Tomlin 3 6 2007

Bixby Program in Population & Reproductive Health, March 2007: 

Bixby Program in Population & Reproductive Health, March 2007 Stephen Tomlin, VP Program Policy & Planning, International Medical Corps stomlin@imcworldwide.org www.imcworldwide.org The Challenge of Reproductive Health in Complex Emergencies

Slide2: 

COMPLEX EMERGENCIES: 1985: 5 1992: 17 1999: 34 2006: 38

COMPLEX HUMANITARIAN EMERGENCIES: 

COMPLEX HUMANITARIAN EMERGENCIES Civil conflict Weak or non-existent central government Mass population movements Massive economic dislocation Food insecurity leading to famine

Complex Emergency Settings: 

Complex Emergency Settings People in need of humanitarian assistance: 1989: 36 million 1996: 50 million 2004: 39 million Many more IDPs: 25 m. IDPs / 49 countries 14 m. Refugees

Since 1984…: 

Since 1984… …providing health care through training / developing local capacity …supporting health care delivery through logistic management systems

IMC Relief, Recovery, & Development Programs - 2007: 

IMC Relief, Recovery, & Development Programs - 2007 Afghanistan Azerbaijan Burundi Chad DR Congo Eritrea Ethiopia Indonesia Ingushetia/Chechnya Iraq Kenya Liberia Pakistan Sierra Leone Somalia northern Sudan (Darfur) southern Sudan Sri Lanka Uganda USA (Louisiana)

Humanitarian Space Shrinking: 

Humanitarian Space Shrinking View from IMC driver’s seat, Darfur, Feb 28 ‘07

Humanitarian Space is Shrinking: 

Humanitarian Space is Shrinking 1997-2005 Over 9 year period: major acts of violence against aid workers doubled annually 408 acts of major violence 947 victims 434 fatalities Today, most victims deliberately targeted, w/ political targeting on the rise. 2006: 83 aid workers killed 78 aid workers wounded 52 aid workers kidnapped #1. Afghanistan (26 killed) #2. Sri Lanka (23 killed) #3. Sudan (15 killed) Sudan accounted for 40% of incidents

Approach to Security Management : 

Approach to Security Management The Evolving Security Environment - Greater exposure, new threats, diminishing respect for IHL The Acceptance Strategy - Establishing, and then fiercely defending, relationships with local actors - Built on trust, transparency, and predictability…as perceived by locals - Protection and Deterrence strategies also employed, but secondary - At IMC, underpinned by strong security management policy and procedures Arms - Humanitarians do not themselves carry weapons - With some noteworthy exceptions, they do not employ or accept armed protection in the course of their work

Levels of Activity (community-based/grassroots): 

Levels of Activity (community-based/grassroots) Ministry of Health Tertiary referral hospital Provincial Hosp District Hosp Health Center Community Health Workers Health Post Charitable hospitals Charitable hospitals clinics Charitable hospitals clinics clinics For profit hospitals doctors doctors doctors doctors doctors Primary Health Care doctors

Community-based Relief & Recovery: 

Community-based Relief & Recovery Health Under-5 Child Health Reproductive Health Immunization (EPI) Nutrition Mental Health Recovery & Development Mobilization Psychosocial Water & Sanitation Livelihoods Micro-finance SUSTAINABLE WELL-BEING TRAINING

Slide12: 

Uganda: Therapeutic & Supplementary Feeding Programs

What is Reproductive Health?: 

What is Reproductive Health? RH is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes. RH implies that people are able to have a satisfying and safe sex life and that they have capability to reproduce and the freedom to decide, if, when and how often to do so. 1

RH Rights Include:: 

RH Rights Include: The right to health in general The right to reproductive choice The right to RH services The right of men and women to marry and found a family The right of the family to have special protection Special right in relation to motherhood and childhood

Cycle of Reproductive Ill-Health: 

Cycle of Reproductive Ill-Health Source: WHO. Reproductive Health during Conflict and Displacement: A Guide for Program Managers. Geneva: World Health Organization, Department of Reproductive Health and Research, 2000. 5

Life Span Profile of Discrimination Against Women: 

Life Span Profile of Discrimination Against Women Source: WHO. Reproductive Health during Conflict and Displacement: A Guide for Program Managers. Geneva: World Health Organization, Department of Reproductive Health and Research, 2000. 7

Key Components of RH Program: 

Key Components of RH Program Gender-based violence prevention and response Safe motherhood STIs, including HIV/AIDS Family planning 1 IMC MCH Clinic, Liberia

Slide18: 

New Orleans

Slide19: 

Iraq – Vulnerable Populations

Displacement Trends, Iraq: 

Displacement Trends, Iraq

Gender-based Violence: 

