The 2018 Inter-agency field manual on reproductive health in humanitarian settings: revising the global standards
Publication date: 2018
Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=zrhm21 Reproductive Health Matters An international journal on sexual and reproductive health and rights ISSN: 0968-8080 (Print) 1460-9576 (Online) Journal homepage: https://www.tandfonline.com/loi/zrhm20 The 2018 Inter-agency field manual on reproductive health in humanitarian settings: revising the global standards Angel M. Foster, Dabney P. Evans, Melissa Garcia, Sarah Knaster, Sandra Krause, Therese McGinn, Sarah Rich, Meera Shah, Hannah Tappis & Erin Wheeler To cite this article: Angel M. Foster, Dabney P. Evans, Melissa Garcia, Sarah Knaster, Sandra Krause, Therese McGinn, Sarah Rich, Meera Shah, Hannah Tappis & Erin Wheeler (2017) The 2018�Inter-agency�field�manual�on�reproductive�health�in�humanitarian�settings: revising the global standards, Reproductive Health Matters, 25:51, 18-24, DOI: 10.1080/09688080.2017.1403277 To link to this article: https://doi.org/10.1080/09688080.2017.1403277 © 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group Published online: 12 Dec 2017. Submit your article to this journal Article views: 4688 View related articles View Crossmark data Citing articles: 10 View citing articles The 2018 Inter-agency ﬁeld manual on reproductive health in humanitarian settings: revising the global standards Angel M. Foster ,a Dabney P. Evans ,b Melissa Garcia,c Sarah Knaster,d Sandra Krause,e Therese McGinn,f Sarah Rich,g Meera Shah,h Hannah Tappis ,i Erin Wheelerj a Associate Professor, Faculty of Health Sciences, University of Ottawa, ON, Canada. Correspondence: firstname.lastname@example.org b Assistant Professor, Hubert Department of Global Health & Director, Center for Humanitarian Emergencies, Rollins School of Public Health, Emory University, Atlanta, GA, USA c Technical Advisor, International Consortium for Emergency Contraception hosted by Management Sciences for Health, New York, NY, USA d Coordinator for the Inter-Agency Working Group on Reproductive Health in Crises, Women’s Refugee Commission, New York, NY, USA e Director, Sexual and Reproductive Health Program, Women’s Refugee Commission, New York, NY, USA f Professor, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA g Senior Advisor, Sexual and Reproductive Health, Women’s Refugee Commission, New York, NY, USA h Global Advocacy Adviser, Center for Reproductive Rights, New York, NY, USA i Senior Monitoring, Evaluation and Research Advisor, Jhpiego, Baltimore, MD, USA j Technical Advisor for Contraception and Abortion Care, International Rescue Committee, New York, NY, USA Abstract: Since the 1990s, the Inter-agency ﬁeld manual on reproductive health in humanitarian settings (IAFM) has provided authoritative guidance on reproductive health service provision during different phases of complex humanitarian emergencies. In 2018, the Inter-Agency Working Group on Reproductive Health in Crises will release a new edition of this global resource. In this article, we describe the collaborative and inter- sectoral revision process and highlight major changes in the 2018 IAFM. Key revisions to the manual include repositioning unintended pregnancy prevention within and explicitly incorporating safe abortion care into the Minimum Initial Service Package (MISP) chapter, which outlines a set of priority activities to be implemented at the outset of a humanitarian crisis; stronger guidance on the transition from the MISP to comprehensive sexual and reproductive health services; and the addition of a logistics chapter. In addition, the IAFM now places greater and more consistent emphasis on human rights principles and obligations, gender-based violence, and the linkages between maternal and newborn health, and incorporates a diverse range of ﬁeld examples. We conclude this article with an outline of plans for releasing the 2018 IAFM and facilitating uptake by those working in refugee, crisis, conﬂict, and emergency settings. DOI: 10.1080/ 09688080.2017.1403277 Keywords: Abortion, contraception, displaced persons, gender-based violence, human rights, maternal and newborn health, refugees, sexual and reproductive health Setting the context In 2015, the United Nations High Commissioner for Refugees (UNHCR) estimated that the global forci- bly displaced population exceeded 65 million for the ﬁrst time in history.1 This included over 21 million refugees, 40 million internally displaced persons, and more than 3 million asylum seekers.1 Of those needing humanitarian assistance, approximately one in four are women and girls of reproductive age.2 The global community began prioritising the sexual and reproductive health needs of refugee and displaced populations in the mid-1990s. In 1995, more than 50 governments, UN agencies, PERSPECTIVE 18 © 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. and non-governmental organisations (NGOs) com- mitted themselves to strengthening reproductive health services for refugee populations and sub- sequently formed the Inter-Agency Working Group on Reproductive Health in Crises (IAWG).