Assessment
of Needs
Background
information on reproductive health (RH) in the country of origin should
be available from pre-existing data. Sources for this information include
UNAIDS, UNFPA, WHO and other governmental and non-governmental agencies
that work in reproductive health and family planning. Headquarters and
regional offices should be able to provide this information to field
operations.
A
review of the national or other (UNFPA, NGO, bilateral, etc.) family
planning programmes of the host country must be conducted to find ways
and means for collaboration and to identify any differences in protocols
which must be resolved. If services are made available to refugees,
they should also be available to the surrounding local population on
request.
The
following activities will help assess the demand for family planning
within a refugee population:
-
Carry
out an investigation of attitudes held by the refugee population
concerning contraception.
-
Assess
attitudes and knowledge of providers from the refugee population,
including those involving traditional methods.
-
Gather
information on contraceptive prevalence by method in the country
of origin.
-
Verify
in-country availability of supplies and continuity of supplies.
-
Determine
if refugees can use existing facilities in the host country.
The
support of community, social and religious leaders should be sought
before setting up family planning services. Without this support, only
those willing to risk community censure may use the services. For example,
in some traditional cultures, talk of women's reproductive rights may
provoke opposition. But support may be given for an information, education
and communication (IEC) campaign emphasising child spacing, safe motherhood
and the health of women.
Discussions
should be held with individual women (including leaders and traditional
birth attendants [TBAs]) and women's organisations to obtain their advice
on the location of service points, the timing of services at the health
facilities and the level of privacy and confidentiality that will ensure
maximum use.
Implementation
of Family Planning Services
To
ensure an appropriate and effective family planning programme, the following
components must be integrated, according to the findings of the assessment:
All RH
services should be of the highest quality possible. High-quality contraceptive
care involves providing women and men with safe and appropriate methods
to meet individuals' and couples' needs at every stage of their reproductive
lives. Accurate and complete information should be provided, allowing
women and men to select freely a method that suits their needs.
High quality
means that:
- the
needs of clients are assessed;
- an appropriate
range of methods is provided;
- complete
and accurate information about all methods is offered, thus ensuring
informed choice;
- a mix
of methods matches the needs of all potential clients;
- providers
have the necessary technical skills to offer the methods safely (i.
e., providers screen women for medical contraindications, assess STD/
HIV risks, and can medically manage side effects);
- providers
are trained in technically accurate and culturally appropriate counselling
techniques and use them effectively;
- services
are convenient, accessible and acceptable to clients;
- follow-up
care to ensure continuity of services is provided; and
- an
adequate logistics system ensures a continuity of supplies.
It
is not possible to provide quality services unless an uninterrupted
supply of contraceptives is ensured and staff are appropriately trained.
Local supply channels should be investigated. If these are inadequate,
supplies should be obtained through reliable suppliers or with support
from UNFPA, UNHCR or WHO. These agencies can facilitate the purchase
of bulk quantities of good-quality contraceptives at low cost.
The
following are the basic steps required to manage stocks of contraceptives:
-
Select
contraceptives.
Selection should be based on past use within the refugee community,
the providers' skills, and consideration for the laws, procedures
and practices of the host country. Negotiation maybe necessary to
resolve any differences.
-
Estimate
quantities to be procured.
Estimates should initially be based on data from the country of
origin and, later, on data generated within the refugee situation.
-
Set
up a system for record keeping.
See section below on monitoring.
-
Set
up procedures for efficiently managing the procurement, distribution
and inventory of contraceptives.
Under-or over-supply may be avoided by careful organisation, primarily
by appointing an individual who will assume this specific responsibility.
Planning
Outlets and Opportunities for Family Planning Services
Family
planning delivery sites should be accessible and convenient. Ideally,
family planning services should be available at health centres, outreach
health posts and through community-based distribution channels, when
appropriate. Some groups, such as adolescents, unmarried women and men,
may need special consideration so they feel comfortable using the services
and so they can avoid the risk of stigmatisation by the community. Contraceptives
should be available at the consultation point; the client should not
be referred to a central pharmacy to obtain the selected method.
Counselling
and family planning methods should be systematically offered to refugees
after providing services related to post-abortion care, STDs or after
childbirth.
