INFO Coping with Crises

Publication date: 2005

Published by the INFO Project, Center for Communication Programs, The Johns Hopkins Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA www.infoforhealth.org How providers can meet reproductive health needs in crisis situations Population Reports Series J, Number 53 Family Planning Programs December 2005 Coping with Crises Photo: Reproductive health care needs in crisis situations should not be neglected. A tsunami survivor and her newborn receive care in a tent in Aceh, Indonesia. Know what to do. The materials that guide international humanitarian relief providers— particularly the Inter-Agency Field Manual and its Minimum Initial Service Package (MISP)— can inform local providers of the reproductive health care needs of refugees. Kits of supplies that are part of the MISP can be ordered. Disaster preparedness training courses can help providers and government officials respond effectively when crises occur. Plan ahead. Make emergency preparedness plans that consider staffing, logistics, supplies, infrastructure, establishing relationships with news media, and coordination with other organizations. Plan for contingencies. Offer care immediately if a crisis occurs. Coordination is desirable but takes time, while health needs are urgent and great. Collaborate with international relief agen- cies as soon as possible to help provide sus- tained, integrated emergency care. Offer what- ever skills, services, and knowledge you have. Coordinate with other relief and health care organizations for efficiency and speed. One organization or person should serve as the focal point for reproductive health care. Focus on refugees not living in camps. Refugees dispersed among the host commu- nities need as much help as refugees in camps, and local organizations may be able to serve them better than relief agencies can. Seek help from the survivors. Some refugees may be health care professionals themselves. Often, they can contribute their skills to care for others. Work toward recovery. When the interna- tional relief workers leave, local health care organizations and providers take back the full responsibility for serving people’s needs. With adequate support, capable health care services with a strong reproductive health care component can speed the transition from relief to recovery. Around the world, conflicts and natural disasters challenge health care providers to meet people’s basic needs, including reproductive health care, under the most difficult condi- tions. What can local health care providers do when crisis strikes? Key Points C C P,C o u rtesy o fPh o to sh are CONTENTS 3 4 6 8 11 2 POPULATION REPORTS 12 15 19 This report was prepared by Deepa Ramchandran, MHS, and Robert Gardner, PhD. Bryant Robey, Editor; Richard Blackburn, Editorial Supervisor. Design by Mark Beisser, Fran Mueller, and Linda Sadler. Production by John Fiege, Monica Jiménez, and Catherine Richey. Population Reports appreciates the assistance of the following reviewers: Doris Bartel, Meriwether Beatty, Bruno Benavides, Sara Casey, Gloria Coe, Duff A. Gillespie, Samantha Guy, Nancy Harris, Anne Hyre, Susan Igras, Monica Jasis, Sandra Krause, Mahua Mandal, Therese McGinn, Christopher Orach, Todd Ritter, Mary Anne Schwalbe, Ritu Singh, J. Joseph Speidel, Youssef Tawfik, Beth Vann, and Martin Vaessen. Suggested citation: Ramchandran, D. and Gardner, R. Coping with Crises: How Providers Can Meet Reproductive Health Needs in Crisis Situations. Population Reports, Series J, No. 53. Baltimore, Johns Hopkins Bloomberg School of Public Health, The INFO Project, December 2005. Available online: http://www.populationreports.org/j53/ Volume XXXIII, Number 1 The INFO Project Center for Communication Programs The Johns Hopkins Bloomberg School of Public Health Jane T. Bertrand, PhD, MBA, Professor and Director, Center for Communication Programs and Principal Investigator, The INFO Project Earle Lawrence, Project Director Stephen Goldstein, Chief, Publications Division Population Reports is published at 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA, by the INFO Project of the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs Population Reports is designed to provide an accurate and authoritative overview of important developments in family plan- ning and related health issues.The opinions expressed herein are those of the authors and do not necessarily reflect the views of the US Agency for International Develop- ment or The Johns Hopkins University. Crises Pose Major Challenges for Reproductive Health Care Health care systems, often struggling to meet people’s needs in the best of times, can be quickly overwhelmed by the added burden of injury and infectious diseases in a crisis. At the same time, health sys- tems themselves may be crippled by disaster or conflict. As a result, many people’s reproductive health needs—including safe motherhood and family planning—are often neglected. Box: Millions Need Care in Crises Every year natural disasters such as earthquakes, floods, and tsunamis cost many millions of people, their homes, property, means of making a living, and even their lives. In the last 20 months alone, disasters have affected 200 million people. Armed conflicts have displaced more than 40 million people. Box: Reducing Violence Against Women: Health Care Providers Can Help Violence against women is a serious problem that is especially com- mon in crisis situations. Health care providers need to become more aware of the situations in which violence against women occurs. Providers can help protect women by providing care and counseling, working with camp management to reduce women’s vulnerability, advocating leadership by women, and involving the refugee commu- nity to support survivors of violence. Box: International Relief Agencies Provide Reproductive Health Care Key organizations that conduct research and training, provide monitor- ing and evaluation, and offer technical assistance to local organizations include agencies of the UN, several international nongovernmental organizations (NGOs), and donor organizations such as the United States Agency for International Development (USAID) and the European Commission Humanitarian Aid Office (ECHO). Box: What To Do First in a Crisis Suggestions from a senior reproductive health expert with the Reproductive Health Response in Conflict Consortium. Reproductive Health Care Providers Can Help Health care providers understand people’s needs and have experience meeting them, but few have worked in humanitarian relief. By learning more and being prepared, family planning providers and managers—at the community level and internationally—could help in several ways. This includes developing emergency preparedness plans for their facili- ties and communities, establishing relationships with the news media, following guides to crisis care, and building links with relief agencies. Box: Minimum Initial Service Package Guides Crisis Care The Inter-Agency Working Group designed the Minimum Initial Service Package (MISP) to guide quick response to reproductive health needs during the early, acute phase of a crisis. It lists a series of high-priority actions and basic health care equipment, supplies, and materials needed. Bibliography Note: Italicized reference numbers in the text refer to citations printed on page 19. These were the most helpful in preparing this report. Other citations can be found online at http://www.populationreports.org/j53/. Published with support from the United States Agency for International Development (USAID), Global, GH/POP/PEC, under the terms of Grant No. GPH-A-00-02-00003-00. Every year armed conflicts and natural disasters kill hundreds of thousands of people and inflict great suffering. Armed conflicts tear soci- eties apart and disrupt people’s lives, often for years. Natural disasters devastate whole regions without warning, as the December 2004 Asian tsunami, the August 2005 New Orleans hurricane, and the October 2005 Pakistan earthquake have demon- strated. Health care systems, often struggling to meet people’s needs in the best of times, can be quickly overwhelmed by the added burden of injury and infectious diseases. At the same time, health systems themselves may be crippled by disas- ter or conflict. As a result, many people’s reproductive health needs— including safe motherhood, protection from and response to sexual and gender-based violence, prevention and treat- ment of HIV/AIDS and other sexually transmitted infections (STIs), family planning, and adolescent reproductive health—are often neglected. Unless concerted attention, effort, and resources can be mobilized, meeting people’s immediate needs becomes impossible, and many lives are put at risk. As of mid-2005 some 45 countries, predominantly in Africa and Asia, faced crises related to armed conflicts or natural disasters (123). Today, nearly 40 million people have fled their homes as a result of conflicts and now are living as refugees outside their countries or, more often, as displaced people within their own countries. Natural disas- ters affect millions more (see box, pp. 4–5). Although the United Nations (UN) formally distinguishes refugees from internally displaced persons (IDPs), accord- ing to whether or not they have crossed an international border (106), in general, this report uses the term “refugees” to include all people displaced by crises, whether internationally or within their own country. Whatever their status, people who have been uprooted by armed conflicts or natural disasters have similar needs for protection, food, shelter, and health care, including repro- ductive health care. No international treaty defines respon- sibility for the protection of people displaced within their own country, however, as is the case for international refugees (20, 106). There is a common perception of refugees as people crowded into camps with few amenities. In reality, people living in refugee camps are usually better off than refugees who are dispersed within local communities. Food, water, and basic health care are more likely to be available in camps (18, 55). Where refugees are dispersed, their status and needs are unknown, and it is more difficult for relief Crises Pose Major Challenges for Reproductive Health Care POPULATION REPORTS 3 Refugees dispersed within communities depend on existing local services. Contrary to common perception, the needs of refugees who are dispersed within local communities are usually greater than those living in camps. Survivors of the October 2005 Pakistan earthquake, seen here, receive blankets at a relief distribution site. EC /E C H O ,N ew D el h i/ A la m A ft ab agencies to meet their emergency needs (53). Out of sight of international relief agencies, these people must depend on existing local services for health care and other needs. Conventionally, in a crisis situation, humanitarian and relief workers have focused on providing basic emergency services such as food, water, shelter, security, and primary health care, with a focus on controlling infectious diseases (16). These are priorities in a major emergency because many lives are at risk. Reproductive health care is also a serious public health issue in crises. More attention to reproductive health care, and to providing it immediately—particularly emergency obstetric care—saves lives in refugee settings (7, 121). Increasingly, international relief agencies are making reproductive health care a key emergency service. National and community reproductive health care organizations and providers, too, can become better prepared and able to respond—particularly to the needs of refugees living outside camps or beyond the reach of relief agencies. This issue of Population Reports is intended to help national and community reproductive health care providers respond to crisis situations