* One of the ﬁrst activities of the new organisation was to develop guidelines for providing reproduc- tive health services in refugee settings. After exten- sive ﬁeld-testing of a beta version, in 1999 IAWG- afﬁliated agencies released Reproductive health in refugee situations: an inter-agency ﬁeld manual.3 Importantly, the manual outlined a set of mini- mum reproductive health interventions, known as the MISP, to be put in place at the outset of a humanitarian crisis. The manual also served as a tool to: facilitate discussion and decision-making in the planning, implementation, monitoring, and evaluation of comprehensive reproductive health interventions; guide sexual and reproduc- tive health ofﬁcers, programmemanagers, and ser- vice providers in introducing and/or strengthening evidence-based interventions; advocate for a multi-sectoral approach to meeting the compre- hensive needs of affected populations; and foster coordination among partners.3 In 2010, IAWG released a new edition of the manual. Reﬂecting the relevance of the document for a broad array of refugee, crisis, conﬂict, and emergency settings, IAWG agencies retitled the manual the Inter-agency ﬁeld manual on reproduc- tive health in humanitarian settings (IAFM).4 In addition to technical updates, the 2010 IAFM reframed safe motherhood as maternal and new- born health, included standalone chapters on ado- lescent reproductive health, HIV, and sexually transmitted infections, and introduced a new chapter on comprehensive abortion care. Available in print and online versions, the multi-modal resource also linked users to detailed clinical guidelines issued by normative bodies. In 2016, IAWG embarked on a 24-month process to revise the IAFM. In this article, we describe the frameworks and principles that undergird the 2018 version of the manual. We then highlight major changes to the new edition. We conclude with a discussion of IAWG’s plans to disseminate information about the changes and facilitate adop- tion of the manual by humanitarian agencies and ﬁeld staff. The 2018 IAFM: A collaborative global effort Consistent with previous versions of the manual, human rights principles and evidence-based pol- icies and practices ground the IAFM. The 2018 ver- sion explicitly recognises that sexual and reproductive health and rights are central to the realisation of fundamental human rights, includ- ing the right to life, the right to health, the right to be free from torture and ill-treatment, the right to privacy, the right to education, and the prohibition of discrimination, particularly on the basis of sex and gender. In alignment with international human rights obligations and gui- dance from numerous human rights and political bodies, the 2018 IAFM emphasises that advancing sexual and reproductive health and rights requires that women and girls in crisis-affected settings have access to comprehensive reproductive health information and services and the ability to make informed decisions free from violence, discrimi- nation, and coercion.5 Sexual and reproductive health guidelines issued by normative bodies, and particularly those of the World Health Organization (WHO), pro- vide the technical foundation for the manual. Where possible, this manual incorporates speciﬁc evidence from or examples about the application and adaptation of global sexual and reproductive health or human rights standards in humanitarian settings. Although national laws, policies, and resources in speciﬁc contexts may complicate implementation of global standards, the 2018 IAFM presents evidence-based interventions that should be offered in all settings and to all affected populations, a position consistent with broader human rights principles. The manual is intended for use in the ﬁeld by a range of implementing agency staff and thus does not provide detailed clinical guidelines; users are directed to and encouraged to consult additional resources as necessary. Since the release of the 2010 IAFM, IAWG mem- bers