Gender-based Violence Sexual violence Rape, attempted rape Sexual coercion Sexual harassment Physical violence Domestic violence, spouse beating Assault Emotional, psychological and social abuse Humiliation Harmful traditional practices Female genital cutting (FGC) Early, forced marriage

Factors Contributing to GBV : 

Factors Contributing to GBV Lack of police protection and lawlessness Coercion around food and other ration distributions Insecure living quarters; distance women have to travel to collect firewood, to latrines, etc. Political motivation Collapse of traditional family and societal support Strains of life when displaced from home 6

GBV Prevention and Response (1): 

GBV Prevention and Response (1) Prevention Involve refugee women Public information Camp design, location Food and other distributions Protection Ensure physical safety Psychosocial Counseling Support groups Community education to decrease stigma Justice/legal support Policy/management Train and monitor authorities and staff to reduce sexual extortion Ensure proper documentation for women Increase women protection officers Increase visibility of problem and seriousness of response Document cases, care and other responses Legal 7

GBV Prevention and Response (2): 

Medical Trauma care Emergency contraception Pregnancy testing Voluntary testing for HIV Voluntary testing and treatment for STIs Awareness and sensitivity of staff Confidentiality Referral for legal, social and other services GBV Prevention and Response (2) International Women’s Day, Refugee Camp, Chad

Slide25: 

Uncomplicated pregnancy, delivery, postpartum period Complication Severe Complication Life Threatening Complication Well Recovered short and long-term morbidity possible Death Maternal Morbidity and Mortality Survived near miss

Complications are Unpredictable: 

Complications are Unpredictable At least 15% of pregnant women in any population are expected to have life- threatening complications. Cannot predict or prevent complications: any delivery can become complicated and require emergency intervention Best practice: reduce delays through training in recognition danger signs and referral to health facility IMC Trained Midwife, Darfur

Perinatal Deaths: 

Perinatal Deaths 28 weeks gestation through 7 days after birth 7.6 million perinatal deaths/year 4.3 million stillbirths; 3.3 early neonatal deaths Leading causes of Perinatal Death Syphilis Infection (sepsis) Asphyxia Trauma Neonatal tetanus Complications of preterm delivery

Key Strategies for Preventing Maternal and Perinatal Deaths: 

Key Strategies for Preventing Maternal and Perinatal Deaths Prevent unwanted pregnancies through family planning Early recognition of complications, with referral Access to skilled attendants and emergency obstetric care Management of post-abortion complications Breastfeeding support Essential newborn care Rabia Balki Hospital for Women, Kabul

Antenatal care: 

Antenatal care Health assessment Detection and management of complications Maintenance of maternal nutrition Health education Health promotion interventions such as tetanus toxoid (TT) vaccinations, folic acid and ferrous sulfate supplements, malaria prophylaxis or presumptive treatment, and testing for syphilis, depending on the context TBA Training, Pakistan

Slide30: 

Training TBAs in Darfur

Intrapartum/Delivery Care: 

Intrapartum/Delivery Care 100% of women who develop a complication should be treated by a skilled attendant in an emergency obstetric care facility Basic emergency obstetric care (equipped health center) Comprehensive emergency obstetric care (referral hospital) Transport for deliveries outside an equipped health facility Support for breastfeeding Sudanese mother, Chad

Slide32: 

Rabia Balki Hospital for Women, Kabul

Slide33: 

Chad

Postpartum Care: 

Postpartum Care Monitor for danger signs and refer Postpartum visit Education Newborn weighing and referral Support for breastfeeding Promoting health of newborn, including thermal protection, eye care, cord care, vaccinations Postpartum family planning

Sexually Transmitted Infections (STIs): 

Sexually Transmitted Infections (STIs) Trichomoniasis HIV Chancroid Hepatitis B Genital Warts Herpes Syphilis Gonorrhea Chlamydia Elders meeting, NWFP, Pakistan In women between 15 and 44 years of age, the morbidity and mortality associated with STIs, not including HIV, are second only to maternal causes.

Regional HIV / AIDS: 

Regional HIV / AIDS Worldwide 17.7 million 48% Women Sub-Sahara Africa 13.3 million 59 % Women South & South East Asia 2.2 million 29% Women Caribbean 120,000 50% Women Community Mobilizers, Kibera slum, Nairobi

Slide37: 

Kibera slum, population 800,000

Family Planning: 

Family Planning Saves women’s lives Avoids unsafe abortion Limits exposure to the health risks of pregnancy and childbirth Limits births to the healthiest ages Limits the number of births Saves children’s lives Offers women more choices Encourages adoption of safer sexual behavior Effective Programs: Coordinated Robust logistic systems Extensive training & education Discrete

Gender Inequality: 

Gender Inequality Women’s autonomy and decision-making authority are traqditionally limited 45

Slide41: 

Livelihoods & Micro-Finance Micro-Finance

IMC Training Highly Valued: 

IMC Training Highly Valued