and to collaborate with interna- tional relief agencies. (For more on the steps that health care providers can take to prepare for crises and tools they can use, see p. 12.) This issue also discusses how relief agencies can address the reproductive health needs of refugees as part of emergency care. Through cooperation and collaboration, international relief agencies and nation- al and local reproductive health programs can help people survive an emergency, sustain their health, and rebuild their lives. Range of Reproductive Health Care Needed in Crises According to the United Nations High Commissioner for Refugees (UNHCR), meeting a range of reproductive health needs is crucial in a crisis situation. These needs include: safe motherhood, protection from and response to sexual and gender-based violence, prevention and treatment of STIs including HIV/AIDS, family planning, and adolescent reproductive health (63, 93). Safe motherhood. After the tsunami 400,000 refugees sought shelter in camps around Banda Aceh, Indonesia. An estimated 25,000 of these were pregnant women. The local health care system could do little for them, however, because the tsunami had destroyed most of the clinics and killed most of the midwives (9). In many developing countries maternal mortality is one of the leading causes of death among women of reproduc- Millions Need Care in Crises Every year natural disasters such as earthquakes, floods, and tsunamis cost many millions of people their homes, property, means of making a living, and even their lives. Armed conflicts kill or displace millions more.1 Conflicts displace more than 40 million. The United Nations High Commissioner for Refugees (UNHCR) estimates that, as of January 1, 2005, there were more than 19 million people “of concern to the UNHCR,” including over 9 million refugees, who had left their countries, and more than 9 million internally displaced persons, asylum seekers, returned refugees, and others (97) (see Table 1). Including Palestinian refugees and many internally displaced persons not formally categorized as “of concern to the UNHCR,” the estimated number of people dislocated by civil conflicts rises to more than 40 million (25, 86, 95) (see Table 2). 1 The United Nations High Commissioner for Refugees (UNHCR) provides estimates of the num- bers of refugees and others displaced by conflict situations. Although no single institution has a similar role for natural disasters, the Centre for Research on the Epidemiology of Disasters (CRED) publishes data on victims of disasters obtained from a wide variety of sources (14). Data on the number of refugees are usually given in terms of prevalence–that is, the number as of a given date (often January 1st). Data on the number of victims of natural disasters are usually given in terms of incidence–that is, the total number affected in a given period, usually one year. 4 POPULATION REPORTS tive age (124). In most crisis situations about 15% of pregnant women suffer life-threatening complications of pregnancy and delivery, about the same percentage as among pregnant women in general (65, 93). But maternal complications are far riskier for women in crisis situations. The majority of refugee women are in countries where pregnancy can represent a serious health threat even in normal times (48). In crisis situations the need for emer- gency services to treat obstetric complications is acute, both because trauma, malnutrition, and psychological distress are widespread (38) and because many health care personnel and facilities are no longer available (18, 62). Better care could prevent most maternal deaths. A study among Afghan refugees in camps in Pakistan found that, compared with women who died of other causes, those who died of maternal causes had faced greater barriers to health care. These barriers included failure to recognize the problem, the decision of family members not to seek care, lack of emergency transport to a health facility, and not receiving good quality, timely treatment (7). Sexual and gender-based violence. Armed conflict and its aftermath unleash widespread sexual and gender-based violence—that is, acts of violence committed against females because they are female and against males because they are male (112). Sexual and gender-based violence includes sexual violence, domestic violence, emotional and psychological abuse, sex trafficking, forced prostitution, sexual exploitation, sexual harassment, harmful traditional practices (such as female genital cut- ting and forced marriage), and discriminatory practices. The victims are most often women and girls, although men and boys are also subject to sexual violence (121). Violence occurs during all phases of conflicts—before and during flight, in camps, and during repatriation (50, 93). In particu- lar, rape used as a weapon of war has been documented in Algeria, Bangladesh, Bosnia and Herzegovina, Indonesia, Liberia, Rwanda, and Uganda (122). While rape and other forms of sexual and gender-based violence take place in all societies at all times, conflicts often increase the incidence. The main factors behind increased sexual and gender-based violence are loss of security, psychological trauma, ethnic tensions, and the breakdown of family and community life. Other factors include overcrowding in camps and predominantly male camp leadership who do not see preventing gender-based violence as a high priority (96, 114, 118, 122). In some Natural disasters affect 200 million in 20 months. From January 2004 to September 2005, natural disasters displaced, injured, or killed nearly 240 million people (see Table 3). The December 2004 tsunami alone devastated communities in 12 Asian countries and killed more than 225,000 people. Floods affected more than 33 million people in China, India, and Bangladesh during the period (15). 5POPULATION REPORTS Many of these people have been displaced for years. UNHCR estimated that, as of January 1, 2004, in developing countries there were 38 “protracted situations”–that is, crises involving 25,000 or more people in exile for five years or more (99). In crisis situations emergency services to treat obstetric complications are desperately needed. instances peacemakers and humanitarian workers have been the perpetrators, exchanging food for sex by threat- ening to withhold food rations (71, 92). Domestic violence also wells up in many refugee settings. Men compensate for the loss of control over their lives by exerting violent control over their spouses (57, 71). In some cases, domestic violence is more common than violence by those outside the family. For instance, in a study among conflict-affected populations in East Timor, nearly half of women reported abuse by intimate partners, both during the crisis and afterwards. By comparison, 24% of women reported violence by perpetrators outside the family during the crisis; 6%, after the crisis (36). During the crisis the perpetrators outside the family were mainly militia members, soldiers, and police. After the crisis about 6 POPULATION REPORTS Violence against women is a serious and com- mon problem in crisis situations. What can health care providers do? Awareness is the first step. Providers who are unaware, indifferent, or judgmental often miss opportunities to help their clients (34). Providers need to become more aware of the situations in which violence against women occurs and learn what they can do to help protect women (112). Caring for survivors of violence. The best way to determine if a female client has been abused is to ask her about it. Women who have experienced violence may be willing to discuss their experience. They typically do not disclose such information on their own, however, but might if someone they trust raises the issue, such as a counselor, health care provider, or close friend or relative. Women are more likely to disclose violence and other abuse to a female health care provider than to a male provider (34). Health care providers often do not ask women about violence, however, because they feel unprepared to address clients’ needs. Humanitarian and local health care providers need training in counseling women subject to violence and abuse. They should be alert to physical injuries, health conditions, and clients’ behavior that may indicate trauma from sexual violence or other abuses. If a woman discloses abuse, providers can take the following steps to support her (17, 34, 94, 112, 113): • Provide appropriate care. If a woman has been sexually assaulted, appropriate medical care includes a medical exam, treatment of any injuries, preventing unwanted pregnancy, treatment for STIs, including post-exposure prophylaxis against HIV/AIDS, and counsel- ing. Providers should also refer women for other levels of care needed, such as referral to Reducing Violence Against Women: Health Care Providers Can Help Darfur, Sudan: “The soldiers and Janjawid [militia] arrived by car, camels, and horses. Some 15 women and girls who had not fled quickly enough were raped in different huts in the village. The Janjawid broke the limbs of some women and girls to prevent them from escaping. After the rapes, they looted the houses.” —A female refugee interviewed by Amnesty International (1) Northern Uganda: “I was taken under a tree. They told me to lie upside down. I refused. One of the rebels told me I was stubborn, and they would teach me a lesson I would never forget. Two rebels spread my legs and tied them with ropes. Then they started piercing my private parts with a knife and cut the area open up to my anus. They beat me and left me unconscious.” —A female refugee interviewed by Isis-Women’s International Cross-Cultural Exchange (120) Putting water supply points in well-lit, well-traveled locations, as in this Ghanaian refugee camp, helps women stay out of remote parts of the camp where they might be attacked. N ell Ku ssian ,C C P,C o u rtesy o f Ph o to sh are two-thirds of perpetrators were neighbors or other community members (36). Conditions in refugee camps can expose women and girls to violence (50). In some camps women must wait in line to fetch water until late into the night, when they are vulnera- ble to attacks (61). Sexual attacks occur when women are doing other daily chores, too, such as collecting firewood in isolated areas, or when they have to use latrines in remote parts of the camp. Young children also are vulnerable to sexual predators when they are either separated from their families or are left unprotected in camps. (For information on how health care providers can address sexual violence in conflict situations, see box, p. 6.) HIV/AIDS and other STIs. Of the 45 major crisis zones in the world, 28 are in Africa and 12 are in Asia—the conti- nents where HIV/AIDS is most prevalent (123). Coupled with crisis situations, HIV and other STIs can spread rapidly, especially where HIV prevalence is already high. Poverty, powerlessness, food insecurity, and displacement often make refugees more vulnerable to sexual transmission of HIV (82). For example, in Liberia the prevalence of HIV was esti- mated at about 8% before the civil war. The war brought widespread sexual violence, including mass rapes and abduction of women and girls to act as sex slaves for soldiers. STI screenings after the war showed that 93% of male combatants and 83% of female combatants had at least one STI. Projecting from these high STI rates, health care providers in the country now estimate that HIV prevalence is much higher than before the war (51). Family planning. In general, family planning is as much in demand during a crisis as it was beforehand (37). Yet refugees may have far less access to contraception because services and supplies have been disrupted (57). The result can be more unintended pregnancies (18, 62) and rising abortion rates (60). Also, women who rely on contraceptive methods that require