Bixby Program in Population & Reproductive Health, March 2007

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

2. COMPLEX EMERGENCIES: 1985: 51992: 171999: 342006: 38

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

4. 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

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

6. 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) IMC Relief, Recovery, & Development Programs - 2007

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

8. Humanitarian Space is Shrinking 1997-2005 Over 9 year period:major acts of violence against aid workers doubled annually 408 acts of major violence947 victims434 fatalities Today, most victims deliberately targeted, w/ political targeting on the rise. 2006:83 aid workers killed78 aid workers wounded52 aid workers kidnapped #1. Afghanistan (26 killed)#2. Sri Lanka (23 killed)#3. Sudan (15 killed) Sudan accounted for 40% of incidents

9. 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

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

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

12. Uganda: Therapeutic & Supplementary Feeding Programs

13. 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

14. 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

15. 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

16. 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

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

18. New Orleans

19. Iraq – Vulnerable Populations

20. IDPs 140,000 120,000 IMC 100,000 MoDM IOM inc. KRG IOM UNHCR 80,000 DisplacedFamilies 60,000 40,000 20,000 0 2/2/06 3/24/06 5/13/06 7/2/06 8/21/06 10/10/06 11/29/06 1/18/07 3/9/07 Date Displacement Trends, Iraq

21. 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 Gender-based Violence

22. 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

23. 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 GBV Prevention and Response (1) 7

24. 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 International Women’s Day, Refugee Camp, Chad

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

26. 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 Complications are Unpredictable IMC Trained Midwife, Darfur

27. 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 Perinatal Deaths

28. 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

29. 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

30. Training TBAs in Darfur

31. 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

32. Rabia Balki Hospital for Women, Kabul

33. Chad

34. 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

35. 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.

36. 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

37. Kibera slum, population 800,000

39. 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

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

41. Micro-Finance Livelihoods & Micro-Finance

42. IMC Training Highly Valued