Timely
Reproductive Health Interventions
Providing
adequate food, clean water, shelter, sanitation and primary health care
(PHC) are priority activities in any refugee emergency. These interventions
help combat the major killers in refugee situations: malnutrition, diarrhoeal
diseases, measles, acute respiratory infections (ARI) and malaria (where
prevalent). However, RH care is also crucial for the physical, mental
and social well being of any individual. As an integral part of PHC,
RH care is important in overcoming such problems as:
-
complications
of pregnancy and delivery, which are leading causes of death and
disease among refugee women of child-bearing age;
-
malnutrition and epidemics, which can further diminish the physiological
reserves of pregnant or lactating women, thus endangering their
health and that of their child; and
-
an absence of law and order, commonly seen in refugee emergencies,
which, together with men's loss of power and status, leads to an
increased risk of sexual violence. Violence against refugee women,
rape, sexual abuse, involuntary prostitution, even physical assault
during pregnancy have been found to be far more widespread than
was previously acknowledged.
Unquestionably,
women are most affected by reproductive health problems. For refugee
women, this burden is further compounded by the precariousness of their
situation.
The
Complexity of Intervening
It is
important that RH interventions are not only timely but also appropriate
and consistent with national laws and development priorities. RH programmes
affect highly personal aspects of life, so programmes must be particularly
sensitive to religious and ethical values and cultural backgrounds of
the refugee population.
It may
not always be feasible for one organisation to implement the full range
of RH services. Providing comprehensive RH services may require cooperation
and coordination among agencies.
The complexities
of reproductive health were discussed at the Fourth World Conference
on Women (Beijing 1995). Participants listed the following as some of
the reasons why many of the world's people do not benefit from reproductive
health:
"...
inadequate levels of knowledge about human sexuality; inappropriate
or poor-quality RH information and services; the prevalence of high-risk
sexual behaviour; discriminatory social practices; negative attitudes
towards women and girls; and the limited power many women and girls
have over their sexual and reproductive lives."
Platform
of Action, paragraph 7.3 -- Beijing 1995
"Adolescents
are particularly vulnerable," they concluded.
Refugees
face even greater difficulties in obtaining RH services. Among them:
-
The breakdown of pre-existing family support networks means that
young men and women lose their traditional sources of information,
assistance and protection.
-
Loss of income reduces the refugees' ability to make free choices.
-
Women may become solely responsible for the welfare of their families.
Fulfilling the role of breadwinner often represents a great emotional
and physical burden that is not adequately compensated by appropriate
services.
-
Attention is often focused exclusively on immediate life-saving
measures; RH care is not considered a priority. (Hence the development
of this Field Manual and the recommendations for the Minimum Initial
Service Package -- MISP -- described in Chapter
Two.)
Guiding Principles
for Intervention
A successful
RH programme requires adequate and well-trained staff, sufficient funding,
and effective
These
principles are applicable to every aspect of RH assistance and to all
subsequent chapters of this Field Manual.
Community
participation is essential at all stages to ensure the acceptability,
appropriateness and sustainability of RH programmes. It is necessary
for empowering refugees, particularly women, to have greater control
over their lives and over the services that are provided to them.
In an
emergency, refugees are extremely vulnerable. It may be easy to overlook
their particular needs in the urgency of providing services. Their participation
is vital in ensuring that this does not happen, and that the services
are adapted to the users rather than vice versa. In each situation it
is necessary to identify groups and channels through which participation
can be fostered. However, it is also important to recognise that the
leaders may not be best placed or able to provide the information and
support needed to successfully adapt RH services to the population concerned.
Participation may be best achieved through the family unit.
It is
only by taking into account the cultural, economic, ethical, legal,
linguistic and religious backgrounds of the refugees and host country
population that appropriate services can be offered to and used by refugees.
By actively participating, refugees develop the sense of "ownership"
over programmes that is essential for sustainability.
It is
through community participation that essential information will be gathered
to direct the planning of services. Such information includes:
-
identification of the training needs of care providers;
-
selection of appropriate sites to avoid stigmatisation of users;
-
analysis of the appropriate level of privacy and confidentiality
required by local customs, cultures or beliefs;
-
decisions on whether primarily female staff must be used; and
-
recognition of birthing preferences.
A failure
to obtain such information may have a negative impact on the use of
services, for example, if family members are excluded from a birth when
they have an important cultural role to play at such times.
It is
important that both men and women be involved in many aspects of the
RH programme to promote responsible and caring attitudes and behaviour
for the benefit of all. Although men may be poorly informed about RH
matters, they are often the decision-makers. Health providers need to
be aware of the roles and decision-making process within the family
so they can provide services effectively and in the best interests of
the whole family.
Quality
RH services require that organisations, programmes and providers,
-
use appropriate technologies and have trained staff,
-
respect refugees' rights to informed consent by providing adequate
information and counselling, and
-
ensure accessible services, privacy, confidentiality, and continuity
of care.