continual supplies, such as pills or injectables, may have to discontinue use abruptly when they flee their communities. Many women who use IUDs or implants no longer have access to safe removal and replacement (31). Adolescent reproductive health. Worldwide, approxi- mately 6.6 million adolescents are displaced by armed conflict (54). In crisis situations social support networks weaken and often break down entirely (18, 48). Adoles- cents, especially girls, are at particular risk of forced sex and of sexual coercion in exchange for food, shelter, and protection (93, 105). In crisis situations unsafe sex and other risk-taking among youth often increase. In a refugee camp in the Republic of Congo, girls as young as 10 to 12 years old were reported to be sexually active, often with adult men (100). In a refugee camp in Kenya, a study found that despite the availability of free condoms and other reproductive health 7POPULATION REPORTS In crisis situations sexual risk-taking among youth often increases. hospital for surgery, and offer transportation when needed. In addition, providers should offer information about other available services, such as counseling, economic assistance, or legal advice, and refer as requested by the survivor. (For further information see the WHO report, “Clinical Management of Rape Survivors,” available on the Internet at http:// www.rhrc.org/pdf/Clinical_Management_2005_rev.pdf) • Document the woman’s condition. Documenting a woman’s injuries and symptoms helps medical staff to follow up. Documentation also can help providers to understand the types and extent of sexual violence and to monitor and evaluate care. • Support women’s self-esteem. Health care providers can reaffirm to each client that the violence against her was not her fault and that no one deserves to be beaten, raped, or assaulted under any circumstances. Preventing violence in camps. Health care providers in refugee camps can take several steps that help prevent violence against women (4): • Work with camp management. To reduce vulnera- bility among refugees, providers can help camp management committees to locate water collection points and latrines in places that are well-traveled and well-lit. • Work with refugee health care providers. Providers should try to locate health care providers within the refugee population. Refugees who are providers may already be aware of the violence and could be trained how to handle it. • Advocate leadership by women. Providers can support female representation on governing councils for refugees in camps or communities. • Work with security forces. Providers can work with security forces to create awareness of women’s needs for protection in and around camps. • Involve the community. Community-based strategies can reduce emotional and social harm and promote community support for survivors. In the long term, sexual violence can be reduced by reaching out to community leaders and men to change attitudes that permit abuse of women. These kinds of community- based strategies for social change are most feasible in the recovery phase, when communities no longer face immediate disruption. care, about 70% of young men and women had unplanned sex without condoms (84). Health Care Providers Face Unique Challenges in Crises Crises pose enormous and unique difficulties for reproductive health care providers (55, 121). Although reproductive health care in crisis situations is similar in many respects to care in more stable settings (30, 59), there are important differences. Crises disrupt services. In a crisis situation transportation and communications are often disrupted, distribution net- works dissolve, and infrastructure is partly or completely destroyed (18, 48, 121). The local health care system itself may have suffered severely. Hospitals may have been looted, and medical staff may have fled or been killed (48, 74). Providers may even face armed factions that want to take control of health care facilities (3). The post-conflict period often remains unstable, as security is lacking and permanent peace appears uncertain (76, 121). Crises overwhelm health systems. When a crisis strikes, reproductive health programs often cannot accommodate the huge numbers of refugees who urgently need services (105). For example, during the Great Lakes crisis in Africa in the early 1990s, one million Rwandans fled their homes in just a few days to surrounding Zaire, Tanzania, Burundi, and Uganda, countries that had limited health services to begin with. The sheer number of people was enough to over- whelm the capacity of any agency (66). Crises come on top of existing problems. Since most conflicts occur in developing countries, where health conditions often are poor, many displaced groups already suffer from ill health, including malnutrition and STIs (18). Moreover, most refugees have few possessions left and cannot afford to buy health care, food, or much else. Conflicts and natural disasters differ in important ways. Most communities are surprised by a natural disaster and have little chance of responding adequately, unless they have emergency plans already in place (26). In contrast, conflicts usually result from worsening political or social conditions, which may provide warning before the situa- tion deteriorates into violence and chaos. Conflicts are unstable, preventing providers from res- ponding effectively. Episodes of tension and violence can punctuate periods of relative calm. In contrast, in a natural disaster the extent of the damage can be determined, and relief workers and providers can respond more quickly (56). Conflicts by definition involve groups fighting each other. One or more of the opposing sides, including the govern- 8 POPULATION REPORTS International Relief Agencies Provide Reproductive Health Care Reproductive health program directors should be aware that a number of international organizations provide reproductive health care as part of their relief efforts in crisis situations. Key organizations that conduct research and training, provide monitoring and evaluation, and offer technical assistance to local organizations include agencies of the UN, several international nongovern- mental organizations (NGOs), and donor agencies such as the United States Agency for International Development (USAID) and the European Commission Humanitarian Aid Office (ECHO). (For a list of organizations that focus on reproductive health care in crisis situations and their Web sites, see box, page 18 and http://www.populationreports.org/j53/ j53tables.shtml) UNHCR. The United Nations High Commissioner for Refugees leads the coordination of international response to refugee situations. Its primary purpose is to defend refugees’ rights and provide care for refugees. UNHCR supports reproductive health care for refugees worldwide (98). RHRC Consortium. The Reproductive Health Response in Conflict Consortium, formerly the Reproductive Health for Refugees Consortium, promotes and provides reproductive health care in crisis situations. The consortium consists of seven organizations. Four provide reproductive health care directly to refugees—CARE, Marie Stopes International, the American Refugee Committee, and the International Rescue Committee. JSI Research and Training Institute and the Heilbrunn Department of Population and Family Health, Mailman School of Public Health at Columbia University, conduct research and training and provide technical assistance to local organizations. The Women’s Commission for Refugee Women and Children is an advocacy organization. Member organizations have provided funding and technical assistance to cooperating local organizations during emergencies. The Consortium also has played a key role in developing materials, tools, and other resources for use in crisis situations (see Table 4, p. 13 and Web Table 1). 9POPULATION REPORTS The Inter-Agency Working Group on Reproductive Health in Refugee Situations. The Inter-Agency Working Group (IAWG) focuses on strengthening reproductive health care for refugees and internally displaced persons (93). The IAWG comprises about 30 organizations, including reproductive health NGOs, UN agencies, and academic institutions (62). It was established in 1995 following the first symposium on Reproductive Health in Refugee Situations, organized by the United Nations Population Fund (UNFPA) and UNHCR. UNICEF, UNFPA, and UNRWA. Among UN agencies, the United Nations Children’s Fund (UNICEF), UNFPA, and the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) all have become increasingly involved in serving refugees (72). UNICEF had worked in about 60 conflict-affected countries as of 2003, the date of the most recently published estimate (102). UNICEF is the lead agency in the Safe Motherhood Initiative, a global effort to reduce maternal mortality. In this role UNICEF provides clean delivery kits for use in conflict situations (89, 91). For example, in 2003 UNICEF distributed approximately 26,000 clean delivery kits to almost 100 facilities throughout Somalia (90). UNFPA is the largest supplier of emergency reproductive health supplies and equipment (105). UNFPA currently sup- ports emergency reproductive health projects in more than 50 countries (104, 107). Following the 2004 tsunami UNFPA helped reproductive health care providers in Indonesia to re-establish services. UNFPA continues to provide the refugee camps with reproductive health kits for midwives and personal hygiene packs for women and girls (108). (For information on ordering reproductive health kits, see Table 4, p. 13.) UNRWA works exclusively to provide emergency aid, relief services, education, and health services to Palestinian refugees (88). These services include family planning and maternal and child health care (81, 111). The International Medical Corps (IMC) has responded to con- flicts and disasters in more than 40 countries and currently works in 20 countries. IMC helps local communities by providing reproductive health care including maternal and child health care and HIV/AIDS and STI prevention, and by providing training to increase awareness of sexual and gender-based violence (42). Health professionals from the IMC also recruit and train local doctors, nurses, and other health care providers to ensure that health programs are sustainable once the crisis has passed (41, 43). Refugees International (RI) is an advocacy organization dedi- cated to improving the reproductive health of refugees. In 2004 Refugees International had programs in over 60 countries, including Sudan, where it provided relief in the Darfur region. Among its services RI addresses sexual violence, family planning, and emergency obstetric care (69). US government agencies. Within the US government, the State Department Bureau of Population, Refugees, and Migration and the USAID Office of Foreign Disaster Assistance share primary responsibility for refugee assistance programs (87). The Office of Foreign Disaster Assistance provides substantial assistance in humanitarian crisis situations (85). Recently, USAID has provided funds for reproductive health care in crisis-affected areas of Sudan and tsunami relief in Indonesia, Sri Lanka, and elsewhere (87). ECHO. The European Commission Humanitarian Aid Office funds refugee projects worldwide, including emergency reproduc- tive health care (23, 109). The ECHO program, Aid for Uprooted People, focuses on creating conditions that foster long- term development. In Asia and Latin America it provides funds to refugee camps, for repatriation, and to assist with reintegration into communities (58). Yo sh i S h im iz u, In te rn at io n al F ed er at io n o f R ed C ro ss a n d R ed C re sc en t So ci et ie s Coordinating with other relief and health care organizations improves the efficiency and speed of efforts on the ground. In Sonagazi, Bangladesh, Red Crescent volunteers