UNHCR Reproductive Health in refugee situations

Publication date: 1999

Reproductive Health in refugee situations an Inter-agency Field Manual in refugee situations Reproductive Health an Inter-agency Field Manual This document is issued for general distribution. All rights are reserved. Reproductions and translations are authorised, except for commercial purposes, provided the source is acknowledged. This Inter-agency Field Manual replaces the above field-test version. Additional copies of the Field Manual can be obtained from the agencies cited on the back cover. Any comments can be directed to the following: — World Health Organisation (WHO) Department of Reproductive Health and Research — United Nations Fund for Population Activities (UNFPA) Emergency Relief Office, Geneva — United Nations High Commissioner for Refugees (UNHCR) © 1999 United Nations High Commissioner for Refugees F O R E W O R D Gro Harlem Bruntland Director General WHO Reproductive health is a right ; and like all other human rights it applies to refugees and persons living in refugee-like conditions. To exercise this right, populations caught up in conflict and living in emergency situations must have an enabling environment and access to complete reproductive health information and services so they can make free and informed choices. They also must feel comfortable and secure in discussing their most private concerns with those who seek to help them. Quality reproductive health services must be based on refugees’, particularly women refugees’, needs. They must also respect refugees’ various religious and ethical values and cultural back- grounds while conforming to universally recognised international human rights standards. There- fore, full information on options, and access to reproductive health services should be provided, leaving the decision to the individual. Reproductive health care covers a wide range of services. These are defined as follows in the Programme of Action of the International Conference on Population and Development (ICPD) held in Cairo, Egypt, in September 1994: family-planning counselling, information, education, communi- cation and services; education and services for prenatal care, safe delivery and post-natal care, and infant and women’s health care; prevention and appropriate treatment of infertility; prevention of abortion and the management of the consequences of abortion; treatment of reproductive tract infections, sexually transmitted diseases, including HIV/AIDS; breast cancer and cancers of the reproductive system, and other reproductive health conditions; and active discouragement of harmful traditional practices, such as female genital mutilation. Providing comprehensive and high-quality reproductive health services requires a multi-sectoral integrated approach. Protection, health, nutrition, education and community service personnel all have a part to play in planning and delivering reproductive health services. The best way to guarantee that reproductive health services meet the needs of the refugee community is to involve the community in every phase of the development of those services: from designing programmes to launching and maintaining them to evaluating their impact. Only then will refugees benefit from services specifically tailored to their needs and demands; and only then will they have a stake in the future of those services. This Inter-agency Field Manual on Reproductive Health in Refugee Situations is the result of a collaborative effort of many UN agencies, governmental and non-governmental organisations and refugees themselves. Information in this Manual is based on the normative, technical guidance of the World Health Organization. A draft of the Field Manual was first issued in 1996 and tested extensively in the field. This new version can, and should, be shaped and adapted to suit the particular circumstances and requirements of each refugee situation as it arises and evolves. We are pleased with the progress already made in meeting the reproductive health needs of refugees and persons living in refugee-like situations; but we also know this is no time to lose momentum. We hope the Field Manual will serve to improve the health and well-being of refugees and foster more responsive and appropriate actions in the field. Nafis Sadik Executive Director UNFPA Sadako Ogata High Commissioner for Refugees UNHCR At an Inter-agency Symposium on Reproductive Health in Refugee Situations held in Geneva, Switzerland in June 1995, more than 50 governments, non-governmental organisations (NGOs) and UN agencies committed themselves to strengthening reproductive health (RH) services to refugees. Following the symposium, an Inter-agency Field Manual on Reproductive Health in Refugee Situations was produced and distributed for field-testing around the world. This 1999 revision of the Field Manual is the result of two years of field use and comprehensive field-testing conducted under the auspices of the Inter-agency Working Group on Reproductive Health in Refugee Situations. More than 100 experienced staff from 50 agencies working in refugee situations in 17 countries applied the Field Manual in their programmes and provided comments and suggestions for improving the content of the publication. The Field Manual supports the delivery of quality RH services. Technical standards included in the Field Manual are those set by the World Health Organization. In several important