These
aspects of quality of care are also guiding principles of medical ethics
in the protection of human rights.
Appropriate
Technologies and Skills
Appropriate technologies must be selected according to internationally
accepted standards. Providers must be adequately trained, equipped and
supervised. Appropriate supplies must be available, clean, and, when
necessary, sterile. All invasive procedures must involve infection prevention,
proper use of drugs, etc. All interventions must be safe -- which requires
a sufficiently staffed health facility, technically competent providers,
properly functioning equipment, adequate supplies, and a responsive
logistics system.
Access
Primary health care (PHC) services must be available within a reasonable
distance from all patients. A referral network, including transportation,
to higher-level facilities should be coupled to PHC services. Patients'
access to services should not be contingent on social or cultural backgrounds
nor on age, marital status, parity, number of male children, sexual
orientation, or partner or parental consent. Patients should not be
required to accept one service in order to gain access to another type
of service.
Informed
Consent
A patient has the right to know, before any procedure is performed,
what the procedure involves as well as its expected benefits, possible
risks, duration of treatment, and cost to the patient or her/ his family.
This information must be presented to the patient in a language that
s/ he can understand.
Informed
consent means that the patient not only has choices, but also can make
an educated decision among various options. To make such a decision,
the patient must know her/ his condition and have ample opportunity
to ask questions and receive answers from a knowledgeable provider.
Privacy
Visual and auditory privacy must be maintained during all phases of
patient care -- from presentation through diagnosis, testing, treatment,
and counselling. Examination tables should face away from doors and
windows so that a woman will not risk exposure during examination, particularly
during pelvic examination. Windows should be covered, and partitions
placed between examination areas. Others within the health facility
should not be able to overhear the interaction between the patient and
health provider.
Confidentiality
All information regarding the patient, her/ his history, treatment,
condition, circumstances, and prognosis is discussed only between the
patient, the provider and supervisors. No staff member should share
patient information with anyone who is not directly involved in the
patient's care without the patient's permission. Medical records should
be stored in a locked room or file cabinet to which only providers and
supervisors have access. Medical records should never leave the clinic
unless required for patient referral to another clinic.
Respect
All health staff should talk with patients politely and manage patient
care in a compassionate and non-judgmental fashion. Patients have the
right to ask questions and to expect those questions will be answered
in a timely, complete and understandable manner. Patients need to know
how to recognise and manage common complications of their condition,
signs and symptoms indicating the need for additional medical attention,
and when and how to obtain follow-up care.
It is
important to distinguish between different aspects of integration. Reproductive
health services should be integrated into primary health care. Integration
may occur in relation to the place at which services are provided or
the personnel who provide those services.
The potential
to integrate services provided at any particular site will depend on
the skills and resources available. It is unreasonable to expect the
community health worker to provide too wide a range of services. A health
centre will have greater resources and more skilled personnel, and so
greater integration at one site becomes possible. The referral-level
facility must be able to provide services to meet all needs.
Successful
integration is dependent on the quality of communication among the various
personnel, at different levels, within the overall service. All personnel
must be fully aware of how the system operates, what services are provided
at each level, and how those who want to use the services can do so.
The staff at one level must be able to provide information about all
other levels. Communication must also ensure that when referrals are
made between levels, adequate information is received about a patient
at both ends of the service. Information must travel in both directions
and must cover both the reasons for a referral and the eventual consequences
of any action taken.
Good communication
among levels is essential to deal satisfactorily with issues relating
to support, supervision and training, all of which are essential in
maintaining quality. Specific training of personnel may be necessary
to ensure that the designated services can be provided at each level
by appropriately skilled personnel.
RH services
should be considered neither as optional nor as special projects. They
should be integrated in a timely fashion within PHC and community service
activities. Even when the delivery of RH services calls for special
arrangements or resources, this cannot justify their postponement or
neglect.
Reproductive
health requires knowledge and understanding about human sexuality and
appropriate, adequate and accessible information.
It is
important to raise the level of knowledge about reproduction and sexuality.
Women, men and adolescents should understand how their bodies work and
how they can maintain good reproductive health. Scientifically validated
knowledge should be shared to promote free and informed choice and to
counter misperceptions and harmful practices.
IEC activities
are essential for sharing this knowledge. Such activities range from
"one-to-one" conversations between service providers and refugees to
highly developed formal campaigns.
There
are also effective IEC strategies that promote community participation
and individual commitment to changing behaviours.
IEC essentials
can be found in Appendix One.
The active
promotion of reproductive health should be part of all refugee assistance
programmes from the outset. A lack of awareness of the issues involved
in protecting and promoting reproductive health may be found in all
groups involved in a refugee setting, from the providers of health care
to the community they serve. This lack of awareness may become a real
barrier to improved reproductive health and responsible sexual behaviour.