use a megaphone and motorcycle to broadcast cyclone warnings among rural villagers. ment, may have no regard for the health and welfare of the refugees. Refugee camps are not sanctuaries and have been attacked. Health care staff themselves can be the tar- gets of armed groups. In contrast, a natural disaster often evokes an outpouring of support, and the government of the affected country takes on the responsibility of mount- ing a response (56). As a result, survivors of natural disas- ters often receive more aid and support than survivors of armed conflicts. Conflicts force some people to live as refugees for years (110). In contrast, natural disasters displace most people for weeks or months rather than years, although the damage and disruption may take a long time to repair (26). International Response Improving Reproductive health care for refugees has improved in the past decade, but gaps remain (59). The less familiar the type of service, the less likely that it is provided (12). For example, services to address sexual and gender-based violence and STIs are more limited than either maternal health care or family planning services. Also, family planning services vary in the availability of contraceptives and the skills of providers (100). In the last 20 years the international community has paid increasing attention to the reproductive health needs of refugees (80). Leaders of these efforts are UNHCR, the Reproductive Health Response in Conflict Consortium (RHRC Consortium), and the Inter-Agency Working Group on Reproductive Health in Refugee Situations. UN agen- cies, international nongovernmental organizations (NGOs), and a few donor governments all provide substantial support for reproductive health in crisis situations (72, 80) (see box, pp. 8–9). Following a natural disaster or armed conflict, local NGOs and community organizations are often the first to respond. They typically have an advantage over interna- tional relief agencies because they know the area and its people (72). Few local reproductive health programs, however, have the mandate or funding to provide full services in a crisis situation. Community-based programs and organizations, including reproductive health care providers, can play important roles in improving response to crisis situations. Community involvement is particularly valuable where many interna- tional aid organizations, local NGOs, local self-help groups, district public health systems, and regional administrations are all operating at the same time. Working together, local services and relief agencies can help avoid duplication of services and wasting of resources (73). For example, the Colombian organization PROFAMILIA has provided reproductive health care to refugees from the continuing armed conflict and political violence in that country. PROFAMILIA found that local organizations were already providing services in some communities. As a result, they were able to re-allocate funds to other projects and thus help to assure that, overall, more people received services (73). Community-based organizations also can identify and raise awareness of specific problems, identify appropriate pre- ventive measures, and sometimes take the lead in helping survivors (93). For their part, international NGOs and relief agencies that collaborate with communities can help build the capacity of local institutions and bolster the confidence of their service providers (6). Not Enough Funding An effective and coordinated humanitarian response to an emergency requires substantial sums of money (103). Relief agencies often cannot provide complete reproductive health care for refugees because they lack the funds for this purpose. More and more, donors are allocating money for specific programs and telling relief agencies how they want their money spent (49). Just a few bilateral donors, chiefly the United States and the European Union, provide most of the financial assis- tance for reproductive health care in crisis situations. 10 POPULATION REPORTS Ru ss Vo g el,C C P,C o u rtesy o f Ph o to sh are Reproductive health care for refugees has improved, but gaps remain. Helping to speed the transition from relief to recovery, construction workers in the village of Nusa, Subdistrict Lhoknga, Aceh, Indonesia, begin renovating a health clinic destroyed by the December 2004 tsunami. USAID Indonesia is funding the renovation through the Health and Environmental Services Programs. Overall levels of funding for humanitarian assistance increased from $2.1 billion ($2.8 billion adjusted for inflation) in 1990 to $5.9 billion in 2000 (49). Since 2000 funding for reproductive health care in crisis situations has declined, however, as donor priorities have shifted to other areas of humanitarian assistance (100). Donor funding tends to focus on a few large-scale emer- gencies. Often, political priorities within donor countries determine how much funding goes to specific emergen- cies. In addition, emergencies that are covered extensively by the news media tend to generate more public interest and thus attract more money (49, 100). Sometimes, donors focus on one aspect of reproductive health at the expense of other important aspects. Funding for HIV/AIDS programs in conflict situations has increased in recent years. Some donors see AIDS prevention as sepa- rate from other reproductive health care, however, rather than an integral part. The perception that comprehensive reproductive health care in crisis situations is not as impor- tant may lead to decreased funding (49, 100). 11POPULATION REPORTS Crises often strike with little or no warning. What can you, as a reproductive health care provider, do immedi- ately to begin to help? Doris Bartel, a senior reproductive health expert with the RHRC Consortium, suggests the following: • Immediately approach someone working for a UN organization and ask which organizations and/or individuals are coordinating and implementing reproductive health care or the Minimum Initial Service Package (MISP) (see box, p.15). Offer your services and give your qualifications. If you represent your hospital or clinic, provide its roster of staff names and qualifications and the health services it can offer. • If you or your clinic/hospital has the skills and equipment to provide any component of the MISP, start doing so immediately. • Ask a UNFPA, UNICEF, or international NGO representative responding to the crisis to order supplies for you according to how many people you think you can serve. Also ask that they include your clinic in distribu- tion of supplies. • Go to the reproductive health care coordination meetings and say what you observe about the crisis and what you are doing in response. If no agency is arranging coordination meetings, arrange one your- self and determine who is doing what to carry out the actions in the MISP. Ask for volunteers to fill the gaps. • If there are many displaced people, talk to the relief workers organizing shelter, water, latrines, and food. If you know how to set up water pumps and latrines, let them know, and set them up in well-lit places. • Work with the people distributing food rations to make sure that women are equally represented on distribution committees. • Make sure that sanitary supplies (cloth pieces or small towels) as well as clean delivery kits are distributed with food rations. • If you notice that vulnerable groups such as children are being neglected by the food distribution system, make this known to the UN representative in charge of food distribution. • Do not forget to get enough rest and nutrition. Taking care of yourself will help you take care of others as well. Source: Bartel 2005 (5) What To Do First in a Crisis Immediate care is always the top priority in crisis situations. In Tamil Nadu, India, relief personnel treat survivors of the 2004 tsunami. EC /E C H O S o u th A si a O ff ic e How can family planning providers do more to help in crisis situations? Health care providers understand people’s needs and have experience meeting them, but few have worked in humanitarian relief (32). By learning more and being prepared, family planning providers and managers— whether at the community level or internationally—could help in several ways: • Join the Inter-Agency Working Group (IAWG); • Develop emergency preparedness plans for their facilities, organizations, and communities, including establishing a relationship with the news media; • Follow guides to crisis care, particularly the Minimum Initial Service Package (MISP); • Build links with relief agencies; • Focus on refugees not living in camps; and • Assist the transition from relief to reconstruction. Join the Inter-Agency Working Group Any reproductive health organization or humanitarian relief agency can join the Inter-Agency Working Group on Reproductive Health in Refugee Situations (see box, p. 9). Established in 1995, the working group seeks to improve interagency collaboration and improve reproduc- tive health care for people in crisis situations, among other objectives (45, 93). Reproductive health care providers can join the IAWG electronic mailing list to receive updates on reproductive health care in crisis situations. Additionally, providers can join or start a national, district, or local interagency reproductive health working group. These groups could serve as focal points and collaborate with relief agencies that work with refugees. (For further information contact Nadine Cornier at UNHCR, <CORNIER@unhcr.ch>) Disaster Preparedness A growing focus on community-based prepared- ness is replacing the conventional approach to disaster preparedness, which has emphasized centralized emergency response. If local communi- ties and NGOs are trained and prepared, a quicker response can be mounted and more lives can be saved (40). International agencies, governments, commu- nity programs, and local health care providers can work together to build their capacity for crisis response. They can anticipate the demand for care in a crisis situation, develop effective logistics systems, create rosters of people with the skills urgently needed during crises, and establish relationships with the news media. Disaster preparedness training. Training can help inter- national and local health care providers and government officials respond quickly and effectively when a disaster or crisis occurs. Many countries offer disaster preparedness training through the International Committee of the Red Cross (ICRC). An example is the “Health Emergencies in Large Populations (H.E.L.P.)” course, a three-week module focused on reproductive health that gives providers the tools to make decisions in large-scale emergency situa- tions. Although intended primarily for health professionals, anyone in a decision-making position can participate (39). Reproductive Health Care Providers Can Help A focus on community-based preparedness is replacing the conventional approach. © 2 00 1 Ji m S ti p e/ Lu th er an W o rl d R el ie f, C o u rt es y o f P h o to sh ar e Emergency preparedness plans should consider staffing, logistics, supplies, and infrastructure. Above, a local emergency brigade in El Salvador discusses disaster prevention and risk management, post-hurricane Mitch. 