Human
Resource Needs
Family
planning programmes should be organised and supervised by an experienced
nurse, midwife or doctor and maximum use should be made of qualified
or experienced refugees or local staff. If lay workers are used for
community- based distribution, they must be trained in appropriate skills
and attitudes and must be supervised.
Those involved
in providing family planning services must show respect for the client's
opinion and for the need for confidentiality. To increase use, the provider
may need to be of the same sex and cultural background as the user and
have strong communication skills.
To ensure
administrative, technical and referral support, there must be coordination
and cooperation with the host country's family planning programme and
with NGOs or UN agencies, such as UNFPA. Such cooperation will also
increase the chances of sustainability of the refugee family planning
programme.
Preparation
of the information, education and communication (IEC) component
Counselling
should always be an integral part of family planning services. Appropriate,
culturally acceptable IEC materials help individuals and couples make
free contraceptive choices. Information must include the benefits and
constraints of different methods, and how to use them. (See Appendix One -- The Essentials of IEC Programmes.)
Preparation
of an adequate training programme for service providers
In
many situations, there will be trained providers among the refugee population.
These people should be employed to the fullest extent possible. All
staff involved in providing family planning services must have adequate
training on contraceptive methods and counselling, as indicated in the
list below. This training should be supplemented by periodic refresher
courses. On-the-job training and supervised practice are essential to
ensure adequate performance and must be integral components of the supervisory
programme.
The
elements of an adequate training programme for service providers include:
-
Technical
Competence
-- description of methods (including advantages and effectiveness)
-- mode of action, side-effects, complications, danger signs
-- appropriate groups of users and instructions for use or administration
-- contraindications and drug interactions
-- technical skills relating to the provision of each method (e.
g., insertion of IUD or hormonal implant)
-- follow-up and re-supply requirements, including ordering supplies
-- record keeping
For methods that require specific technical skills -- such as implants,
IUDs, voluntary sterilisation and the diaphragm -- providers need
hands-on training in method provision and close supervision.
-
Interpersonal
Skills
-- communication and counselling skills
-- appropriate attitudes towards users and non-users and respect
for their choices
-- appropriate responses to rumours and misconceptions
-- respect for dignity, privacy, confidentiality
-- understanding of the needs of specific groups, such as adolescents,
single women and men
-
Communication
Skills
It is important for providers to be trained in culturally sensitive,
unbiased communication techniques that encourage open, interactive
relationships with clients. Skills necessary for this kind of communication
include listening, clarifying, encouraging clients to speak, acknowledging
client feelings, and summarising what has been said. In addition,
providers should be taught strategies for effective counselling
of clients about method choices in a limited time period. Providers
should also be trained to use visual and other support materials
and to identify clients with special needs, such as those with a
high risk of STDs, post-abortion clients, breast-feeding women,
adolescents, etc.
-
Administrative
Skills
Many family planning providers must also perform routine administrative
and managerial tasks, such as record keeping, referrals and inventory
control, and should therefore be trained in these activities. Training
should emphasise not only the specific skills necessary to carry
out these functions, but also why they are important.
Plan
protocols to be used during the family planning consultation
First
contact involves:
- registration
and taking an individual RH history;
- physical,
gynaecological and pelvic examination when indicated (for example,
to ascertain whether a woman is pregnant, to investigate unexplained
vaginal bleeding, to determine the presence of an STD);
- counselling
regarding available methods and the user's preferred choice according
to her/ his STD/ HIV risk;
- provision
of the contraceptive method supply, as indicated;
- counselling
on when and how to use the contraceptives;
- counselling
on possible side effects and reassurance that she/ he can return to
the health facility at any time and change methods;
- scheduling
a follow-up visit.
See
Annex 2 for an example of the decision-making process
during a first visit.
Annex 3 shows an example of a checklist used at a first
visit to screen female refugees for contra-indications against the use
of various methods. Host-country checklists may exist for each method
and should be used where appropriate.
For
a new user, frequent follow-up (at one month, three months and six months)
gives the client opportunities to ask questions about use and any side-effects
which she/ he may have experienced. As the user becomes familiar with
a method, he/ she no longer needs frequent follow- up visits. With some
methods, such as pills, condoms, and injectables, clients must make
regular visits to obtain the contraceptives, so follow-up is more automatic.
Whatever the frequency of follow-up visits, the user should be assured
of immediate access if she/ he experiences any difficulties. When arranging
follow-up visits, providers must be sensitive to the literacy and numeracy
of the client.