have conducted both formal and informal evaluations of the use of the manual and the implementation of sexual and reproductive health interventions in humanitarian settings.6 Taken together these evaluations indicated that despite considerable progress in funding for, awareness of, and capacity to deliver sexual and reproduc- tive health programming, signiﬁcant gaps existed with respect to providing adolescent sexual and*IAWG was originally called the Inter-Agency Working Group on Reproductive Health in Refugee Situations. AM Foster et al. Reproductive Health Matters 2017;25(51):18–24 19 reproductive health services, offering a full range of contraceptive methods and comprehensive abortion care, providing emergency obstetric and newborn care, and preventing sexual violence. These ﬁndings informed the revision process. Feed- back from practitioners in the ﬁeld also provided direction for the latest revision. In addition to tech- nical updates, users of the manual working in a range of countries and settings expressed the need for simpliﬁed language, enhanced linkages between topics and chapters, and incorporation of case studies and programmatic examples to guide implementation. The 2018 IAFM is a product of IAWG and thus the existing leadership structure of a network that includes over 2,100 members and 450 agencies governed the overall effort.7 IAWG for- mally began the revision process in March 2016. IAWG sub-working groups took the lead on individ- ual chapter revisions, providing substantive input and technical updates through consultation and a review of published sources. These sub-working groups also reached out to ﬁeld staff in multiple countries, and in some cases engaged, directly with refugee and displaced populations for feed- back. The 2018 IAFM Taskforce, a body comprising more than 50 individuals from 21 UN agencies, international NGOs, and academic institutions, further developed and ultimately approved the substantive changes to individual chapters and made decisions regarding overarching structural revisions. Regular conference calls and three in-per- son meetings allowed for robust debate, compro- mise, and agreement. The ﬁnal step in the process involved a technical review by the WHO and sign off by the IAWG Steering Committee. Thus, the 2018 IAFM resulted from a deliberate collaborative process that included hundreds of individuals from dozens of agencies and organisations working in humanitarian settings at global, regional, and local levels. The updates to the IAFM, detailed below, represent the consensus positions of a wide cross-section of agencies working on sexual and reproductive health in the humanitarian sector. Changes to the Minimum Initial Service Package One of the hallmarks of the IAFM is the Minimum Initial Service Package (MISP) for Reproductive Health.8 The MISP deﬁnes which sexual and repro- ductive health services are most important in pre- venting morbidity and mortality, while protecting the right to life with dignity, particularly among women and girls, at the onset of a humanitarian emergency (within 48 h whenever possible). All ser- vice delivery activities of the MISP need to be implemented simultaneously through coordinated actions with all relevant partners. The components of the MISP form a minimum requirement and are intended to be implemented in all circumstances. In the 2010 IAFM, the MISP outlined a set of objectives and corresponding priority activities designed to coordinate sexual and reproductive health efforts at the outset of a crisis, prevent and manage the consequences of sexual violence, reduce HIV transmission, prevent excess maternal and newborn morbidity and mortality, and plan for comprehensive sexual and reproductive health services.4 The manual referenced the provision of speciﬁc contraceptives in the context of responding to sexual assault and preventing maternal death and disability, as well as in a note highlighting a number of additional priorities. In the 2018 IAFM, prevention of unintended pregnancy is a standalone objective. The identiﬁed priority activities are to: (1) Ensure availability of a range of long-acting reversible and short-acting contraceptive methods (including condoms and emergency contraception) at primary healthcare facilities to meet demand; (2) Provide information, including information, education, and communication materials, and ensure contraceptive counselling that empha- sises informed choice, effectiveness, and sup- ports client privacy and conﬁdentiality; and (3) Ensure the community is aware of the avail- ability