12 POPULATION REPORTS International Committee of the Red Cross Educational Resources Organization: Health Emergencies in Large Populations (H.E.L.P.) CourseTitle: Description: Three-week course with two training modules. Gives providers a better understanding of disaster preparedness. Covers reproductive health needs of displaced populations. Guides and Guidelines International Rescue CommitteeOrganization: Title: Public Health in Complex Emergencies (PHCE) CARE on behalf of Reproductive Health Response in Consortium (RHRC Consortium) Organization: Description: A practical guide for field staff working with displaced Organization: Title: Description: John Snow, Inc./Family Planning Logistics Management Contraceptive Logistics Guidelines for Refugee Settings Providers can use this manual to design and implement simple contraceptive logistics systems in refugee camps where family Organization: Title: Description: Availablilty:Inter-Agency Standing Committee (IASC) Guidelines for HIV/AIDS Interventions in Emergency Situations Information on developing responses to HIV/AIDS during crises. A matrix that can be photocopied helps obtain information in chart form. Download at: http://www.unfpa.org/upload/lib_pub_file/249_filename_guidelines-hiv-emer.pdf To order printed copies, e-mail martinez@unfpa.org or write to: Media Services Branch, IERD UNFPA 220 East 42nd St. New York, NY 10017, USA Tools and Kits Organization: Title: Description: United Nations High Commissioner for Refugees Inter-Agency Field Manual A tool for planning, implementing, monitoring, and care in conflict situations. Help field staff introduce Availablilty: Download at: http://www.unfpa.org/emergencies/manual/ For printed copies in English, contact: Women, Ink. 777 United Nations Plaza New York, NY 10017, USA Tel: +1 212 687 8633 ext 212 • Fax: +1 212 661 2704 E-mail: wink@womenink.org • Web site: http://www.womenink.org/ Women’s Commission for Refugee Women and ChildrenOrganization: Minimum Initial Services Package (MISP) Fact Sheet and Insert Monitoring and Evaluation Checklist) Title: ( Description: Description of the MISP and the contents of its reproductive health kits. Provides information about ordering the Kit-98. Availablilty: Download PDF at: http://www.rhrc.org/pdf/fs_misp.pdf or http://www.rhrc.org/pdf/fs_misp_insert.pdf For information on the New Emergency Health Kit-98, contact: IDA Foundation P.O. Box 37098 1030 AB Amsterdam, The Netherlands Tel: +31 20 403 3051 • Fax: +31 20 403 1854 E-mail: info@ida.nl Organization: United Nations Population Fund (UNFPA) Title: UNFPA Reproductive Health Kits for Emergency Situations Materials for use in the acute phase of an emergency. Consists of 12 subkits that include condoms, delivery supplies, post-rape supplies, contraceptives, surgical delivery equipment, and Description: Availablilty: Procurement Unit 220 East 42nd St. New York, NY 10017, USA Tel: +1 212 297 5384 Fax: +1 212 297 4916 E-mail: myint@unfpa.org or dsmith@unfpa.org Or from: UNFPA Emergency Relief Office 9 Chemin des Anemones 1219 Geneva, Switzerland Fax: +41 22 979 9049 : unfpaero@undp.org Web site : www.unfpa.org Organization: United Nations Children Fund (UNICEF) Clean Delivery KitsTitle: Description: These clean delivery kits can be used by traditional birth attendants or by pregnant women themselves. Each kit contains a plastic sheet, two pieces of string, one clean razor blade, and one bar of soap. Availablilty: Kits can be made locally or ordered from: UNFPA Procurement Unit 220 East 42nd St. New York, NY 10017, USA Tel: +1 212 297 5384 • Fax: +1 212 297 4916 : saunders@unfpa.org or contact UNICEF country office Additional information on resources can be found in Web Table 1 at http://www.populationreports.org/J53 • Availablilty: For more information see: http://www.icrc.org/web/eng/siteeng0.nsf/ 9B64E6211AF41256F40004BD259 or write to: International Committee for the Red Cross, HELP Courses 19, Avenue de la Paix CH-1202 Geneva, Switzerland I B4661iwpList303/ E-mail: shortcourse@theirc.org • Web site: http://www.theirc.org/phce Or write to the attention of Lorna Stevens at: International Rescue Committee (IRC) 122 E. 42nd Street New York, NY 10168, USA Tel: +1 212 551 3005 • Fax: +1 212 551 3185 Availablilty: For more information see: Description: Two-week course designed to give providers a better understanding of how to respond to the health needs of refugees and internally displaced persons. Training Program Conflict Availablilty: Moving from Emergency Response to Comprehensive Reproductive Health Programs Download PDF at: http://www.rhrc.org/pdf/FinManual.pdf To order printed copies or CD-ROM, write to: CARE 1625 K Street, NW, Suite 500 Washington, DC 20006, USA Title: populations. Ten modules can be used separately or together to create a training program. Includes training materials, presentation slides, participatory exercises, and resource materials. (Draft for field testing) Availablilty: Download at: http://portalprd1.jsi.com/pls/portal/url/item/ To order printed copies, write to: John Snow, Inc. DELIVER Project/ 1616 N. Fort Myer Drive, 11th Floor Arlington, VA 22209, USA Tel: +1 703 528 7474 • Fax: +1 703 528 7480 E915EC0251D621B6E030007F01007A69 evaluating and strengthen activities that are based on refugees' and internally displaced people's needs, interests and values. blood transfusion supplies. Each subkit can be ordered separately. (Note: this kit can be used to implement the Minimum Initial Service Package.) (UNHCR) UNFPA reproductive health kits and the New Emergency Health Order kits from: E-mail E-mail UNFPA planning programs are already in place. 13POPULATION REPORTS Also, the International Rescue Committee (IRC) offers a two-week training program,“Public Health in Complex Emergencies.”This course addresses key public health issues, including reproductive health care, that providers face in emergencies. The course is intended for medical coordinators, public health coordinators, program man- agers, and district medical officers from international and national health organizations (44). In addition, numerous training tools specifically address reproductive health in conflict situations. For example, CARE, on behalf of the RHRC Consortium, has developed a series of 10 training modules,“Moving from Emergency Response to Comprehensive Reproductive Health Programs.” (For more information on training, see Table 4, page 13 and Web Table 1 at http://www.populationreports.org/j53/j53tables.shtml) Logistics. Uninterrupted flow of supplies is a basic requirement for good-quality reproductive health care at any time (2, 22). Crisis situations, however, present special logistical challenges. In most crisis situations adequate storage facilities are not available, and program man- agers must find ways to minimize damage to supplies (19). Also, roads are often impassable, fuel supplies are not adequate, utilities no longer work, and security is compromised (27, 75). Crises often undermine existing contraceptive logistics systems that were weak to begin with. Nonetheless, any reproductive health program can design and use a basic logistics management system in crisis situations to help decide what supplies to stock, how much to stock, and when to reorder. Principles of contraceptive logistics are generally the same in a crisis situation as at other times (22). A logistics management information system (LMIS) identifies, at a minimum, stock on hand, stock on order, and average monthly consumption (19). Storage and transportation of contraceptives are necessary infrastructure. The DELIVER project of John Snow, Inc. (JSI) has devel- oped a manual, Contraceptive Logistics Guidelines for Refugee Settings, which outlines basic principles of logis- tics management. The manual explains how to calculate contraceptive needs, how to develop a basic LMIS, and how to store contraceptives, among other information. In planning logistics for emergencies, reproductive health care providers should understand that demand for contraceptives continues. In fact, demand often becomes more urgent. Many people lose access to sources of supplies and services that they had relied on, including contraceptives and condoms to prevent STI transmission, as well as supplies and equipment to treat complications of labor and delivery and to treat the con- sequences of sexual and gender-based violence (37). Some government officials have said that in crisis situations people do not need family planning services because they will not be having sex or, alternatively, because they will want more children to rebuild their families in the face of so much loss of life (37). While some refugees may feel this way, many others want to avoid pregnancy in a crisis because they have few resources and face the trauma and uncertainties of displacement (35). Family planning statistics help to demonstrate the extent of the need. In Indonesia after the December 2004 tsunami, for example, the immediate need for family planning was estimated at approximately 80,000 contraceptive units (including condoms and other methods), while the available stock was about 16,000 units (9, 67, 83). Create a skills roster. To respond effectively in a crisis situation, providers must be able to quickly identify people with essential skills (33). It can help to collect information in advance on the availability of health care providers and others with family planning and reproduc- tive health skills. Gathering information from refugees in camps can also be useful. Many refugees have training in health care and some may be health professionals, but their skills can be incorporated into the overall effort only if they are known to relief organizers (18). Without a skills roster, expertise can go unused. For example, in Tanzanian camps after the Rwandan genocide, some providers knew how to insert and remove implants. Relief workers did not know about these providers’ skills, however, so women who needed such services did not have access to them (33). Establish a relationship with the news media. As part of disaster prepared- ness, governments and humanitarian agencies should have a plan of work- ing with the news media in crisis situations (77). In times of conflict and natural disaster, radio and other media can provide survivors with information about the security situation and about where to find shelter, food and water, and health services including repro- ductive health care (21). The broadcast media may well be the only working means of communicating with the public. The Inter-Agency Field Manual helps programs introduce and strengthen reproductive health activities that respond to refugees’ needs and reflect their values. 14 POPULATION REPORTS Minimum Initial Service Package Guides Crisis Care The Inter-Agency Working Group designed the Minimum Initial Service Package (MISP) to guide quick response during the early, acute phase of a crisis. It lists a series of high-priority actions and the basic health care equipment, supplies, and materials needed. Reproductive health care providers can familiarize themselves with the MISP and integrate it into emergency preparedness training and response plans. (For further information on the MISP fact sheet and how to order its components, see Table 4, p.13.) The objectives of the MISP are to: • Identify organizations and individuals to coordinate and implement the MISP (this organization or person is known as the reproductive health focal point); • Reduce sexual violence and manage its consequences; • Reduce HIV transmission by (1) enforcing adherence to the universal precautions for infection control and (2) guaranteeing the free availability of condoms; • Reduce neonatal and maternal illnesses and deaths by (1) providing delivery kits for use by mothers and birth attendants, (2) providing delivery kits to mid- wives, and (3) initiating a referral system to manage obstetric emergencies; • Plan for provision of complete reproductive health care, integrated into primary health care, as the situation permits (93, 117). Emergency Kits Support MISP. Three principal kits support implementation of the MISP. They are (1) simple clean delivery kits for home use; (2) the New Emergency Health Kit-98, developed and revised by WHO; and (3) the UNFPA Reproductive Health Kit (see Table 4, p.13). These kits can be ordered at any time, without waiting for an emergency situation. Traditional birth attendants or pregnant women themselves can use the clean delivery kits. The kits can be made using simple, locally available supplies—a plastic sheet, two pieces of string to tie the umbilical cord in two places, a clean razor blade to cut the cord, and a bar of soap. These are the basic supplies needed to avoid umbilical cord infections in newborns and genital tract infections in mothers following the birth. The New Emergency Health Kit-98 contains two different sets of drugs and medical supplies. One set is a basic unit and the other is supplementary. The basic unit should meet the needs of a population of 1,000 people for three months. The supple- mentary unit should cover a population of 10,000 people for three months. The basic kit is meant for use by health care providers who may have had only limited training. It contains some medicines such as antimalarial drugs; renewable supplies such as gauze, gloves, and soap; equipment such as forceps, scissors, and syringes for surgical deliveries at health centers; supplies for some obstetric emergencies; and materials for post-rape care. Only professional health workers should use the supplemen- tary kit. It contains more drugs, renewable supplies, and equipment than the basic kit. (For details see http://www.who.int/medicines/library/par/new-emergency- health-kit/nehk98_en.pdf ) The UNFPA Reproductive Health Kit, which is meant to be used only during the acute phase of an emergency, consists of 12 subkits that include condoms and other contraceptives, clean delivery kits for home births, post-rape supplies, surgical delivery equipment, and blood transfusion supplies. Each sub- kit can be ordered separately (93). 