaire (IRC). the medical coordinator of UNHCR Goma recommended the provision of only two methods Where communities have not been involved in of contraceptives: combined oral contraceptives planning it is possible to provide services which and injectables. The rationale for this was to keep ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ do more harm than good. For example, a number family planning simple in the beginning due to of Somali women rape survivors who were the difficulty of follow up and poor hygiene in transferred to the coastal refugee camps in Kenya the camps (De la Rosa, 1995). subsequently asked to return to their previous camps. The reason they gave was that they had Concerns have been raised about the availability been put in a special area for women who had been of financial and human resources to implement raped where they had become isolated and quality reproductive health services. There is some stigmatised (pers. comm., NGO health worker). indication that there is an expectation from donors that they want to see the introduction of such Just as it is difficult to assume the priorities of a services at no extra cost (pers. comm., RH community it is also difficult to make assumptions programme manager). This is unlikely to be about their needs. In Former Zaire up until early realistic when many agencies are already July 1995 only one NGO was providing family struggling to provide what was previously planning to the Rwandan refugees but they were considered a minimum service (World Disasters reported to have informal sources through private Report, 1996). RH coordinators have already pharmacies and refugee medical doctors in one of identified a need for extensive training (Obaso- the camps. These refugees often brought their own M, 1997). Results of cost-effectiveness studies supplies (mostly oral contraceptives, injectable suggest that money provided for RH services will contracpetives and Norplant) with them (De la produce considerable saving in the future and this Rosa, 1995). One year later, contraceptives were is a strong argument in making the case for being provided in all camps and the contraceptive increased funding to ensure they can be provided. prevalence rate doubled (pers. comm. K. Burns, The lack of available resources may UNHCR). disproportionately affect those who are internally displaced as there is no single international agency 5.3 Ensuring a high quality of care with the responsibility to help them. Even if services are made available, beneficiaries The problems of resourcing may be solved to some will not use them if their quality is poor (Parker extent by working collaboratively with local et al, 1990). Quality of care has been shown to hospitals and indigenous NGOs already play a significant role in women’s use of prenatal REPRODUCTIVE HEALTH for displaced populations established in the area. There are a number of care (Locay et al, 1990), whether in choosing to reasons why working closely with the host country give birth at home (Sargent, 1989) or continuing or region may be beneficial: it may contribute to contraception use (Mensch, 1993). the continuity of care, it will ensure that tension There are many aspects to quality of care and in does not arise between the host and displaced emergency contexts poor quality generally results communities and finally there is an opportunity from lack of continuity, lack of infrastructure, to enhance local capacity (Toole, 1990). insufficient staff, inadequately trained staff, Local communities are often affected by infectious insensitivity to patients, lack of involvement of disease spread from the displaced community and the community, shortages of equipment and vice versa. When the Rwandan refugees arrived supplies, and inadequate evaluation. In addition, in Tanzania there were concerns about the spread long waits and lack of monitoring and privacy or of HIV to the local populations. The refugees were confidentiality also reflect a lower standard of coming from a country with prevalence rates care. varying between 5-35% whereas the district in The provision of continuity of care is especially which they arrived had low prevalence rates of difficult in unstable contexts due to short term between 3-8%. If services are only provided for funding, short contracts of humanitarian aid the displaced populations then inequities between workers and the unpredictable future of the them and the host population will rapidly increase. displaced population. Some RH interventions fit (De la Rosa, 1995). The limitations of the mandate more easily into short term programmes than of UNHCR to provide services for the local 29

29 ○○○○○○○○ population may be a barrier to solving this iron and folate tablets. A subgroup of the IAWG problem. has recommended indicators which could be used in these settings and these are described in detail Programme monitoring and evaluation will need in the field manual. Involving the community and to be undertaken to ensure quality services are local health workers in evaluation as well as