Examples
of Methods That May Be Provided in Refugee Settings
Providers
and users must be aware of the particularities of each method, its effectiveness,
safety, side effects. They should also know its effect on the risk of
STD transmission, its appropriateness for breastfeeding women and the
usual length of time between discontinuation of the method and return
to normal fertility. Information on the common methods is presented
here. "In no cases should abortion be promoted as a method of family
planning" (ICPD para 8.25).
Barrier
Methods
In
most refugee situations, the most important barrier method will be male
latex condoms. Consistent and correct use of condoms can play the dual
role of protection against STD and HIV infection and prevention of conception.
They can be used alone or in combination with another method to increase
effectiveness. Only water-based lubricants should be used with condoms.
Other
barrier methods, such as spermicides and female condoms, may be requested
by refugees who are familiar with these methods from their country of
origin. If requested, every effort should be made to supply these methods.
Hormonal
Contraceptives
Oral
Contraceptive Pills should include at least:
Injectable
Contraceptives could include depot-medroxyprogesterone acetate (DMPA,
Depo-provera), one injection every three months, norethisterone enatharem
(NET-EN) one injection every 2 months, or Cyclofem, one injection per
month. Trained health professionals should administer injectables. It
is recommended that only one injectable method should be used to avoid
confusion and misunderstanding over the schedule for reinjection.
Supportive
counselling and continued reassurance during follow-up visits will help
clients tolerate common side effects, such as changed patterns of menstrual
bleeding.
See
Chapter Four for details about the provision of Emergency
Contraceptive Pills (ECPs). National policies and the demands of well-informed
users should guide the use of ECPs in refugee situations.
Copper
IUDs (Intra-Uterine Devices)
IUD
insertion, like sterilisation and implants, requires special training,
facilities and equipment that must be in place before these methods
are provided.
Women
known to be infected or at high risk for an STD, including HIV, should
not have an IUD inserted. For nulliparous women, an IUD is not the method
of first choice.
Natural
Family Planning (NFP) Methods
Natural
Family Planning methods include the basal body temperature method, the
cervical mucus or ovulation method, the calendar method and the sympto-thermal
method. NFP is particularly appropriate for people who do not wish to
use other methods for medical reasons or because of religious or personal
beliefs. Counselling must be provided to both partners when choosing
these methods and when practising them. The methods require initial
training and regular follow-up until confidence is achieved in detecting
fertility signs. Teaching these methods to potential users is relatively
time consuming, and requires separate sessions for those refugees who
wish to use them.
Breastfeeding
Breastfeeding
is effective as a contraceptive method if a woman is exclusively breast-feeding
on demand her infant (no other food being given to the baby), she is
not menstruating and her infant is less than six months old. If any
one this these three criteria are not met, then an additional method
of contraception is advised.
Family
planning methods recommended for breastfeeding mothers are:
-
from
delivery up to six weeks postpartum: barrier methods, postpartum
IUD insertion and sterilisation;
-
from
six weeks to six months postpartum: barrier methods, progestin-only
methods (pills, injectables, implants), IUDs, and sterilisation;
-
after
six months postpartum: COCs and combined injectables, and natural
family planning methods.
Hormonal
Implants
An
implant is a long-lasting progestogen-only contraceptive. The most widely
used types (Norplant and Norplant 2) consist, respectively,
of
six or two silastic capsules containing the progestogen levonorgestrel.
The capsules, inserted under the skin of the arm, slowly release the
progestogen. These implants are effective for five years. They should
only be inserted or removed by properly trained personnel.
Before
using any long-term contraceptive within a refugee situation, service
providers must be sure that the necessary facilities and skilled personnel
exist in the country of origin to reverse or remove the method, since
refugees may return home at any time. If such facilities do not exist
in the country of origin, the method should not be used.
Voluntary
Surgical Contraception
Both
male (vasectomy) and female sterilisation are desirable methods of contraception
for some clients. As a surgical method, sterilisation should only be
performed in safe conditions, with the formal consent of the user and
by trained personnel with the necessary equipment. Sterilisation should
not be excluded especially if it is familiar to the refugees from their
country of origin and is allowed within the host country.