areas, the Field Manual provides programmatic direction with frequent reference to additional resource materials that should be obtained and used to ensure comprehensive and reliable RH services for refugees. Field managers of health services in refugee situations are the primary audience for the Field Manual. Community-services officers, protection officers and others working to meet the needs of refugee women, young people and men should also benefit from the guidance offered in the Field Manual. The purposes of the Field Manual are: § to serve as a tool to facilitate discussion and decision-making in the planning, implementation, monitoring and evaluation of RH interventions; § to guide field staff in introducing and/or strengthening RH interventions in refugee situations, based on refugee needs and demands and with full respect for their beliefs and values; and § to advocate for a multi-sectoral approach to meeting the RH needs of refugees and to foster coordination among all partners. Chapter One lays the foundation for the subsequent technical chapters on reproductive health and provides the guiding principles for undertaking all RH care. It should be read carefully. The components of reproductive health described in the Field Manual are: § Minimum Initial Service Package § Safe Motherhood § Sexual Violence § Sexually Transmitted Diseases, including HIV/AIDS § Family Planning § Other Reproductive Health Concerns § Reproductive Health of Young People P R E F A C E A C K N O W L E D G M E N T S Action Contre la Faim African Medical and Research Foundation American Refugee Committee CARE Centre for Research on the Epidemiology of Disasters Centro de Capacitación en Ecología y Salud para Campesinos Center for Population and Family Health – Columbia University’s Mailman School of Public Health Family Health International International Centre for Migration and Health International Federation of the Red Cross and Red Crescent Societies Ipas International Planned Parenthood Federation International Rescue Committee International Organization for Migration JSI Research and Training Institute London School of Hygiene and Tropical Medicine Marie Stopes International Médecins du Monde Médecins sans Frontières MERLIN (Medical Emergency Relief International) Population Council Save the Children Fund UK United Nations Children’s Fund United Nations High Commissioner for Refugees United Nations Joint Programme on AIDS United Nations Fund for Population Activities U.S. Agency for International Development U.S. Centers for Disease Control and Prevention U.S. Department of Health and Human Services U.S. Department of State Women’s Commission for Refugee Women and Children World Association of Girl Guides and Girl Scouts World Health Organization The entities listed contributed to this Field Manual and are among those who believe it will facilitate the delivery of reproductive health services in refugee situations. The UN, NGO and Government members of the Inter-agency Working Group on Reproductive Health in Refugee Situations (IAWG) are gratefully acknowledged for their continuous review of this Field Manual. Each collaborating agency will implement the interventions described in this Field Manual according to its mandate. T A B L E O F C O N T E N T S 1 2 3 4 5 6 7 9 8 a1 a2 a3 a4 Chapters Fundamental Principles 1 Minimum Initial Service Package (MISP) 11 Safe Motherhood 19 Sexual and Gender-based Violence 35 Sexually Transmitted Diseases, Including HIV/AIDS 47 Family Planning 65 Other Reproductive Health Concerns 79 Reproductive Health of Young People 89 Surveillance and Monitoring 95 Appendices Information, Education, Communication 119 Legal Considerations 127 Glossary of Terms 131 Reference Addresses 137 Fundamental Principles 1 C H A P T E R O N E Contents: n Timely Reproductive Health Interventions n The Complexity of Intervening n Guiding Principles 4 Community Participation 4 Quality of Care 4 Integrating Services 4 Information, Education and Communication 4 Advocacy for Repro- ductive Health 4 Coordinating Activities n Needs Assessment n The Structure of the Field Manual Special Notes: a This Field Manual is intended for use in refugee situations. It may also be of use in refugee-like situations, such as in situ- ations with internally displaced persons or returnee-affected areas. a The term “refugee” is used herein to de- scribe the beneficiaries of RH care, re- gardless of their legal status. a UNHCR defines an emergency as “any situation in which the life or well-being of refugees will be threatened unless imme- diate and appropriate action is taken and which demands an extraordinary re- sponse and exceptional measures.” Fundamental Principles 1 Reproductive health (RH) care should be available in all situations and be based on the needs and expressed demands of refugees, particularly women, with full respect for the various religious and ethical values and cultural backgrounds of the refugees while also conforming with universally recognised international human rights. The above principle is the cornerstone of this Field Manual and should be the basis of all RH interventions. 