○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ maintained. Where data are available, health ensuring they are informed of results and action service indicators should be used to measure to be taken will help ensure success. Limiting the programme impact: changes in the prevalence of number of indicators to those essential to the neo-natal tetanus for example or the proportion programme may simplify data collection and of maternal deaths from obstructed labour. ensure more accurate information and timely Indicators will have to be developed in accordance feedback. with resources, priorities and needs and in Initiatives are currently under way to both develop consultation with the host and displaced a set of minimum standards in the provision of communities. However resources may be limited food, health, nutrition, shelter and water/sanitation and/or where technical measurement of impact elements of humanitarian assistance, known as the may be difficult. In these circumstances field Sphere Project9, and the People in Aid initiative workers may have to place reliance on process which seeks to ensure the appropriate briefing and indicators. Process indicators measure either training of all aid workers both prior to, during inputs or outputs of a programme: an example of and following their field work. The team working an input would be the percentage of staff trained on minimum standards in health will be covering in gender awareness and an output would be the reproductive health in its ambit. proportion of pregnant women who have received REPRODUCTIVE HEALTH for displaced populations REPRODUCTIVE HEALTH

30 ○○○○○○○○ 6 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○

Conclusion

“If you concentrate too much on the provision of material aid, on saving lives, you forget about the human dignity you say you want to restore”, Hugo Slim.

Despite the difficulties of implementing the RH opportunity for accelerating more extensive agenda, these services have the potential to greatly changes in the way relief services are organised. improve the health of populations yet remain cost- Relief aid is increasingly criticised (Toole, 1993, effective. Investments in reproductive health may Macrae and Zwi, 1994) and calls made for more benefit not only the individual and their family accountability, particularly to the beneficiaries but also the community and the next generation. (Macrae, de Graaf, 1997). Some of the critique The first steps in initiating change, through a has centred around what many consider an greater awareness of RH issues, are under way at artificial division between relief and development an international level but a commitment must be which is also reflected in funding structures. This made to ensure that such changes take place at model now appears out of step with the reality of field level. situations where populations have no possibility of a fast return to normality and receiving relief In order to ensure the implementation of high becomes a way of life. IFRC, among others, are quality programmes a number of investments will advocating a new approach they have named be required. First, international field staff will need developmental relief (World Disasters Report,

to understand the reproductive health agenda. REPRODUCTIVE HEALTH for displaced populations 1996). It has three specific features: it seeks to They should be informed, for example, about communicate with beneficiaries, it looks to sustain gender issues as well as the social, cultural and livelihoods, not just lives and it aims to build on psychological aspects of sexuality and local realities. The community’s participation in reproduction and available methodologies to all aspects of the relief effort from planning assess need. some of the recommended services through implementation and evaluation are said and techniques will not be familiar to international to be key. This has also been shown to be workers in their home countries. A commitment particularly important in the field of reproductive should therefore be made to utilising local capacity health (Barnett-B, 1995; Zulkifli 1994) and is and enhancing it where necessary. Secondly a essential in order to ensure that these services are commitment to evidence-based policy and practice acceptable, appropriate and sustainable (Robey, will be necessary; if evidence is available and 1994). Without this approach suspicion and generalisable it should be incorporated into current opposition from the community is more likely and guidelines. Further research to address specific may lead to under-use of good safe services (John issues may be required and efforts should be made Hopkins University, forthcoming). to ensure that it takes place. Finally the evaluation and monitoring of programmes will be essential Donors, policymakers and service providers are tools that will also need an increase in both human now facing crucial decisions about how to and financial resources in order to be effective. integrate the new RH agenda and their greatest challenge may be to ensure that rhetoric about The introduction of the RH agenda is at a crucial community participation becomes a reality. period for humanitarian aid and could create the

