Feature Story

20 June 2008

In Times of Crisis, a Minimum Initial Package of Services Yields Maximum Reproductive Health Benefits

KAMPAL, Uganda --- In an instant, the life and well-being of an entire population can be threatened by a cyclone, a tsunami or the eruption of political violence. In the event of a crisis, immediate and appropriate action must be taken in order to ensure that individuals are provided with food, clean water, shelter, sanitation and primary health care.

Sandra Krause, director of the reproductive health programme for the Women's Commission for Refugee Women and Children

What is sometimes forgotten is how critical reproductive health care can be, especially in terms of dealing with complications of pregnancy and delivery, which are the leading causes of death and disability among women of child-bearing age.

Sandra Krause works for the Women’s Commission for Refugee Women and Children, an expert resource and advocacy organization that monitors the care and protection of refugee women and children. In an interview at the Reproductive Health in Emergencies Conference, she explained why reproductive health care is integral to emergency response and how organizations work together in emergency situations to care for the reproductive health, including HIV prevention and sexual violence, of displaced populations.

When an emergency strikes, why is it important to integrate comprehensive reproductive health services into primary health care as soon as possible?

It is essential to plan for the integration of reproductive health activities into primary health care during the initial phase of a crisis. If not, the provision of these services may be delayed unnecessarily, which may increase the risk of unwanted pregnancies, HIV transmission, and complications due to pregnancy and delivery.

Why is it important for humanitarian agencies to coordinate their response in emergency situations?

Since it may not always be feasible for one organization to implement priority minimum initial reproductive health services, delivering this package of services may require cooperation and coordination. Coordination of reproductive health care activities is necessary at multiple levels, including within each agency. Coordination within and among various levels and across sectors is aimed at ensuring that efforts are not duplicated, that useful data and information are shared among humanitarian actors and that scarce resources are used efficiently.

How does the humanitarian community work together to ensure that priority services are delivered effectively and efficiently ?

In order to provide effective emergency comprehensive reproductive health care to populations in crisis the Minimum Initial Service Package (MISP) for reproductive health was established as a set of priority activities to be taken in a coordinated manner by trained staff during the onset of an emergency situation.

When implemented in the early days of an emergency, the MISP can save lives and prevent illness, especially among women and girls. This is done through actions and guidelines set in place by the MISP that work to prevent sexual violence and provide care for survivors, reduce the transmission of HIV, prevent excess maternal and newborn mortality and morbidity, and plan for the provision of comprehensive reproductive health services that are integrated with primary health care, as the situation permits.

How does the MISP work to prevent excess neonatal and maternal morbidity and mortality in emergency situations?

"Due to systematic and exceptionally violent gang rape, doctors in the Democratic Republic of Congo now classify vaginal destruction as a war crime."
--Sandra Krause

The desperate circumstances in which displaced women and girls flee conflict put them at exceptional risk of pregnancy-related death, illness and disability. Health care services and resources that women and girls may have had before displacement are usually no longer available to them. Childbirth may take place in a ditch alongside the road, in the forest or in makeshift shelter. The leading causes of maternal death are due to five factors: haemorrhage, sepsis, complications resulting from unsafe abortion, prolonged or obstructed labour and hypertensive disorders. Millions of women also suffer infections and debilitating injuries from complications of pregnancy and childbirth.

The MISP works to prevent excess neonatal and maternal morbidity and mortality by establishing a referral system that is functional 24 hours a day, seven days per week to manage obstetric and newborn emergencies. It calls for provision of midwife delivery kits (with newborn resuscitation supplies) to facilitate clean and safe deliveries at the health facility, provision of clean delivery kits (with simple instructions) to visibly pregnant women and birth attendants, and identification of skilled birth attendants who are capable of providing essential newborn care and resuscitation.

How does the MISP work to reduce HIV transmission in emergency settings?

The relationship between conflict and vulnerability to sexually transmitted infections, including HIV, is complex. Typically, all STIs thrive under crisis conditions — conditions of poverty, powerlessness and instability, often coinciding with limited access to the means of prevention, treatment and care. Until recently, HIV/AIDS programmes were frequently excluded in relief agencies’ immediate response to emergencies. However, the humanitarian community now understands that interventions must begin immediately at the onset of an emergency and involve other sectors, such as education. New evidence demonstrates the effectiveness of providing basic HIV information and prevention methods among displaced populations.