Male
Involvement in Family Planning Programmes
Men must
be involved in family planning programmes to increase recognition of
other RH issues, such as the prevention of STDs/ HIV/ AIDS, and to increase
acceptance within the community. Activities might include couples counselling,
condom promotion, special health facility times for men, peer-group
sessions and social groups. Consideration of men's perspectives and
motivation must be integral to programme activities. Contraceptive use
by men enables them to share the responsibility of family planning with
their female partners. Some services may need to be specifically tailored
to meet the needs of male users.
Providers
should maintain a daily activity register and individual forms to help
them record information and offer effective follow-up. The following
information should be recorded:
-
date
-
user
name -- or, if required for confidentiality, only a number
-
user
information (age, parity, address)
-
method
selected (and brand name)
-
side
effects experienced
-
type
of user (new, repeat, etc.)
-
reason
for discontinuation -- dropout or changed to other method
-
date
of next visit (for follow-up).
Record-keeping
forms should be simple and appropriate to the information gathered and
to staff literacy levels. All staff should receive training in how to
maintain appropriate records and be informed of how the information
being collected will be useful to users and providers.
Family
Planning Indicators
-
Indicators
to be collected at the health-facility level
Contraceptive Prevalence Rate (CPR)
CPR is the percentage of women who are using (or whose partner is
using) a method of contraception at a given point in time.
-
Indicators
to be collected at the community level
Community-based surveys
could be carried out to assess the knowledge, attitudes and practices
of refugees concerning family planning services.
-
Indicators
concerning training and quality of care
Regular skills training and assessments
Health personnel implementing family planning programmes should
be trained and their skills assessed regularly. An indicator of
this competency should be monitored at least once a year. A possible
indicator to assess the skills of family planning workers is the
proportion of health workers appropriately implementing family planning
services.
(Refer
to Chapter Nine -- Monitoring and Surveillance.)
-
Assessment
of attitudes of different groups undertaken
-
Contraceptive
prevalence in country of origin known
-
Family
planning services sites established with participation of refugees
-
Contraceptives
procured and logistics system in place
-
Health
and community workers trained in family planning service delivery
-
Family
planning record keeping system in place
-
Involvement
of male community undertaken
Annexes
to this chapter
Annex 1
Appropriate
family planning methods at different stages in a woman's reproductive
life
Annex
2
Contraceptive Choice Decision Tree for Refugees Who Desire Children
Annex
3
Family
Planning Consultation Card
Annex
4
Calculating
Contraceptive Requirements: example of needs for one year in Two Camps:
A and B
"Pocket
Guide for Family Planning Service Providers", Blumenthal, P. et al.
JHPIEGO, Baltimore, MD, 1995.
"Contraceptive
Logistic Guidelines for Refugee Settings", Family Planning Logistics
Management Project, John Snow, Inc., Arlington, VA, 1996.
Hatcher,
R. and W. Rinehart, R. Blackburn, and J. Geller. "The Essentials of
Contraceptive Technology", a joint WHO/ USAID publication, Population
Information Program, Centre for Communication Programs, The Johns Hopkins
School of Public Health, Baltimore, MD, 1997.
"Improving
Access to Quality Care in Family Planning: Medical Eligibility Criteria
for Contraceptive Use", WHO, Geneva, 1996.
"Medical
and Service Delivery Guidelines for Family Planning", WHO, IPPF, AVSC,
Second Edition, 1997.
Technical
and Managerial Guidelines on Family Planning, WHO, Geneva
-
Barrier
Methods and Spermicides: Their Role in Family Planning Care, 1987.
-
Natural
Family Planning -A Guide for Provision of Services, 1988.
-
Norplant
Contraceptive Implants: Managerial and Technical Guidelines, 1990.
-
Injectable
Contraceptives: Their Role in Family Planning Care, 1991.
-
Guidelines
for Community-based Distribution of Contraceptives, 1994.
-
Emergency
Contraception: A Guide Service Delivery, 1998.
-
Female
Sterilisation: A Guide to the Provision of Services, 1992.
-
Technical
and Managerial Guidelines for Vasectomy Services, 1988.
-
Intrauterine
Devices: Technical and Managerial Guidelines for Services, 1997.
WHO Brochures:
What Health Workers Need to Know
-
Natural
Family Planning
-
Providing
an Appropriate Contraceptive Method Choice
-
Female
Sterilisation
-
Vasectomy
-
Breastfeeding
and Child Spacing
-
IUDs
-
Injectable
Contraceptives
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