32 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ REPRODUCTIVE HEALTH for displaced populations ○○○○○○○○ s s s s s s s s s s s s s s s s agenciesAdditional membersorinterestednow : parties s s s s s s s s s s s s s Original SignatoriestotheManual s s s s s s s s IPAS International RescueCommittee IFRC American RefugeeCouncil International RescueCommittee International PlannedParenthoodFederation Red CrescentSocieties International FederationoftheRedCrossand Government oftheUSA Family HealthInternational Columbia University para Capesinos Centro deCapaciaciónenEcologiaySalud CARE International Andrew W. MellonFoundation American RefugeeCommittee African MedicalResearchFoundation Action ContrelaFaim Action AfricainNeed LSHTM IPAS International CentreforMigrationandHealth GOAL Department forInternationalDevelopment CRED CONCERN Centre forDiseaseControl International PlannedParenthood Federation International Organization forMigration SPHERE Project International CentreforMigrationandHealth Family HealthInternational Department forInternationalDevelopment Department ofHumanitarianAffairs Université CatholiquedeLouvain Columbia UniversitySchoolofPublicHealth Centers forDiseaseControl CARE International Action ContrelaFaim Participants oftheInterAgencyWorkingParticipants Group Signatories totheInter-Agency FieldManualon Reproductive Health inRefugeeSituations Appendix s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s World Vision International VOICE USAID OfficeofPopulation UNAIDS Refugee PolicyGroup Population Council MERLIN World HealthOrganization Scouts World AssociationofGirlGuidesand Children Women’s CommissionforRefugeeWomen and Wellstart International UNICEF UNHCR UNFPA Save theChildrenFundUK Marie StopesInternational John SnowInc. IPAC FlemishAIDSCoordination Centre International OrganizationforMigration WCRWC US DepartmentofState USAID UNICEF UNHCR UNAIDS Save theChildrenUK Permanent MissionoftheUSA OXFAM Médecins SansFrontières–Belgium John SnowInc. World HealthOrganisation Population Council Médecins SansFrontières–International Marie StopesInternational LSHTM Glossary ○○○○○○○○

Abortion/Termination of pregnancy These terms are used to describe a pregnancy ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ended deliberately either by a health professional or any other person including the mother herself. Anencephalus A condition where the child is born with part of the skull and brain absent. Emergency contraception The administering of a high dosage of the combined pill within 72 hours of sexual intercourse to prevent a pregnancy. Female Genital Mutilation All procedures that involve partial or full removal of the female external genitalia and or injury to the female genital organs for cultural or other non-therapeutic reasons. Gender-based Violence Any act of physical or psychological violence occurring within the home or the community. Hydrocephalus A condition causing the normal flow of cerebral spinal fluid to be obstructed resulting in the accumulation of fluid in the brain. Subfertility Assuming normal sexual relations, the inability of a couple to become pregnant after 12 months. Maternal mortality ratio The number of maternal deaths per 100,000 live births Miscarriage The unintended loss of pregnancy before 28 weeks gestation Peri-natal mortality The number of stillbirths and deaths in the first week of life. Sexual Violence Any act of sexual violence occurring in the family or within the general community. Unsafe Abortion A procedure for terminating unwanted pregnancy either by

persons lacking the necessary skills or in an environment REPRODUCTIVE HEALTH for displaced populations lacking minimal medical standards or both. Acronyms

AMREF African Medical and Research Foundation FGM Female Genital Mutilation HIV/AIDS Human Immunodeficiency Virus/Auto-immune deficiency syndrome IAWG Inter-agency working group. ICPD International Conference on Population and Development IDPs Internally displaced persons IEC Information, education and communication IPPF International Planned Parenthood Federation IRC International Rescue Committee IUCD Intra-Uterine Contraceptive Device (coil) MCH Maternal and Child Health 33