2 Some General Facts About Reproductive Health a 585,000 women die each year–one every minute–from pregnancy-related causes. Ninety-nine per cent of these deaths occur in developing countries. a Girls aged 15-19 are twice as likely to die from childbirth as women in their twenties. Those under 15 are five times as likely to die from childbirth. a More than 330 million new cases of sexually transmitted diseases (STDs) occur every year, affecting 1 of every 20 adolescents. a By the year 2000, up to 40 million people could be HIV-infected. a 120 million women say they do not want to become pregnant, but are not using any method of family planning. a 20 million unsafe abortions occur every year–55,000 each day– resulting in some 80,000 deaths and hundreds of thousands of disabilities. Source: WHO–World Health Day–Safe Motherhood–1998 Definition of Reproductive Health Reproductive health is a state of complete physical, mental and social well being and not merely the absence of disease and infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproduc- tive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the rights of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to ap- propriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. International Conference on Population and Development – Cairo 1994; Programme of Action, para 7.2 Timely Reproductive Health Interventions Providing adequate food, clean water, shelter, sanitation and primary health care (PHC) are priority activities in any refugee emergency. These interventions help combat the major killers in refugee situations: malnutrition, diarrhoeal diseases, measles, acute respira- tory infections (ARI) and malaria (where prevalent). However, RH care is also crucial for the physical, mental and social well being of any individual. As an integral part of PHC, RH care is important in overcoming such problems as: § complications of pregnancy and delivery, which are leading causes of death and disease among refugee women of child- bearing age; § malnutrition and epidemics, which can further diminish the physiological re- serves of pregnant or lactating women, thus endangering their health and that of their child; and § an absence of law and order, commonly seen in refugee emergencies, which, to- gether with men’s loss of power and status, leads to an increased risk of sexual violence. Violence against refu- gee women, rape, sexual abuse, involun- tary prostitution, even physical assault during pregnancy have been found to be far more widespread than was previously acknowledged. Fundamental Principles Fundamental Principles 3 C H A P T E R O N EUnquestionably, women are most affected by reproductive health problems. For refugee women, this burden is further compounded by the precariousness of their situation. The Complexity of Intervening It is important that RH interventions are not only timely but also appropriate and consist- ent with national laws and development prior- ities. RH programmes affect highly personal aspects of life, so programmes must be par- ticularly sensitive to religious and ethical val- ues and cultural backgrounds of the refugee population. It may not always be feasible for one organi- sation to implement the full range of RH serv- ices. Providing comprehensive RH services may require cooperation and coordination among agencies. The complexities of reproductive health were discussed at the Fourth World Conference on Women (Beijing 1995). Participants listed the following as some of the reasons why many of the world’s people do not benefit from repro- ductive health: “. inadequate levels of knowledge about hu- man sexuality; inappropriate or poor-quality RH information and services; the prevalence of high-risk sexual behaviour; discriminatory social practices; negative attitudes towards women and girls; and the limited power many women and girls have over their sexual and reproductive lives.” Platform of Action, paragraph 7.3–Beijing 1995 “Adolescents are particularly vulnerable,” they concluded. Refugees face even greater difficulties in ob- taining RH services. Among them: § The breakdown of pre-existing family support networks means that young men and women lose their traditional sources of information, assistance and protection. § Loss of income reduces the refugees’ ability to make free choices. § Women may become solely responsible for the welfare of their families. Fulfilling the role of breadwinner often represents a great emotional and physical burden that is not adequately compensated by appropriate services. § Attention is often focused exclusively on immediate life-saving measures; RH care is not considered a priority. (Hence the development of this Field Manual and the recommendations for the Minimum Initial Service Package–MISP–described in Chapter Two.) Guiding Principles for Intervention A successful RH programme requires ad- equate and well-trained staff, sufficient fund- ing, and effective § community participation § quality of care § integration of services § inclusion of information, education and communication (IEC) activities § advocacy for reproductive health § coordination among relief agencies. These principles are applicable to every aspect of RH assistance and to all subse- quent chapters of this Field Manual. Community Participation Community participation is essential at all stages to ensure the acceptability, appropri- ateness and sustainability of RH pro- grammes. It is necessary for empowering refugees, particularly women, to have greater control over their lives and over the services that are provided to them. 1 4 In an emergency, refugees are extremely vul- nerable. It may be easy to overlook their par- ticular needs in the urgency of providing serv- ices. Their participation is vital in