15POPULATION REPORTS Women in South Darfur, Sudan, assemble safe delivery kits from locally obtained materials. The women are participating in a project of the American Refugee Committee and a local NGO, Ayya, to generate income for women in this strife-torn area. Sa n d ra K ra u se ,W o m en ’s C o m m is si o n fo r Re fu g ee W o m en a n d C h ild re n News reporters often are the main source of firsthand information about the extent of crises and the problems that survivors and relief efforts face. The news media are often the first to define an event as an emergency and to raise public awareness and concern. In turn, the extent of public awareness usually determines the level of atten- tion that an emergency situation receives (10). To work effectively with the news media, humanitarian providers and government officials in charge of crisis response should anticipate the needs of the news media and be able to provide them with facts needed for accur- ate reporting (68). Organizations should designate a per- son with direct access to decision makers and train this person for working with the news media. Keys to work- ing well with the media include finding ways to help the media report the news, respecting media deadlines, always being truthful and factual, and using language that is clear, concise, and easy to understand (13, 78). Follow Guides to Crisis Care Reproductive health field guides and other materials that humanitarian agencies use also can help local providers. The Inter-Agency Field Manual—the most comprehensive and widely used guide for refugee reproductive health programs—is a key tool for plan- ning, implementation, monitoring, and evaluation (93). It can help programs introduce and strengthen repro- ductive health activities that respond to refugees’ needs and reflect their values (24). UNHCR published a 1999 revision of the manual after two years of field use and testing by staff in 50 relief agencies. The revised manual can be downloaded from the Internet or ordered by mail. (For more information on availability of the Inter-Agency Field Manual, see Table 4, p. 13.) A key tool—the Minimum Initial Service Package. A key component of the Inter-Agency Field Manual is the Minimum Initial Service Package (see box, p.15). The package (often referred to as the MISP) is a series of activities and supplies designed to avoid maternal and neonatal deaths and illness, reduce HIV transmission, prevent and respond to sexual and gender-based violence, and plan for integrating reproductive health care with primary health care (93, 117). The Minimum Initial Service Package applies both in conflict situations and in natural disasters. It is intended for the acute phase of a crisis and can be implemented immediately, without a needs assessment (93). Its develop- ers, the Inter-Agency Working Group, created the MISP to: • Give health care providers the tools that they need to deal with critical steps in a natural disaster or conflict where many people are displaced; • Minimize mistakes that health care workers might make because they are unfamiliar with crisis situations; and, as a result, • Save lives. Although relief agencies have become increasingly aware of this innovation, most have yet to implement it completely. For example, in Sudanese refugee camps in Chad, few relief workers knew about the MISP or about the importance of emergency response to reproductive health needs. Relief agencies made efforts to prevent sexual violence by setting up latrines and water supply points in safe locations and in some camps establish refugee committees with equal male and female repre- sentation. They did not, however, take other steps, also called for in the MISP, that would have helped avoid sexual violence and would have addressed other aspects of reproductive health (116). Similarly, after the tsunami in Indonesia, a study found that about half of humanitarian providers interviewed were aware of the MISP, but few could accurately describe its objectives and priorities (119). In Banda Aceh UNFPA designated a “reproductive health focal point,” recommended as the first step in the MISP—that is, an individual or organization that coordinates and imple- ments the service package—and set up working group meetings among local and international organizations. These meetings demonstrated the effectiveness of a reproductive health focal point to coordinate emergency reproductive health care. Nonetheless, other steps called for in the MISP—for example, managing consequences of sexual violence, reducing HIV transmission by practicing universal precautions, and taking adequate measures to decrease neonatal and maternal mortality—were not put in place (119). The Inter-Agency Working Group on Reproductive Health in Refugee Situations recommends that all international organizations integrate the MISP into their emergency preparedness training and response plans and increase awareness of reproductive health in these situations (100). Similarly, governments and particularly ministries of health can prepare for emergency situations by familiarizing themselves with its goals, objectives, and components (116, 119). Build Links Better coordination between relief organizations and local health systems can lead to more integrated and efficient reproductive health care in crisis situations, both for community members and for refugees. Cooperation can combine the differing but complemen- tary experience and expertise of relief workers and local health care providers. 16 POPULATION REPORTS Reproductive health care providers need not wait for international humanitarian agencies to ask for commu- nity assistance in a crisis situation. Instead, they can take the first step by offering their services (28, 47, 79). They could go to reproductive health care coordination meet- ings to make their observations about the crisis and explain how they are responding (5) (see box, p. 11). Local agencies responding in a crisis may receive fund- ing, supplies, and equipment from the UN and other international agencies (46). In Sri Lanka, for instance, Marie Stopes International, a member of the RHRC Consortium, helped a local agency mobilize teams of community reproductive health workers to help victims of the 2004 tsunami (29). Cooperation among agencies has become more impor- tant in recent years as the nature of crisis situations has changed. Humanitarian crises have become more complicated in the last 15 years, and the number of people displaced within their own countries has increased drastically. As a result, providing adequate health services in these situations has become more difficult (11, 64). As the number of NGOs and other groups involved in humanitarian relief has increased to address this need, so have problems of organization, coordination, and accountability (66). The services that refugees receive from relief organiza- tions largely depend on which organizations provide care. Criteria do not exist specifying which NGOs should offer which services, which camps they should serve, or how these matters should be decided (72). The lack of criteria means that the kind and quality of reproductive health care that people receive in crisis situations can vary substantially, depending on which agency responds. Focus on Refugees Not in Camps International relief organizations and NGOs can work with local reproductive health care providers to offer care for refugees who are not in camps but instead are living in the host communities. Refugees living in com- munities often receive less health care than other com- munity residents. For example, Burmese refugee women in Thailand living outside the refugee camps had less access to modern contraception and other reproductive health care than the general population, and their rates of unwanted pregnancy and maternal health problems were higher (8). When refugees are dispersed among the general popu- lation, health care providers who are able to continue serving their regular clients—that is, if their work has not been disrupted—may be able to incorporate the refugees into their services, offering them the same qual- ity of care (56). Their ability to do so, however, would often depend on the level of international support. Many programs have barely enough resources to provide basic care for their usual clientele on a day-to-day basis. Nevertheless, with adequate funding and supplies, local providers may be better able than international agencies to provide good care, because they understand the cul- ture and people’s needs, particularly if they are dealing with internally displaced refugees from within their own country (28). After the Crisis: From Disaster to Development Even after conflicts or natural disasters end, suffering often continues. Many refugees return home to find their communities in ruins and health care and other services destroyed. People usually need continued support to help them recover and rebuild their lives (70). Health care programs can help the survivors of crises regain responsibility for their own health and well-being (6, 115). Most crises eventually move from an acute stage through a stabilization phase to a post-emergency relief and recovery phase. During this transition humanitarian providers can cooperate with other local health care providers and coordinate activities that focus on sustainability to help communities rebuild as quickly as possible (52). 