34 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ REPRODUCTIVE HEALTH for displaced populations ○○○○○○○○ .SPHEREProject:MinimumStandards inHumanitarianResponse.AprogrammeoftheSteering GroupdiscussionwithdisplacedmeninKotobi. 9. 8. Groupdiscussionwithsettledwomen inMaridi.To ‘steal outside’meanttosleepwithawoman KeyinformantinterviewwithcommunityleaderinMaridi. 7. Young settledwomanspeakingatagroupdiscussioninMariditown. 6. 5. Scenariosinvolvetellingastoryofsituationoccurringinsimilarcontexttothatthebeneficiary 4. Atabiologicallevel,themodeofactionisuncertaininthatemergency pillmayacttoprevent Howeverthereareexceptionstothis,especiallyinlong-termcamps 3. Afteraperiodof2years,Syphilismaygointolatentphasewhereitisnotinfectious. 2. 1. World HealthOrganisation UnitedNationsChildrensFund UnitedNationsHighCommissionerforRefugees UnitedNationsPopulationFund WHO TerminationUNICEF ofPregnancy UnitedNationsJointProgrammeonHIV/AIDS UNHCR SexuallyTransmitted Diseases UNFPA ReproductiveHealthforRefugeesConsortium ReproductiveHealth UNAIDS TOP Non-governmentalOrganisation STDs NationalCouncilofChurchesKenya MarieStopesInternational RHR RH MédecinsSansFrontières NGO Minimuminitialservicepackage NCCK MSI MSF MISP Committee forHumanitarianResponseandInterAction. ProjectManager, SusanPurdin,IFRC. other thanyourwife. advantage ofmakingthediscussionslesspersonal. and discussingwhatwouldhappenifthesamesituationoccurredintheircommunity. Thishasthe demand. different sidesofthedebate,whichmayhinderimplementation,evenwherethereisinformed a highlysensitiveandpoliticisedissuemeansthatthepositionofagenicesarelikelytofallon consider abortiontohaveoccurredatdifferentstages,thisuncertaintyandthefactthatis either ovulationand/orfertilisationimplantation.Giventhatdifferent individualsandgroups Endnotes Bibliography ○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Achta Djibrinne, S. O’Connell, H. ed. (1993) Conflict and the Women of Chad in “Women and Conflict”. Oxfam, Oxford, UK. Adam, G., Harford, N., (1997). Radio and health education: making a difference. Health Unlimited. Anderson, M.B. Walker, B. ed. (1994). Understanding the disaster-development continuum in Women and Emergencies. Oxfam. Oxford, UK. Anonymous (Ed.). Reproductive Freedom for Refugees. Lancet 1993;341 (8850)(Apr 10):929-30. Bailey et al. (1988) A hospital study of illegal abortion in Bolivia. PAHO Bulletin 22 (1) 27-41. Barker GK, Rich S. Influences on adolescent sexuality in Nigeria and Kenya: findings from recent focus- group discussions. Stud Fam Plan 1992;23(3):199-210. Buzra-J, Lush, L. 1997 (submitted for publication) Planning reproductive health in conflict: a conceptual framework. Carballo M, Simic S, Zeric D. Health in countries torn by conflict: lessons from Sarajevo. Lancet 1996;348:872-4. Christensen, H. The reconstruction of rural Afghanistan. A chance for Rural Afghan Women. Geneva. UNRISD. 1990; Cossa-HA, Gloyd-S, Vaz-RG, Folgosa-E, Simbine-E, Diniz-M, Kreiss-JK. Syphilis and HIV infection among displaced pregnant women in rural Mozambique. Int-J-STD-AIDS 1994;5(2):117-23. D’Agnes-T and D’Agnes-L. Community-based approach to refugee relief: esperiences from Thailand. IPPF Medical Bulletin. 1982; 16(5). 3-4. De La Rosa, R. Reproductive Health Cordination in Goma and Bukavu. Lake Kivu region, Zaire. Mission report 10 February - 12 August 1995. John Snow Inc; UNHCR. 1995; Eriksson et al. Joint Evaluation of Emergency Assistance to Rwanda. The International Response to Conflict and Genocide: Lessons from the Rwanda Experience. Book 4. Rebuilding Post-War Rwanda.