ensuring that this does not happen, and that the services are adapted to the users rather than vice versa. In each situation it is necessary to identify groups and channels through which participation can be fostered. However, it is also important to recognise that the leaders may not be best placed or able to provide the information and support needed to successfully adapt RH serv- ices to the population concerned. Participation may be best achieved through the family unit. It is only by taking into account the cultural, economic, ethical, legal, linguistic and religious backgrounds of the refugees and host country population that appropriate services can be of- fered to and used by refugees. By actively par- ticipating, refugees develop the sense of “own- ership” over programmes that is essential for sustainability. It is through community participation that es- sential information will be gathered to direct the planning of services. Such information in- cludes: § identification of the training needs of care providers; § selection of appropriate sites to avoid stigmatisation of users; § analysis of the appropriate level of privacy and confidentiality required by local customs, cultures or beliefs; § decisions on whether primarily female staff must be used; and § recognition of birthing preferences. A failure to obtain such information may have a negative impact on the use of services, for example, if family members are excluded from a birth when they have an important cultural role to play at such times. It is important that both men and women be involved in many aspects of the RH pro- gramme to promote responsible and caring attitudes and behaviour for the benefit of all. Although men may be poorly informed about RH matters, they are often the decision- makers. Health providers need to be aware of the roles and decision-making process within the family so they can provide serv- ices effectively and in the best interests of the whole family. Quality of Care Quality RH services require that organisations, programmes and providers, § use appropriate technologies and have trained staff, § respect refugees’ rights to informed consent by providing adequate informa- tion and counselling, and § ensure accessible services, privacy, confidentiality, and continuity of care. These aspects of quality of care are also guid- ing principles of medical ethics in the protec- tion of human rights. Appropriate Technologies and Skills Appropriate technologies must be selected ac- cording to internationally accepted standards. Providers must be adequately trained, equipped and supervised. Appropriate sup- plies must be available, clean, and, when nec- essary, sterile. All invasive procedures must involve infection prevention, proper use of drugs, etc. All interventions must be safe– which requires a sufficiently staffed health fa- cility, technically competent providers, prop- erly functioning equipment, adequate supplies, and a responsive logistics system. Access Primary health care (PHC) services must be available within a reasonable distance from all patients. A referral network, including transpor- tation, to higher-level facilities should be cou- pled to PHC services. Patients’ access to services should not be contingent on social or cultural backgrounds nor on age, marital sta- Fundamental Principles 5 C H A P T E R O N Etus, parity, number of male children, sexual ori- entation, or partner or parental consent. Patients should not be required to accept one service in order to gain access to another type of service. Informed Consent A patient has the right to know, before any pro- cedure is performed, what the procedure in- volves as well as its expected benefits, possi- ble risks, duration of treatment, and cost to the patient or her/his family. This information must be presented to the patient in a language that s/he can understand. Informed consent means that the patient not only has choices, but also can make an edu- cated decision among various options. To make such a decision, the patient must know her/his condition and have ample opportunity to ask questions and receive answers from a knowledgeable provider. Privacy Visual and auditory privacy must be main- tained during all phases of patient care–from presentation through diagnosis, testing, treat- ment, and counselling. Examination tables should face away from doors and windows so that a woman will not risk exposure during ex- amination, particularly during pelvic examina- tion. Windows should be covered, and parti- tions placed between examination areas. Others within the health facility should not be able to overhear the interaction between the patient and health provider. Confidentiality All information regarding the patient, her/his history, treatment, condition, circumstances, and prognosis is discussed only between the patient, the provider and supervisors. No staff member should share patient information with anyone who is not directly involved in the pa- tient’s care without the patient’s permission. Medical records should be stored in a locked room or file cabinet to which only providers and supervisors have access. Medical records should never leave the clinic unless required for patient referral to another clinic. Respect All health staff should talk with patients politely and manage patient care in a compassionate and non-judgmental fashion. Patients have the right to ask questions and to expect those questions will be answered in