However,
opportunities to promote RH issues may be limited. Any advocacy that
is undertaken must demonstrate understanding of the culture, values
and belief systems of the local population. Advocacy that is insensitive
or disrespectful may be counterproductive and prompt rejection, or even
reprisals, within the refugee community.
Coordination
is needed among:
-
sectors (health, community services, protection),
-
implementing agencies (government, NGOs, UN agencies), and
-
levels of service providers (doctors, midwives, Traditional Birth
Attendants [TBAs], health assistants).
To foster
this coordination, it is recommended that an individual be identified
as RH Coordinator in each refugee situation. This person would assume
the responsibility for overall organisation and supervision of RH activities,
as well as the integration of these services within other health services.
The issue
of sexual violence provides an excellent illustration of the need to
coordinate among sectors. To deal with the causes and consequences of
violence, health professionals must work closely with staff in the protection
and community services sectors. By doing so, staff can develop detailed
procedures on appropriate care for survivors and strategies to prevent
the occurrence of sexual violence.
Coordination
among implementing agencies requires that, although each agency has
its own expertise and range of qualified staff, there should be a standard
approach used by all agencies involved. Even though an agency may not
provide a full range of RH services, coordination with others would
ensure that the end product is complementary and comprehensive RH care.
Uncoordinated activities result in inappropriate allocations of scarce
resources and reduced impact of the project.
Needs Assessment
RH services
must be based on the expressed needs and demands of refugees. RH needs
assessments should be carried out when the emergency situation has stabilised.
This Field Manual does not give detailed guidance on conducting needs
assessment, but refers the field staff to a set of tools created by
the Reproductive Health for Refugees (RHR) Consortium for this purpose.
(See Further Reading)
The following
RH needs assessment tools have been developed by the RHR Consortium:
-
Refugee Leader Questions
-
Group Discussion Questions
-
Survey (for analysis by computer)
-
Survey (for analysis by hand)
-
Health Facility Questionnaire and Checklist
These
tools assist relief workers in gathering information to assess attitudes
toward RH practices, local medical practices and policies, the scope
of needed services and the degree to which current services provide
what is needed.
The tools,
which should be adapted to each situation, are designed to be used by
people with field management experience and/ or RH experience to design
new RH programmes, assess existing capacity and monitor services. The
refugee community should be involved in the needs assessment process
from the beginning. Refugees should participate in:
-
conceptualising the needs assessment framework,
-
site selection for the assessment,
-
translation/ interpretation of tools,
-
interviewing fellow refugees,
-
data analysis and interpretation,
-
feedback to the community,
-
design or redesign of the RH programme based on the needs assessment
findings.
The Structure
of the Field Manual
The principles
that have been developed within this introduction apply to all chapters
throughout the Field Manual.
Not all
components of RH service provision are appropriate within the initial
phases of a refugee situation. This Field Manual is intended to assist
field staff in implementing such services in phases, moving from minimal
to comprehensive services as the situation gradually stabilises.
In recognition
of the urgency in dealing with some RH issues, Chapter
Two of this Field Manual describes in detail the components of a
"Minimum Initial Service Package" (MISP). It is a range of core RH activities
to be carried out from the beginning of the emergency. The activities
outlined within MISP should be conducted alongside other initial-phase
interventions that take place in any newly identified refugee or emergency
situation.
A more
comprehensive package of RH interventions must then be provided as the
situation stabilises. These interventions should be integrated into
Primary Health Care services.
The remaining
chapters of the Field Manual and the main goal of each are:
Each chapter
of the Field Manual begins with an overall goal and provides detailed
guidance on the elements of the RH component. These elements need to
be adapted to each refugee situation in close collaboration with host-country
authorities. A checklist for establishing the particular RH component
is provided at the end of each chapter. This list can also be used for
supervising and monitoring. Further references can also be found at
the end of each chapter.
This Field
Manual does not address a number of other issues related to reproductive
health, either because they are relatively less significant in terms
of public health, or because they may be approached as in normal situations
and information on the issue is abundant elsewhere. This is the case
for most needs of post-menopausal women, elective abortion, reproductive
tract cancers and infertility.
Further Readings
"Declaration
and Platform for Action", Fourth World Conference on Women, Beijing,
1995.
"Medical
Ethics and Human Rights: Guiding Principles", Commonwealth Medical Association,
London, 1997.
"Programme
of Action", International Conference on Population and Development,
Cairo, 1994.
"Refugee
Reproductive Health Needs Assessment Field Tools", Reproductive Health
for Refugees Consortium, New York, 1997.
"Refugee
Women and Reproductive Health Care: Reassessing Priorities", Women's
Commission for Refugee Women and Children, New York, 1994.
"Reproductive
Health Services During Conflict and Displacement: Guidelines for the
Design and Management of Reproductive Health Programmes" (in preparation),
WHO, Geneva, 1998.
Reproductive
Health One and Five Day Training Packages, RHR Consortium, New York,
1998.
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