of contraceptives for women, adoles- cents, and men. The repositioning of contraception within the MISP reﬂects a signiﬁcant improvement and acknowledges the importance of unintended preg- nancy prevention in women’s health and lives.9 In Figure 1, we provide a list of the 2010 and 2018 MISP objectives. A second major change to the MISP chapter involves explicit references to safe abortion care. Although there is a lack of reliable data on abortion in refugee, crisis, conﬂict, and emergency settings, unsafe abortion is a leading cause of maternal death worldwide and the need for safe abortion care likely increases in humanitarian settings.10 In addition to incorporating pregnancy options coun- selling and provision of or referral for safe abortion care into clinical care for survivors of sexual violence, AM Foster et al. Reproductive Health Matters 2017;25(51):18–24 20 provision of safe abortion care, to the full extent of the law, is now included in the MISP chapter as a standalone “other priority activity”. Finally, in addition to important technical updates and wording changes, the 2018 IAFM strengthens guidance on transitioning from the MISP to comprehensive sexual and reproductive health services. These revisions respond to a gap identiﬁed in the IAWG global evaluation.6 The new version offers expanded content to facilitate planning for comprehensive services and focuses on health system building blocks (see Figure 1). Addition of a logistics chapter The supply chain is a critical component of success- ful sexual and reproductive health service delivery. Without sexual and reproductive health medicines and other supplies, health workers cannot provide effective services. When humanitarian emergen- cies occur, organisations involved in the response must quickly identify or establish functioning, agile supply chains to meet the needs of the affected population, whether in cities or in remote rural areas. Humanitarian response agencies also have a responsibility to contribute to building and maintaining strong, ﬂexible, sustainable supply chains in all settings in which they work; doing so is consistent with the concepts of avail- ability and geographic accessibility present within the human rights corpus. Recognising the impor- tance of these issues, the 2018 IAFM includes a chapter dedicated to logistics. The chapter maps the key stakeholders and processes that are essen- tial to effective sexual and reproductive health supply chains; provides recommendations on tran- sitioning from emergency to ongoing supply chains; outlines key steps including forecasting, Figure 1. Objectives of the Minimum Initial Service Package AM Foster et al. Reproductive Health Matters 2017;25(51):18–24 21 procurement, transportation, and last-mile distri- bution; and identiﬁes staff roles and responsibil- ities for effective supply chain management. The inclusion of this chapter responds directly to feed- back from users in the ﬁeld. Changes in emphasis and language The 2018 IAFM places greater and more consistent emphasis on human rights obligations and prin- ciples, gender-based violence, and the linkages between maternal and newborn health. The intro- duction and the revised chapter on “fundamental principles” engage more fully with the human rights underpinnings of the manual and situate the rec- ommendations within broader international guide- lines. The revised chapter on gender-based violence not only provides robust and updated technical information regarding service delivery, but also includes an expanded focus on a broader array of types of gender-based violence encountered in humanitarian settings. This includes exploration of the relationship among the substantive topics of sexual violence, domestic and intimate partner vio- lence, female genital cutting, and early marriage and sexual and reproductive health. The third edi- tion lays out a survivor-centred, rights-based approach to these issues in humanitarian settings that pays speciﬁc attention to adolescents and les- bian, gay, bisexual, transgender, queer, intersex, and asexual populations. The new version of the manual also places greater emphasis on quality care for mothers and newborns on the day of birth and contains more information about new- born health.11 This includes expanded content related to emergency obstetric and newborn care, essential newborn care, and care for small and sick newborns. Finally, the 2018 version of the man- ual uses “sexual and reproductive health” in place of reproductive health, reﬂecting better the scope of the manual and expanded