a timely, com- plete and understandable manner. Patients need to know how to recognise and manage common complications of their condition, signs and symptoms indicating the need for addi- tional medical attention, and when and how to obtain follow-up care. Integrating Services It is important to distinguish between different aspects of integration. Reproductive health services should be integrated into primary health care. Integration may occur in relation to the place at which services are provided or the personnel who provide those services. The potential to integrate services provided at any particular site will depend on the skills and resources available. It is unreasonable to expect the community health worker to provide too wide a range of services. A health centre will have greater resources and more skilled personnel, and so greater integration at one site becomes possible. The referral-level facility must be able to provide services to meet all needs. Successful integration is dependent on the quality of communication among the various personnel, at different levels, within the overall service. All personnel must be fully aware of how the system operates, what services are provided at each level, and how those who want to use the services can do so. The staff at one level must be able to provide information about all other levels. Communication must also ensure that when referrals are made be- tween levels, adequate information is received about a patient at both ends of the service. In- formation must travel in both directions and must cover both the reasons for a referral and the eventual consequences of any action taken. 6 Good communication among levels is essen- tial to deal satisfactorily with issues relating to support, supervision and training, all of which are essential in maintaining quality. Specific training of personnel may be necessary to ensure that the designated services can be provided at each level by appropriately skilled personnel. RH services should be considered neither as optional nor as special projects. They should be integrated in a timely fashion within PHC and community service activi- ties. Even when the delivery of RH services calls for special arrangements or re- sources, this cannot justify their postpone- ment or neglect. Information, Education and Communication (IEC) Reproductive health requires knowledge and understanding about human sexuality and ap- propriate, adequate and accessible informa- tion. It is important to raise the level of knowledge about reproduction and sexuality. Women, men and adolescents should understand how their bodies work and how they can maintain good reproductive health. Scientifi- cally validated knowledge should be shared to promote free and informed choice and to counter misperceptions and harmful prac- tices. IEC activities are essential for sharing this knowledge. Such activities range from “one-to- one” conversations between service providers and refugees to highly developed formal cam- paigns. There are also effective IEC strategies that promote community participation and indi- vidual commitment to changing behaviours. IEC essentials can be found in Appendix One. Advocacy for Reproductive Health The active promotion of reproductive health should be part of all refugee assistance pro- grammes from the outset. A lack of awareness of the issues involved in protecting and pro- moting reproductive health may be found in all groups involved in a refugee setting, from the providers of health care to the community they serve. This lack of awareness may become a real barrier to improved reproductive health and responsible sexual behaviour. However, opportunities to promote RH issues may be limited. Any advocacy that is under- taken must demonstrate understanding of the culture, values and belief systems of the local population. Advocacy that is insensitive or dis- respectful may be counterproductive and prompt rejection, or even reprisals, within the refugee community. Coordinating Activities Among Relief Agencies Coordination is needed among: § sectors (health, community services, protection), § implementing agencies (government, NGOs, UN agencies), and § levels of service providers (doctors, midwives, Traditional Birth Attendants [TBAs], health assistants). To foster this coordination, it is recommended that an individual be identified as RH Coordina- tor in each refugee situation. This person would assume the responsibility for overall or- ganisation and supervision of RH activities, as well as the integration of these services within other health services. The issue of sexual violence provides an ex- cellent illustration of the need to coordinate among sectors. To deal with the causes and consequences of violence, health profession- als must work closely with staff in the protec- tion and community services sectors. By doing so, staff can develop detailed procedures on Fundamental Principles 7 C H A P T E R O N Eappropriate care for survivors and strategies to prevent the occurrence of sexual violence. Coordination among implementing agencies requires that, although each agency has its own expertise and range of qualified staff, there should be a standard approach used by all agencies involved. Even though an agency may not provide a full range of RH services, coordination with others would ensure that the end product is complementary and compre- hensive RH care. Uncoordinated activities result in inappropriate