At the onset of a new crisis, for example, it is possible to guarantee the availability of free condoms and enforce respect for universal precautions against HIV. Longer term public-awareness campaigns can lead to the reduction of HIV by changing sexual behaviour patterns. The MISP works to reduce HIV transmission by ensuring that blood for transfusion is safe, following infection control guidelines, and guaranteeing the availability of free condoms.

What role does the MISP play in preventing and managing the consequences of sexual violence in emergencies?

The nature of warfare is changing: sexual violence and torture of civilian women and girls during periods of armed conflict is a growing phenomenon. For instance, due to systematic and exceptionally violent gang rape, doctors in the Democratic Republic of Congo now classify vaginal destruction as a war crime. Thousands of Congolese girls and women suffer from vaginal fistula—tissue tears in the vagina, bladder and rectum—after surviving brutal rapes in which guns, branches and broken bottles were used to violate them.

The MISP works to prevent and manage the consequences of sexual violence in emergency situations by ensuring that systems are put in place to protect displaced populations, particularly women and girls, from sexual violence; ensuring medical services, including psychosocial support, are available for survivors of sexual violence; and also making sure that the community affected by the emergency is aware of the medical services available to them.

UNFPA, in collaboration with other organizations, has developed a reproductive health kit as part of the response for emergency situations. What is included in this kit and what role does it play in emergency reproductive health care response?

To address the objectives of the MISP, UNFPA has specifically designed a pre-packaged set of kits containing reproductive health drugs, supplies and equipment aimed at facilitating the implementation of the priority reproductive health services. The reproductive health kits are intended for the early stage of an emergency as the contents of the kits are designed for a limited period of time (three months) and for a particular number of people. Once the basic reproductive health services have been established, the reproductive health coordinator should analyze the situation, assess the needs and re-order disposables and other equipment necessary to ensure the sustainability of the reproductive health programme.

The emergency reproductive health kits have been formulated such that each kit responds to a particular reproductive health need or requirement, such as clinical delivery and medical treatment for rape, and sexually transmitted infections, including HIV. Thus, each of the kits can be ordered separately as a ‘stand-alone’ response to a particular situation, and one kit can serve anywhere from 10,000 people to 150,000 people. UNFPA is in charge of assembling and delivering these interagency reproductive health kits. However, logistical problems can occur in any setting; therefore, agencies should not be fully dependent on one source for supplies. Relief agencies should consider procuring reproductive health commodities with their other medical supplies.

What are some of the challenges humanitarian agencies face while trying to implement the MISP in emergency situations?

In field assessments to northern Uganda in 2007 and to Kenya in 2008 following the post-election crisis, the Women’s Commission for Refugee Women and Children found that the level of MISP implementation varied per objective and per site. It appears that while there was strong attention to preventing the transmission of HIV and more attention to ensuring care for survivors of sexual violence, a gap in reproductive health coordination was evident in both settings. It is still unclear which are the most effective methods for ensuring reproductive health care (including HIV and sexual violence) is considered and linked to all other aspects of humanitarian response in emergencies, such as food, clean water, shelter, sanitation and primary health care.

What are some possible solutions to these problems?

One solution is to develop more information about coordination mechanisms in other areas of emergency response in order to suggest wherethe MISP and subsequent, more comprehensive reproductive health care can be appropriately linked. Another is to develop and implement a roster of trained and qualified reproductive health coordinators to travel to the field at the onset of an emergency and work with a qualified local reproductive health provider from the Ministry of Health or other organization to initiate and sustain reproductive health coordination at all levels. However, while the MISP is an international standard for humanitarian response, much commitment and action is needed to ensure that it is implemented in every new emergency to minimize the risk of morbidity and mortality, particularly among women and girls.

In collaboration with the Women’s Commission for Refugee Women and Children and others from the Inter-agency Working Group (IAWG) on Reproductive Health in Crises, UNFPA is working to ensure that the MISP is systematically implemented in all new emergencies and as a minimum standard in ongoing emergency settings. UNFPA and the Women’s Commission are working to encourage humanitarian actors, policy makers and donors to become more aware and responsible for implementing this critical tool by producing and widely disseminating the Minimum Initial Service Package (MISP) for Reproductive Health: A Distance Learning Module. The Module (see below) is accessible in Arabic, Bahasa Indonesian, English, French, Spanish and Russian.