understanding of the ﬁeld of sexual health. Inclusion of programmatic examples: highlighting successes and challenges In response to expressed needs from the ﬁeld, the 2018 IAFM includes a series of programmatic examples showcasing the implementation of sex- ual and reproductive health programming in different humanitarian settings. These examples involve numerous implementing agencies in differ- ent countries and regions operating during different phases of an emergency. Case studies also explore a range of challenges that are routi- nely experienced by those in the ﬁeld. Next steps for the 2018 IAFM IAWG will ofﬁcially release the third edition in early 2018. At that time, humanitarian stakeholders will have access to both print and electronic versions of the English version of the manual. Supplementary materials, including detailed clinical guidelines, decision aids, and templates will be available online. Arabic, French, and Spanish translations of the manual will become available in late 2018. In the year following the release, members of the 2018 IAFM Taskforce will work with their own organisations and professional networks to ensure adoption of the new version of the manual. IAWG members will undertake a series of efforts to implement the new guidelines and will continue to work with local, regional, and global stake- holders to facilitate monitoring and evaluation of implementation. The new edition of the IAFM and associated dissemination efforts represent sig- niﬁcant steps to improving sexual and reproduc- tive health in humanitarian settings. Acknowledgements The 2018 IAFM revision process includes a Taskforce comprising representatives from more than 20 agencies including: Ribka Amsalu; Rebecca Brown (Center for Reproductive Rights); Sara E Casey (RAISE Initiative, Heilbrunn Department of Popu- lation and Family Health, Mailman School of Public Health, Columbia University); Nadine Cornier (UNFPA); Henia Dakkak (Humanitarian and Fragile Contexts Branch – Programme Division, UNFPA); Aditi Ghosh (International Planned Parenthood Fed- eration); Kamlesh Giri (Care International); Nancy Pendarvis Harris (JSI Research & Training Institute, Inc. (JSI)); Michelle Hynes (U.S. Centers for Disease Con- trol and Prevention); Anushka Kalyanpur (Care Inter- national); Lara S. Martin (Center for Humanitarian Emergencies, Emory University); Kate Meehan (U.S. Centers for Disease Control and Prevention); Janet Meyers; Elizabeth Noznesky (Care International); Bill Powell (Ipas); Jesse Rattan (Care International); Jenni- fer Schlecht (Women’s Refugee Commission); Christina Wegs (Care International). We have also received substantive input throughout the revision process from numerous individuals afﬁliated with IAWG and working in the ﬁeld; we thank all of those who have contributed to this project for their efforts. AM Foster et al. Reproductive Health Matters 2017;25(51):18–24 22 Disclosure statement No potential conﬂict of interest was reported by the authors. Funding An anonymous donor funded the revision of the Inter-Agency Field Manual (IAFM). ORCID Angel M. Foster http://orcid.org/0000-0001- 8848-203X Dabney P. Evans http://orcid.org/0000-0002- 2201-5655 Hannah Tappis http://orcid.org/0000-0002- 4289-5418 References 1. UNHCR. Global trends: forced displacement in 2015 [Internet]. Geneva: UNHCR; 2016 [cited 2017 May 29]. Available from: http://www.unhcr.org/576408cd7.pdf 2. UNFPA. State of the world population 2015: shelter from the storm [Internet]. New York (NY): UNFPA; 2015 [cited 2017 May 31]. Available from: https://www.unfpa.org/ sites/default/ﬁles/sowp/downloads/State_of_World_ Population_2015_EN.pdf 3. UNHCR. Reproductive health in refugee situations: an inter- agency ﬁeld manual [Internet]. Geneva: UNHCR; 1999. [cited 2017 May 29]. Available from: http://www.refworld. org/docid/403b6ceb4.html 4. IAWG. Inter-agency ﬁeld manual on reproductive health in humanitarian settings. New York (NY): IAWG; 2010. [cited 2017 May 29]. Available from: http://iawg.net/resource/ inter-agency-ﬁeld-manual-on-reproductive-health-in- humanitarian-settings-2010/ 5. United Nations. Convention on the elimination of all forms of discrimination against women. General recommendation No. 30 on women in conﬂict prevention, conﬂict and post conﬂict situations; 2013 [cited 2017 May 29]. Available from: http://www.ohchr.org/documents/hrbodies/cedaw/ gcomments/cedaw.c.cg.30.pdf 6. IAWG. Reproductive health in the changing humanitarian context: ﬁndings from the IAWG on reproductive health in crises’ 2012–2014 global evaluation. New York (NY): IAWG; 2015 [cited 2017 May 29]. Available from: http:// iawg.net/wp-content/uploads/2016/08/IAWG-Global- Evaluation-2012-2014-1.pdf 7. IAWG. About IAWG [Internet]; 2016 [cited 2017 May 29]. Available from: http://iawg.net/about-us/ 8. Krause SK, Chynoweth SK, Tanabe M. Sea-change in reproductive health in emergencies: how systemic improvements to address the MISP were achieved. Reproductive Health Matters (Under review, special issue on sexual and reproductive health in humanitarian settings). 