allocations of scarce resources and reduced impact of the project. Needs Assessment RH services must be based on the expressed needs and demands of refugees. RH needs assessments should be carried out when the emergency situation has stabilised. This Field Manual does not give detailed guidance on conducting needs assessment, but refers the field staff to a set of tools created by the Repro- ductive Health for Refugees (RHR) Consor- tium for this purpose. (See Further Reading) The following RH needs assessment tools have been developed by the RHR Consortium: § Refugee Leader Questions § Group Discussion Questions § Survey (for analysis by computer) § Survey (for analysis by hand) § Health Facility Questionnaire and Checklist These tools assist relief workers in gathering information to assess attitudes toward RH practices, local medical practices and policies, the scope of needed services and the degree to which current services provide what is needed. The tools, which should be adapted to each situation, are designed to be used by people with field management experience and/or RH experience to design new RH programmes, assess existing capacity and monitor services. The refugee community should be involved in the needs assessment process from the begin- ning. Refugees should participate in: § conceptualising the needs assessment framework, § site selection for the assessment, § translation/interpretation of tools, § interviewing fellow refugees, § data analysis and interpretation, § feedback to the community, § design or redesign of the RH programme based on the needs assessment findings. The Structure of the Field Manual The principles that have been developed within this introduction apply to all chapters through- out the Field Manual. Not all components of RH service provision are appropriate within the initial phases of a refu- gee situation. This Field Manual is intended to assist field staff in implementing such services in phases, moving from minimal to comprehen- sive services as the situation gradually stabi- lises. In recognition of the urgency in dealing with some RH issues, Chapter Two of this Field Manual describes in detail the components of a “Minimum Initial Service Package” (MISP). It is a range of core RH activities to be carried out from the beginning of the emergency. The activities outlined within MISP should be con- ducted alongside other initial-phase interven- tions that take place in any newly identified refugee or emergency situation. A more comprehensive package of RH inter- ventions must then be provided as the situa- tion stabilises. These interventions should be integrated into Primary Health Care serv- ices. 8 2 The remaining chapters of the Field Manual and the main goal of each are: 6 7 8 3 4 5 9 CHAPTER 2: MISP OVERALL GOAL: initiate selected RH activities as soon as feasible in an emergency CHAPTER 3: Safe Motherhood OVERALL GOAL: prevent excess maternal and peri/neonatal mortality and morbidity CHAPTER 4: Sexual and Gender-based Violence OVERALL GOAL: prevent and manage the consequences of sexual and gender-based violence CHAPTER 5: Sexually Transmitted Diseases (STDs) including HIV/AIDS OVERALL GOAL: prevent and treat STDs, reduce the transmission of HIV infection, and assist in caring for those affected CHAPTER 6: Family Planning OVERALL GOAL: enable refugees to decide freely the number and spacing of their children CHAPTER 7: Other RH Concerns OVERALL GOAL: prevent excess maternal morbidity and mortality due to the complications of spontaneous and unsafe abortions and promote the eradication of Female Genital Mutilation. CHAPTER 8: RH of Young People OVERALL GOAL: promote and support reproductive health of young people CHAPTER 9: Monitoring and Surveillance OVERALL GOAL: set objectives, measure progress and make programmatic decisions based on evidence Fundamental Principles 9 C H A P T E R O N E a1 a2 a4 a3 Each chapter of the Field Manual begins with an overall goal and provides detailed guidance on the elements of the RH component. These elements need to be adapted to each refugee situation in close collaboration with host-coun- try authorities. A checklist for establishing the particular RH component is provided at the end of each chapter. This list can also be used for supervising and monitoring. Further refer- ences can also be found at the end of each chapter. This Field Manual does not address a number of other issues related to reproductive health, either because they are relatively less signifi- cant in terms of public health, or because they may be approached as in normal situations and information on the issue is abundant else- where. This is the case for most needs of post- menopausal women, elective abortion, repro- ductive tract cancers and infertility. Further Readings “Declaration and Platform for Action”, Fourth World Conference on Women, Beijing, 1995. “Medical Ethics and Human Rights: Guiding Principles”, Commonwealth Medical Associa- tion, London, 1997. “Programme of Action”, International Confer- ence on Population and Development, Cairo, 1994. “Refugee Reproductive Health Needs Assess- ment Field Tools”, Reproductive Health for Refugees Consortium, New York, 1997. “Refugee Women and Reproductive Health Care: Reassessing Priorities”, Women’s Com- mission for Refugee Women and Children, New York, 1994. “Reproductive Health Services During Conflict and Displacement: Guidelines for the Design and Management of Reproductive Health