17POPULATION REPORTS Reproductive health care providers need not wait for international humanitarian agencies to ask for community assistance. Have You Looked at These Links to Other Web-based INFO Publications and Services? Global Health Technical Briefs (Broaden your knowledge with these succinct two-page summaries for program managers and others.) http://www.maqweb.org/techbriefs/index.shtml INFO Reports (Discover the latest new research and developments for reproductive health program managers.) http://www.infoforhealth.org/inforeports/index.shtml The Pop Reporter (Stay up to date with this weekly, custom- izable e-zine, providing summaries and links to research and news reports on reproductive health and related topics.) http://www.infoforhealth.org/popreporter/current.shtml POPLINE searchable database (Keep in touch with the World's Reproductive Health Literature.) http://www.popline.org Photoshare searchable database (Browse through thousands of health and development photographs categorized and indexed for easy searching.) http://www.photoshare.org Humanitarian Agencies, Development Organizations, and International NGOs: Aid to Uprooted People (AUP): http://europa.eu.int/comm/external_relations/upp/intro/ American Refugee Committee International (ARC): http://www.archq.org/ CARE: http://www.care.org/ Global IDP Survey: http://www.idpproject.org/ Interaction (American Council for Voluntary International Action): http://www.interaction.org/ International Crisis Group: http://www.crisisgroup.org/home/ International Federation of the Red Cross and Red Crescent Societies: http://www.ifrc.org/ International Medical Corps (IMC): http://www.imcworldwide.org/ International Rescue Committee (IRC): http://www.theIRC.org/ International Organization for Migration (IOM): http://www.iom.int/ Médecins sans Frontières (MSF): http://www.msf.org/ Merlin: http://www.merlin.org.uk/ Oxfam: http://www.oxfam.org/eng/index.htm Relief Web: http://www.reliefweb.int Reproductive Health Response in Conflict (RHRC) Consortium (formerly Reproductive Health for Refugees Consortium): http://www.rhrc.org/ Save the Children: http://www.savethechildren.org/, http://www.savethechildren.org.uk/ United Nations Development Fund for Women (UNIFEM): http://www.unifem.undp.org/ United Nations Development Program: http://www.undp.org/ United Nations High Commissioner for Refugees (UNHCR): http://www.unhcr.ch United Nations Joint Programme on HIV/AIDS (UNAIDS): http://www.unaids.org/ United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA): http://ochaonline.un.org/ United Nations Population Fund (UNFPA): http://www.unfpa.org, especially http://www.unfpa.org/swp/2004/english/ch10/index.htm United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA): http://www.un.org/unrwa United States Agency for International Development (USAID): http://www.usaid.gov/our_work/humanitarian_assistance/ United States Committee for Refugees (USCR): http://www.refugees.org/ United States Department of State Bureau of Population, Refugees, and Migration (PRM): http://www.state.gov/g/prm/ Women’s Commission for Refugee Women and Children: http://www.womenscommission.org/ World Bank: http://www.worldbank.org/ World Health Organization: http://www.who.int/reproductive-health/ World Health Organization, Emergency and Humanitarian Action (EHA): http://www.who.int/hac/crises/en/ Reproductive Health and Family Planning Organizations: Advance Africa: http://www.advanceafrica.org/ EngenderHealth: http://www.engenderhealth.org/index.html Family Care International: http://www.familycareintl.org/ Family Health International: http://www.fhi.org/en/RH/index.htm International Planned Parenthood Federation: http://www.ippf.org/ Ipas: http://www.ipas.org/english/ JHPIEGO: http://www.jhpiego.org/ JSI Research and Training Institute: http://www.jsi.com/ Management Sciences for Health: http://www.msh.org/ Marie Stopes International: http://www.mariestopes.org.uk/ Pathfinder International: http://www.pathfind.org/ Population Council: http://www.popcouncil.org/ Population Reference Bureau: http://www.prb.org/ Population Services International: http://www.psi.org/ Reproductive Health Gateway: http://www.rhgateway.org/ Reproductive Health Outlook: http://www.rho.org/html/refugee.htm# United Kingdom Department for International Development (DFID): http://www.dfid.gov.uk/ United Nations Children Fund (UNICEF): http://www.unicef.org/ Educational Institutions Columbia University Heilbrun Department of Population and Family Health: http://www.mailman.hs.columbia.edu/ popfam/index.html Johns Hopkins Bloomberg School of Public Health Center for International Emergency, Disaster and Relief Studies: http://www.jhsph.edu/dept/IH/Centers/refugee_disaster_ response.html Journal Forced Migration Review: http://www.fmreview.org/ 18 POPULATION REPORTS Organizations with Web-Based Information on Reproductive Health Care in Crisis Situations This list provides Web addresses of humanitarian organizations that provide reproductive health care in crisis situations and also of selected reproductive health organizations with experience in crisis situations. All organizations listed provide relevant information and material through their Web sites. Some sites do not have specific URLs about emergency care, but their search engines can guide readers to relevant information. (Note: All links were live as of November 18, 2005.) Other lists of major organizations can be found at the Web sites of Relief Web, Reproductive Health Gateway, Reproductive Health Outlook, and the UNFPA. ECHO has a list of 184 partners with whom it has a Framework Partnership Agreement: http://europa.eu.int/comm/echo/pdf_files/fpa_partners.pdf. Bibliography This bibliography includes only citations to the materials most helpful in the preparation of this report. In the text, reference numbers for these citations appear in italic. The complete bibliogra- phy can be found on the INFO Web site at : http://www.populationreports.org/J53/ 1. AMNESTY INTERNATIONAL. Sudan, Darfur, Rape as a weapon of war: Sexual violence and its consequences. Amnesty International, 2004. (Stop Violence Against Women) 34 p. (Available: <http://web. amnesty.org/library/pdf/AFR540762004ENGLISH/$File/ AFR5407604.pdf>) 2. ARONOVICH, D. Standardized Measures for Ensuring Reproductive Health Commodity Availability in Refugee Settings. Proceedings of the Reproductive Health from Disaster to Development, Brussels, Belgium, 2003. Reproductive Health Response in Conflict Consortium, United Nations High Commissioner for Refugees, United Nations Population Fund, (Available: <http://www.rhrc.org/pdf/ conf_procdings_forWEB.pdf>) 3. BARTEL, D. (CARE) [Health programs face difficulties in conflict] Personal communication, Jun. 16, 2005. 4. BARTEL, D. (CARE) [How providers can work towards prevention of violence] Personal communication, Jun. 17, 2005. 5. BARTEL, D. (CARE) [What local providers can do when faced with crisis] Personal communication, Jun. 23, 2005. 6. BARTEL, D., IGRAS, S., and CHAMBERLAIN, J. Building partnerships for health in conflict affected settings: A practical guide to beginning and sustaining inter-agency partnerships. Washington, DC, CARE, Sep. 2003. 33 p. (Available: <http://www.rhrc.org/pdf/ BuildingPartnershipsforHealth.pdf>) 7. BARTLETT, L.A., WHITEHEAD, S., CROUSE, C., BOWENS, S., MAWJI, S., IONETE, D., and SALAMA, P. Maternal mortality in Afghanistan: Magnitude, causes, risk factors and preventability. CDC, 2002. 7 p. (Available: <http://www.afghanica.org/dokumente/ mat%20mortality.pdf>) 11. BURNS, K., MALE, S., and PIEROTTI, D. Why refugees need repro- ductive health services. International Family Planning Perspectives 26(4): 161, 192. Dec. 2000. (Available: <http://www.guttmacher.org/ pubs/journals/2616100.pdf>) 12. CASEY, S., PURDIN, S., and MCGINN, T. Evaluation of coverage of reproductive health services for refugees and internally displaced persons. Presented at the Conference 2003: Reproductive Health From Disaster to Development, Brussels, Belgium, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University. 15. CENTRE FOR RESEARCH ON THE EPIDEMIOLOGY OF DISASTERS (CRED). EM-DAT: The OFDA/CRED International Disasters Data Base. Brussels, Belgium, CRED, 2005. (Available: <http://www.em-dat.net/>) 17. COOPERATIVE FOR ASSISTANCE AND RELIEF EVERYWHERE INC. (CARE). Moving from Emergency Response to Comprehensive Reproductive Health Programs: A Modular Training Series. Draft for Field Testing. Draft for field testing ed. Washington, D.C., CARE, 519 p. (Available: <http://cpmcnet.columbia.edu/dept/sph/popfam/ amdd/docs/Krause.ppt>) 18. CREEL, L. Meeting the reproductive health needs of displaced people. [Policy Brief ]. Washington, DC, Population Reference Bureau, Oct. 7, 2003. 4 p. (Available: <http://www.dec.org/pdf_docs/ PNACR719.pdf>) 19. CRYSTAL, P. and EHRLICH, L. No product? No programme! The logistics of reproductive health supplies in conflict affected areas. Forced Migration Review 19: 2. 2004. (Available: <http://www. fmreview.org/FMRpdfs/FMR19/FMR1907.pdf>) 20. DENG, F.M. Introductory note to guiding principles on internal displacement. (Available: <http://www.reliefweb.int/ocha_ol/pub/ idp_gp/idp.html> United Nations Office for the Coordination of Humanitarian Affairs (OCHA), Accessed Aug. 14, 2000) 22. DIXON, G. Contraceptive logistics guidelines for refugee settings. [revised in 1999]. Arlington, VA, John Snow, Inc./Family Planning Logistics Management (FPLM), for the U.S. Agency for International Development (USAID), 1999. 50 p. (Available: <http://portalprd1. jsi.com/pls/portal/url/item/E915EC0251D621B6E030007F01007A69>) 23. EUROPEAN COMMISSION HUMANITARIAN AID OFFICE (ECHO). When disaster strikes. Brussels, Belgium, ECHO, 2004. (Annual review 2004) 36 p. (Available: <http://europa.eu.int/comm/echo/pdf_files/ annual_reviews/2004_en.pdf>) 24. GIRARD, F. and WALDMAN, W. Ensuring the reproductive rights of refugees and internally displaced persons: Legal and policy issues. International Family Planning Perspectives 26(4): 167-173. Dec. 2000. (Available: <http://www.guttmacher.org/pubs/journals/ 2616700.pdf>) 25. GLOBAL IDP PROJECT. Internal displacement: Global overview of trends and developments in 2004. Geneva, Switzerland, Global IDP Project, Norwegian Refugee Council, Mar. 2005. 68 p. (Available: <http://www.idpproject.org/global_overview.htm>) 26. GUHA-SAPIR, D., HARGITT, D., and HOYOIS, P. Thirty years of natu- ral disasters 1974–2003: The numbers. Louvain, Belgium, Presses Universitaires de Louvain., 2004. 15 p. (Available: <http://www. em-dat.net/documents/Publication/publication_2004_emdat.pdf>) 27. GUSTAVSSON, L. Humanitarian logistics: Context and challenges. Forced Migration Review 18: 6-8. Sep. 2003. 28. GUY, S. (Marie Stopes International) [The role of family planning providers in crises] Personal communication, Dec. 16, 2004. 30. HARRIS, N. (John Snow, Inc., Research and Training Institute) [Reproductive health services for refugees] Personal communication, Sep. 19, Oct. 22, and Nov. 24, 2003. 31. HARRIS, N. (John Snow International (JSI)) [The importance of family planning for displaced populations] Personal communication, Jun. 14, 2005. 34. HEISE, L., ELLSBERG, M., and GOTTEMOELLER, M. Ending violence against women. Population Reports, Series L, No. 11. Baltimore, Johns Hopkins School of Public Health, Population Information Program, Dec. 1999. 43 p. (Available: <http://www.infoforhealth.org/pr/l11/ violence.pdf>) 36. HYNES, M., WARD, J., ROBERTSON, K., and CROUSE, C. A determi- nation of the prevalence of gender-based violence among conflict- affected populations in East Timor. Disasters 28(3): 294–321. 2004. 39. INTERNATIONAL COMMITTEE OF THE RED CROSS (ICRC). Humanitarian assistance training H.E.L.P. I (Health Emergencies in Large Populations) H.E.L.P. II (Health, Ethics, Law and Politics). (Available: <http://www.icrc.org/web/eng/siteeng0.nsf/ iwpList303/B46619B64E6211AF41256F40004BD259> ICRC, Accessed Jun. 24, 2005) 40. INTERNATIONAL FEDERATION OF RED CROSS AND RED CRESCENT SOCIETIES. Disaster preparedness training manual. International Federation of Red Cross and Red Crescent Societies, Jun. 2000. 187 p. (Available: <http://www.ifrc.org/WHAT/disasters/dp/ manual.asp>) 45. KRAUSE, S. (Women's Commission for Refugee Women and Children) [The role of family planning providers in crises] Personal communication, Dec. 22, 2004. 46. KRAUSE, S. (Women's Commission for Refugee Women and Children) [Forming links between relief agencies and local programs] Personal communication, Apr. 12, 2005. 