9. Fabic MS, Choi Y, Bongaarts J, et al. Meeting demand for family planning within a generation: the post-2015 agenda. The Lancet. 2015;385(9981):1928–1931. 10. McGinn T, Casey S. Why don’t humanitarian organizations provide safe abortion services? Conﬂ Health. 2016;10(8):1–7. 11. Black RE, Levin C, Walker N, et al. Reproductive, maternal, newborn, and child health: key message from disease control priorities, 3rd ed. The Lancet. 2016;388 (10061):2811–2824. Résumé Depuis les années 90, le Manuel de terrain interor- ganisations sur la santé reproductive en situations de crise humanitaire fournit des conseils faisant autorité sur la prestation de services de santé gén- ésique pendant différentes phases de situations d’urgence humanitaire complexes. En 2018, le Groupe de travail interorganisations sur la santé reproductive en situations de crise publiera une nouvelle édition de cette ressource mondiale. Dans cet article, nous décrivons le processus de révision collaboratif et intersectoriel et mettons en lumière les changements majeurs apportés au Manuel de 2018. Les principales révisions incluent le repositionnement de la prévention des Resumen Desde la década de los noventa, el Manual de Tra- bajo Interinstitucional sobre Salud Reproductiva en Escenarios Humanitarios (IAFM) ha ofrecido orien- tación autoritaria sobre la prestación de servicios de salud reproductiva durante diferentes fases de complejas emergencias humanitarias. En el año 2018, El Grupo de Trabajo Interinstitucional sobre Salud Reproductiva en Situaciones de Crisis publicará una nueva edición de este recurso mun- dial. En este artículo, describimos el proceso de revisión colaborativo e intersectorial, y destacamos cambios importantes en el IAFM 2018. Entre las modiﬁcaciones clave realizadas al manual ﬁguran: reposicionar la prevención del embarazo no AM Foster et al. Reproductive Health Matters 2017;25(51):18–24 23 grossesses non désirées et l’inclusion explicite de soins d’avortement sans risque dans le chapitre sur le dispositif minimum d’urgence (DMU), qui souligne un ensemble d’activités prioritaires à appliquer dès le début d’une crise humanitaire ; des recommandations plus solides sur la transition du DMU à des services complets de santé sexuelle et génésique ; et l’ajout d’un chapitre sur la logis- tique. En outre, le Manuel met désormais davan- tage l’accent sur les obligations et les principes des droits de l’homme, la violence sexiste et les liens entre la santé de la mère et du nouveau-né, et il donne une gamme diversiﬁée d’exemples de terrain. Nous concluons cet article avec un aperçu des activités prévues pour publier le Manuel de 2018 et en faciliter l’emploi par ceux qui travaillent dans des situations de réfugiés, de crise, de conﬂit et d’urgence. intencional e incorporar explícitamente los servi- cios de aborto seguro en el capítulo sobre el Paquete de Servicios Iniciales Mínimos (MISP), que resume una serie de actividades prioritarias a ser implementadas al principio de una crisis humanitaria; mejor orientación sobre la transición del MISP a servicios integrales de salud sexual y reproductiva; y la adición de un capítulo sobre logística. Además, el IAFM pone mayor énfasis, de manera más sistemática, en las obligaciones y los principios relativos a los derechos humanos, violencia de género y los vínculos entre salud materna y salud neonatal, e incorpora una varie- dad de ejemplos del campo. Concluimos este artículo con un resumen de los planes para publi- car el IAFM 2018 y facilitar su aceptación por las personas que trabajan en situaciones de refugia- dos, crisis, conﬂicto y emergencias. AM Foster et al. Reproductive Health Matters 2017;25(51):18–24 24 Abstract Setting the context The 2018 IAFM: A collaborative global effort Changes to the Minimum Initial Service Package Addition of a logistics chapter Changes in emphasis and language Inclusion of programmatic examples: highlighting successes and challenges Next steps for the 2018 IAFM Acknowledgements Disclosure statement ORCID References
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