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36 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ REPRODUCTIVE HEALTH for displaced populations ○○○○○○○○ UNHCR; UNFPA. Overseas DevelopmentInstitute.1996; interventions andaCritiqueofPsychosocialTrauma Projects. Summerfield, D. 1991;107(1):69-80. Smallman-Raynor-MR, Cliff-AD. European JournalofClinicalNutrition Simic S,IdrizbegovicandBukvicI. Press; 1987;7,FamilyPlanning.p.64-75. Sandler-RH, Wray-J. Sandler-RH,Jones-TC,eds. health Sadiq, N.TheStateoftheWorld Population. US CommitteeforRefugees. 1995. Baltimore. JohnHopkinsSchoolofPublicHealth Robey, B.,Piotrow, P.T., andSalter,C. Herzegovnia. 1995; aggression againsttherepublic ofBosniaandHerzegovnia. Republic CommitteeforHealthandSocialWelfare. Potts M. Latin America Paxman JM,RizoA,BrownL,BensonJ. Forthcoming Palmer C,LushL,andZwiA. Mundri Counties Palmer C. 1995;26-31. health services WHO Nyakabwa-K, Lavoie-C. among BurundianRefugeesinTanzania Nduna, S.andGoodyear, L. groundfertile forthespread of HIV Mworozi EA.AIDSandcivilwar:adevilsalliance. Musse-F. Mulley-S. Adolesc-Med 1994;148(7):704-8. Miller-LC, Timouri-M,Wijnker-J,Scheller-JG. First ed.LondonandBasingstoke:MacmillanEducation;1997. Médecins SansFrontières.HanquetG,editor. Marie StopesInternational.1995. Marie StopesInternational.Bosnia-Hercegovnia: assessment inRwandanrefugee campsinTanzania Mayaud P, MsuyaW, Todd J,KaatanoG,West B,BegkoyianG,GrosskurthH,andMabeyD. . NewYork. UNFPA. 1997;p.23. Rapid EvaluationMethodGuidelines forMaternalandChildHealth,FamilyPlanning andother Even thosefleeingfrom Genocide,donotwanttostartfamilies Women victimsofviolence-RapeinKenyasrefugee camps Rapid AssessmentofNeedforReproductiveamongpopulationsinMaridiand HealthServices Family planningforboatpeople . StudiesinFamilyPlanning1993;24(4):205-26. . Geneva.WHO.1993; , SouthernSudan.Forthcoming. The impactofwarandatrocityonCivilianPopulations: BasicprinciplesforNGO Reproductive HealthinRefugeeSituations:Aninteragencyfieldmanual Sexual violenceagainstwomenrefugees intheHornofAfrica Pain toodeepfortears:Assessingtheprevalence ofSexualGenderViolence World RefugeeSurvey Reproductive healthservicesforpopulationsinconflict:apolicyanalysis. Civil War andthespread ofAIDSinCentralAfrica.Epidemiol-Infect . AidsAnalysisAfrica1993;3(6):8-10. Family Planning:lessonsandchallenges:makingprograms work. 1995;4933-6. Nutritional effectsofthesiegeonnew-bornbabiesinSarajevo. . 1997. The ClandestineEpidemic:PracticeofUnsafeAbortionin . People1991;18(4):27-8. The RighttoChoose:reproductive rightsandreproductive RefugeeHealth.Anapproach toemergencysituations. Afghan refugee children andtheirmothers. Reproductive HealthKitEmergencyProject. Medical Care ofRefugees. . 1994;43.PopulationReportsSeriesJ. . GenitourinaryMedicine1997;73(1):33-8. . 1996. Dislocation causedbycivilstrifeinAfricaprovides The bulletin:socialandhealthconsequencesofthe InstituteofPublicHealthR/FBosnia London,UK.RRNNetworkPaper14. . Forthcoming. . People1980;7(4):28-9 Oxford:OxfordUniversity . AfricanWomen Arch-Pediatr- STD rapid . Geneva: London. WHO Womens Health : Improve our health: Improve the World. Geneva. W.H.O. 1995; WHO position ○○○○○○○○ paper on the Fourth World Conference on Women in Beijing, China. 4-15 September 1995. WHO Managerial Guidelines for the introduction of reproductive health services in emergency settings. (draft). Geneva. WHO. 1997;

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39 RRN

Background The Relief and Rehabilitation Network was conceived in 1993 and launched in 1994 as a mechanism for professional information exchange in the expanding field of humanitarian aid. The need for such a mechanism was identified in the course of research undertaken by the Overseas Development Institute (ODI) on the changing role of NGOs in relief and rehabilitation operations, and was developed in consultation with other Networks operated within ODI. Since April 1994, the RRN has produced publications in three different formats, in French and English: Good Practice Reviews, Network Papers and Newsletters. The RRN is now in its second three- year phase (1996-1999), supported by four new donors – DANIDA, ECHO, the Department of Foreign Affairs, Ireland and the Department for International Development, UK. Over the three year phase, the RRN will seek to expand its reach and relevance amongst humanitarian agency personnel and to further promote good practice.

Objective To improve aid policy and practice as it is applied in complex political emergencies.

Purpose To contribute to individual and institutional learning by encouraging the exchange and dissemination of information relevant to the professional development of those engaged in the provision of humanitarian assistance.

Activities To commission, publish and disseminate analysis and reflection on issues of good practice in policy and programming in humanitarian operations, primarily in the form of written publications, in both French and English.

Target audience Individuals and organisations actively engaged in the provision of humanitarian assistance at national and international, field-based and head office level in the ‘North’ and ‘South’.

The Relief and Rehabilitation Network is supported by:

Ministry of Foreign Affairs ECHO DANIDA

Department of Foreign Affairs, Department for International Ireland Development, UK