48. KRAUSE, S.K., JONES, R.K., and PURDIN, S.J. Programmatic responses to refugees' reproductive health needs. International Family Planning Perspectives 26(4): 181–187. Dec. 2000. (Available: <http://www.agi-usa.org/pubs/journals/2618100.html>) 49. MACRAE, J., COLLINSON, S., BUCHANAN-SMITH, M., REINDORP, N., ANNA SCHMIDT, MOWJEE, T., and HARMER, A. Uncertain power: The changing role of donors in humanitarian action. London, Humanitarian Policy Group, Overseas Development Institute, Dec. 2002. 91 p. (Available: <http://www.odi.org.uk/hpg/papers/ hpgreport12.pdf>) 52. MATTHEWS, J., KRAUSE, S., and CHYNOWETH, S. Executive summary. Proceedings of the Reproductive Health from Disaster to Development, Brussels, Belgium, Oct. 7–8, 2003. Reproductive Health Response in Conflict Consortium, United Nations High Commissioner for Refugees, United Nations Population Fund, p. 143. (Available: <http://www.rhrc.org/pdf/conf_procdings_forWEB.pdf>) 53. MATTHEWS, J., KRAUSE, S., and CHYNOWETH, S. Highlights. Proceedings of the Reproductive Health from Disaster to Development, Brussels, Belgium, 2003. Reproductive Health Response in Conflict Consortium, United Nations High Commissioner for Refugees, United Nations Population Fund, (Available: <http://www.rhrc.org/pdf/conf_procdings_forWEB.pdf>) 54. MATTHEWS, J. and RITSEMA, S. Addressing the reproductive health needs of conflict affected young people. Forced Migration Review 19: 6-8. 2004. 55. MCGINN, T. Reproductive health of war-affected populations: What do we know? International Family Planning Perspectives 26(4): 174–180. Dec. 2000. (Available: <http://www.guttmacher.org/pubs/ journals/2617400.pdf>) 56. MCGINN, T. (Department of Population and Family Health Mailman School of Public Health, Columbia University) [The role of family planning providers in crises] Personal communication, Feb. 2, 2005. 57. MCGINN, T., CASEY, S., PURDIN, S., and MARSH, M. Reproductive health for conflict-affected people: Policies, research and programmes. Humanitarian Practice Network (HPN), 2004. (Network Paper) 30 p. (Available: <http://www.rhrc.org/pdf/ networkpaper045.pdf>) 59. O'HEIR, J. Review of literature: Evaluation of reproductive health services for refugees and internally displaced persons. Presented at the Conference 2003: Reproductive Health From Disaster to Development, Brussels, Belgium, UNHCR. 62. OTSEA, K. Prioritizing reproductive health for refugees. Initiatives in Reproductive Health Policy 3(1): 1-3. Sep. 1999. (Available: <http://www.ipas.org/publications/en/initiatives_in_reproductive_ health_policy/P5_E99_en.pdf>) 63. PALMER, C. Reproductive health for displaced populations. London, Overseas Development Institute (ODI), Feb. 1998. (Available: <http://www.odihpn.org/pdfbin/networkpaper024.pdf>) 64. PALMER, C.A., LUSH, L., and ZWI, A.B. The emerging international policy agenda for reproductive health services in conflict settings. Social Science and Medicine 49(12): 1689-1703. Dec. 1999. (Available: <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db= PubMed&dopt=Citation&list_uids=10574239>) 66. POORE, P. Delivering reproductive health care: An examination of the constraints. Refugee Participation Network 20. Nov. 1995. (Available: <http://www.fmreview.org/rpn205.htm>) 72. REPRODUCTIVE HEALTH FOR REFUGEES CONSORTIUM (RHRC). Refugees and reproductive health care: The next step. New York, RHRC, 1998. 85 p. (Available: <http://www.rhrc.org/resources/ general_reports/nextstep/gr_nextstep2.htm>) 74. REPRODUCTIVE HEALTH RESPONSE IN CONFLICT CONSORTIUM (RHRC). Global Decade Report. Accessed Mar. 16, 2004, (Available: <http://www.rhrc.org/pdf/Global_Decade_Report.pdf>) 76. RITTER, T. (Johns Hopkins Bloomberg School of Public Health Center for Communication Programs) [Providing care in post-conflict situations is very difficult] Personal communication, Jun. 16, 2005. 80. SCHRECK, L. Turning point: A special report on the refugee repro- ductive health field. International Family Planning Perspectives 26(4): 162-166. Dec. 2000. (Available: <http://www.guttmacher.org/pubs/ journals/2616200.pdf>) 82. SPIEGEL, P. UNHCR, HIV/AIDS and refugees: Lessons learned. Forced Migration Review 19: 21-23. 2004. (Available: <http://www.fmreview.org/FMRpdfs/FMR19/FMR1909.pdf>) 84. TADIESSE, E.N., ORAGO, A., KAREGA, R., and VIVARIE, R. Socio- cultural determinants of pregnancy and the spread of sexually trans- mitted infections among adolescent residences of Kakuma refugee camp, Northern Kenya. Presented at the Conference 2003: Reproductive Health From Disaster to Development, Brussels, Belgium, Tutorial Fellowship Centre for Complementary Medicine and Biotechnology, Kenyatta University, UNHCR Kenya. 86. U.S. COMMITTEE FOR REFUGEES (USCR). World Refugee Survey 2004. Washington, D.C., USCR, May 24, 2004. 110 p. (Available: <http://www.refugees.org/article.aspx?id=1156>) 92. UNITED NATIONS HIGH COMMISSIONER FOR REFUGEES (UNHCR). 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Sexual and gender-based violence against refugees, returnees and internally displaced persons: Guidelines for prevention and response. Geneva, UNHCR, 158 p. (Available: <http:// www.rhrc.org/resources/gbv/gl_sgbv03.html>) 98. UNITED NATIONS HIGH COMMISSIONER FOR REFUGEES (UNHCR). Global report 2003. Geneva, UNHCR, Jun. 2004. 493 p. (Available: <http://www.unhcr.ch/cgi-bin/texis/vtx/ template?page=publ&src=static/gr2003/gr2003toc.htm>) 100. UNITED NATIONS HIGH COMMISSIONER FOR REFUGEES (UNHCR). Reproductive health services for refugees and internally displaced persons: Report of an inter-agency global evaluation. UNHCR, Nov. 2004. 261 p. (Available: <http://www.rhrc.org/ resources/iawg/>) 103. UNITED NATIONS OFFICE FOR THE COORDINATION OF HUMAN- ITARIAN AFFAIRS (OCHA). OCHA orientation handbook on complex emergencies. New York, OCHA, 1999. 80 p. (Available: <http://www. reliefweb.int/library/documents/ ocha__orientation__handbook_on__.htm#1>) 104. UNITED NATIONS POPULATION FUND (UNFPA). UNFPA support for reproductive health in emergency situations. (Available: <http:// www.pcpafg.org/Organizations/unfpa/unfpa_support_for_ reproductive_health_in_emergency_situations%20.htm> UNFPA, Accessed Apr. 1999. 105. UNITED NATIONS POPULATION FUND (UNFPA). Reproductive health for communities in crisis: UNFPA emergency response. New York, UNFPA, 2001. 38 p. (Available: <http://www.unfpa.org/upload/ lib_pub_file/78_filename_crisis_eng.pdf>) 106. UNITED NATIONS POPULATION FUND (UNFPA). Impact of con- flict on women and girls: A UNFPA strategy for gender mainstream- ing in areas of conflict and reconstruction. New York, UNFPA, 2002. 140 p. (Available: <http://www.unfpa.org/upload/lib_pub_file/ 46_filename_armedconflict_women.pdf>) 112. VANN, B. Gender-based violence: Emerging issues in programs serving displaced populations. Arlington, Virginia, Reproductive Health for Refugees Consortium, JSI Research and Training Institute, 2002. 144 p. (Available: <http://www.rhrc.org/pdf/gbv_vann.pdf>) 114. WARD, J. and BREWER, J. Gender-based violence in conflict- affected settings: Overview of a multicountry research project. Forced Migration Review 19: 26-28. Jan. 2004. 116. WOMEN’S COMMISSION FOR REFUGEE WOMEN AND CHILDREN (WCRWC) and UNITED NATIONS POPULATION FUND (UNFPA). Lifesaving reproductive health care: Ignored and neglected. Assessment of the Minimum Initial Service Package (MISP) of repro- ductive health for Sudanese refugees in Chad. WCRWC and UNFPA, Aug. 2004. (Available: <http://www.womenscommission.org/ pdf/cd_misp%20final.pdf>) 117. WOMEN'S COMMISSION FOR REFUGEE WOMEN AND CHILDREN (WCRWC). Minimum Initial Service Package (MISP). New York, Women's Commission for Refugee Women and Children, Jan. 2003. (Fact Sheet) (Available: <http://www.rhrc.org/pdf/fs_misp.pdf>) 118. WOMEN'S COMMISSION FOR REFUGEE WOMEN AND CHILDREN (WCRWC). Sexual violence in refugee crises: A synopsis of the UNHCR guidelines for prevention and response. [Webpage]. New York, WCRWC, 2003. (Available: <http://www. womenscommission.org/projects/P&P/guidelines/sexviol.shtml>) 119. WOMEN'S COMMISSION FOR REFUGEE WOMEN AND CHILDREN (WCRWC). Reproductive health priorities in an emergency: Assess- ment of the Minimum Initial Service Package in tsunami-affected areas in Indonesia. Women's Commission for Refugee Women and Children, 2005. 16 p. (Available: <http://www.rhrc.org/ pdf/id_misp_eng.pdf>) 121. WORLD HEALTH ORGANIZATION (WHO). Reproductive health during conflict and displacement: A guide for programme managers. Geneva, WHO, 2000. 175 p. (Available: <http://www.who.int/ reproductive-health/publications/RHR_00_13_RH_conflict_and_ displacement/>) 124. WORLD HEALTH ORGANIZATION (WHO), UNITED NATIONS CHILDREN'S FUND (UNICEF), and UNITED NATIONS POPULATION FUND (UNFPA). Maternal mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA. Geneva, WHO, 2004. 38 p. (Available: <http://www.childinfo.org/maternal_mortality_in_2000.pdf>) ISSN 0887-0241 19POPULATION REPORTS POPLINE Digital Services Please send details on the following products/services: POPLINE: the world’s largest bibliographic database on population, family planning, and related health issues, is available in CD-ROM (free of charge to developing countries) and on the Internet, at no charge, at: http://www.popline.org Document Delivery: Receive full-text copies of POPLINE documents by mail or by e-mail. Special topic CD-ROMS: International Family Planning Perspectives CD-ROM New Survey Findings CD-ROM Searches: POPLINE searches can be requested by send- ing an e-mail to: popline@jhuccp.org or by mail or fax to ad- dress above. ORAL CONTRACEPTIVES—Series A ___ A-9 Oral Contraceptives—An Update [2000] (F,S) ___ A-10 Helping Women Use the Pill [2000] (F,S) INTRAUTERINE DEVICES—Series B ___ B-6 IUDs—An Update [1995] (F,P,S) BARRIER METHODS—Series H ___ H-9 Closing the Condom Gap [1999] (F,P,S) FAMILY PLANNING PROGRAMS—Series J ___ J-39 Paying for Family Planning [1991] (F,S) ___ J-41 Supplement: Female Genital Mutilation: A Reproductive Health Concern [1995] (F) ___ J-42 Helping the News Media Cover Family Planning [1995] (F,S) ___ J-43 Meeting Unmet Need: New Strategies [1996] (F,S) ___ J-45 People Who Move: New Reproductive Health Focus [1997] (F,S) ___ J-46 Reproductive Health: New Perspectives on Men’s Participation [1998] (F, S) ___ J-49 Why Family Planning Matters [1999] (F,S) ___ J-50 Informed Choice in Family Planning: Helping People Decide [2001] (F,P,S) ___ J-51 Family Planning Logistics: Strengthening the Supply Chain [2002] (F,S) ___ J-52 Performance Improvement [2002] (F,S) ___ J-53 Coping with Crises: How Providers Can Meet Reproductive Health Needs in Crisis Situations [2005] INJECTABLES AND IMPLANTS—Series K ___ K-4 Guide: Guide to Norplant Counseling [1992] (F,S) ___ K-5 New Era for Injectables [1995] (F,P,S) ___ K-5 Guide: Guide to Counseling on Injectables [1995] (F,P,S) ___ K-5 Fact Sheet: DMPA at a Glance [1995] (F,P,S) ISSUES IN WORLD HEALTH—Series L ___ L-10 Wall chart: Family Planning After Postabortion Treatment [1997] (F,P,S) ___ L-11 Ending Violence Against Women [1999] (F,P,S) ___ L-12 Youth and HIV/AIDS: Can We Avoid Catastrophe? [2001] (F,P,S) ___ L-13 Birth Spacing: Three to Five Saves Lives [2002] (F,S) SPECIAL TOPICS—Series M ___ M-13 Winning the Food Race [1997] (F,S) ___ M-14 Solutions for a Water-Short World [1998] (F,S) ___ M-15 Population and the Environment: The Global Challenge [2000] (F,S) ___ M-16 Meeting the Urban Challenge [2002] (F,S) ___ M-17 New Survey Findings: The Reproductive Revolution Continues [2003] (F,S) ___ M-18 Men’s Surveys: New Findings [2004] (F,S) ___ M-19 New Contraceptive Choices [2005] (F,S) MAXIMIZING ACCESS AND QUALITY—Series Q ___ Q-1 Improving Client-Provider Interaction [2003] (F,S) ___ Q-2 Organizing Work Better [2004] (F,S) 1. q Send ___ copies of each future issue of Population Reports. q I am already on the Population Reports mailing list. q Send me a binder (in developed countries, US$7.00). 2. Language:qEnglishqFrenchqPortugueseqSpanish. Population Reports in Print POPULATION REPORTS Population Reports are free in any quantity to developing countries. 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