Pro- grammes” (in preparation), WHO, Geneva, 1998. Reproductive Health One and Five Day Train- ing Packages, RHR Consortium, New York, 1998. APPENDIX One: Information, Education, Communication OVERALL GOAL: promote reproductive health of refugee populations based on the refugee population’s needs and desires APPENDIX Two: Legal Considerations OVERALL GOAL: provide information on reproductive rights APPENDIX Three: Glossary of Terms OVERALL GOAL: define important terms APPENDIX Four: Reference Addresses OVERALL GOAL: assist the reader in obtaining additional reference documents 10 Minimum Initial Service Package 11 C H A P T E R T W O Contents: n Objectives of the MISP n Components of the MISP 4 Identify an organisa- tion(s) and individual(s) to facilitate the coordination and implementation of the MISP 4 Prevent and Manage the Consequences of Sexual Violence 4 Reduce HIV Transmission 4 Prevent excess neonatal and maternal morbidity and mortality 4 Plan for the provision of comprehensive RH services, integrated into Primary Health Care, as soon as possible n Broad Terms of Reference for a RH Coordinator/Focal Point n Material Resources n Monitoring and Surveillance Minimum Initial Service Package (MISP) 2 This Chapter describes a series of actions needed to respond to the reproductive health (RH) needs of populations in the early phase of a refugee situation (which may or may not be an emergency). The Minimum Initial Service Package (MISP) can be implemented without any new needs assessment since documented evidence already justifies its use. The MISP is not just kits of equipment and supplies; it is a set of activities that must be implemented in a coordinated manner by appropriately trained staff. Special Note: a The reader must refer to the relevant chapters in the Manual to properly implement the MISP. 12 Minimum Initial Service Package (MISP) The major killers in refugee emergencies–di- arrhoea, measles, acute respiratory infections (ARI), malnutrition and malaria, where preva- lent–are well documented. Resources should not be diverted from dealing with these prob- lems. However, there are some aspects of re- productive health that also must be addressed in this initial phase to reduce mortality and morbidity, particularly among women. Please remember that the components of MISP form a minimum requirement. The ex- pectation is that the comprehensive services as outlined in the rest of this Field Manual will be provided as soon as the situation allows. Components of the MISP Identify an Organisation(s) and Individual(s) to Facilitate the Coordination and Implementation of the MISP A qualified and experienced person should be identified to coordinate RH activities at the start of the emergency response. The overall leading agency should be responsible for the designation of such a person, and the person appointed should work under the supervision of the overall Health Coordinator. RH focal points should be designated within each camp, and within each implementing agency. These health professionals, experi- enced in reproductive health, should be in post for a minimum of six months, as it is likely to take this long to establish comprehensive RH services. All relief organisations should, in accordance with their mandates, and within the framework of emergency preparedness and response, train and sensitise their staff on RH issues and gender awareness. (See Terms of Reference for the RH Coordinator at the end of this chapter.) Prevent and Manage the Consequences of Sexual Violence Sexual violence is strongly associated with situations of forced population movement. In this context, it is vital that all actors in the emergency response are aware of this issue and preventive measures are put in place. The UNHCR Guidelines for Prevention and Response to Sexual Violence against Refugees (1995) should be adhered to in the emergency response. Measures for as- sisting refugees who have experienced sexual violence, including rape, must also be established in the early phase of an emergency. Objectives of the MISP: § IDENTIFY an organisation(s) and individual(s) to facilitate the coordination and implementation of the MISP; § PREVENT and manage the consequences of sexual violence; § REDUCE HIV transmission by 4 enforcing respect for universal precautions against HIV/AIDS and 4 guaranteeing the availability of free condoms; § PREVENT excess neonatal and maternal morbidity and mortality by 4 providing clean delivery kits for use by mothers or birth attend- ants to promote clean home deliveries, 4 providing midwife delivery kits (UNICEF or equivalent) to facilitate clean and safe deliveries at the health facility, and 4 initiate the establishment of a referral system to manage obstetric emergencies; and § PLAN for the provision of compre- hensive RH services, integrated into Primary Health Care (PHC), as the situation permits Minimum Initial Service Package 13 C H A P T E R T W OWomen who have experienced sexual vio- lence should be referred to the health services as soon as possible after the incident. Protec- tion staff should also be involved in providing protection and legal support to survivors of sexual violence. Key actions to be taken during the emergency to reduce the risk of sexual violence and re- spond to survivors are: § design and locate refugee camps, in consultation with refugees, to enhance physical security § ensure the presence of female protection and health staff and interpreters § include the issues of sexual violence in the health coordination meetings § ensure refugees are informed of the availability of services for survivors of sexual violence § provide a medical response to survivors of sexual violence, including emergency contraception, as appropriate § identify individual or groups who may be particularly at risk to sexual violence (single female heads-of-households, unaccompanied minors, etc.) and address their protection and assistance needs. See Chapter Four for further information on elements of prevention and response to sexual violence. Reduce HIV Transmission Enforce Respect for Universal Precautions Against HIV/AIDS Universal precautions against the spread of HIV/AIDS within the health care setting must be emphasised during the first meeting of Health Coordinators. Under the pressure of an emergency situation, it is possible that field staff are tempted to take short cuts in proce- dures which can jeopardise the safety of pa- tients and staff. It is essential that universal precautions be respected. (See Chapter Five for details on universal precautions.) Guarantee the Availability of Free Condoms Availability of condoms should be ensured from the beginning so that they can be pro- vided to anyone who requests them. Sufficient supplies should be ordered immediately. (See Annex 3, Chapter Five, Prevention and Care of Sexually Transmitted Diseases including HIV and AIDS for calculating condom supplies.) As well as providing condoms on request, field staff should make sure that refugees are aware that condoms are available and where they can be obtained. Condoms should be made avail- able in health facilities especially when treat- ing cases of STDs. Other distribution points should be established so that those requesting condoms can obtain them in privacy. Prevent Excess Neonatal and Maternal Morbidity and Mortality Provide Clean Delivery Kits for Use by Mothers or Birth Attendants to Promote Clean Home Deliveries A refugee population will include women who are in the later stages of pregnancy, and who will therefore deliver within the initial phase. Simple delivery kits for home use should be made available for women in the late stages of pregnancy. These are very simple kits that the women, themselves, or traditional birth attend- ants (TBAs) can use. They can be made up on site and include: one sheet of plastic, two pieces of string, one clean razor blade and one bar of soap. UNFPA also supplies this kit. A formula, based upon the Crude Birth Rate (CBR), is used to calculate the supplies and services required. With a CBR of three to five per cent per year, there would be some 75-125 births in a three-month period in a population of 10,000. From this, a calculation can be made as to how many kits should be ordered. Provide Midwife Delivery Kits (UNICEF or equivalent) to Facilitate Clean and Safe Deliveries at the Health Facility In the early phase of an emergency, births will often take place outside the health facility with- 14 out the assistance of trained health personnel. Approximately 15 per cent of births will involve some complications. Complicated births should be referred to the health centre. The supplementary unit of the New Emergency Health Kit 98 (NEHK-98) has all the materials needed to ensure safe and clean normal deliv- eries. Many obstetric emergencies can be managed with the equipment, supplies and drugs contained in the NEHK-98. Obstetric complications that cannot be managed at the health centre should be stabilised before trans- fer to the referral hospital. Initiate the Establishment of a Referral System to Manage Obstetric Emergencies Approximately three to seven per cent of deliver- ies will require Caesarean section. Additional obstetric emergencies may need to be referred to a hospital that is capable of performing com- prehensive essential emergency obstetric care. (Refer to Chapters Three and Seven for informa- tion on pregnancy and delivery complications.) As soon as the situation permits, a referral sys- tem that manages obstetric complications must be available for use by the refugee population 24 hours a day. Where feasible, a host-country referral facility should be used and supported to meet the needs of refugees. If this is not feasible because of distance or the inability of the host- country facility to meet the increased demand, then an appropriate refugee-specific referral fa- cility should be provided. In either case, it will be necessary to coordinate with host-country authorities concerning the policies, procedures and practices to be followed within the referral facility. The protocols of the host country should be followed, although some variation may have to be negotiated. Be sure there is sufficient transport, qualified staff and materials to cope with the extra demands. Plan for the Provision of Comprehensive RH Services, Integrated Into Primary Health Care, as Soon as Possible It is essential to plan for the integration of RH activities into primary health care during the ini- tial phase. If not, the provision of these serv- ices may be delayed unnecessarily. When planning, it is important to include the following activities: § The collection of background information on maternal, infant and child mortality, available HIV/STD prevalence and contra- ceptive prevalence rates (CPR). This information can be obtained from the refugees’ country of origin from such sources as WHO, UNFPA, the World Bank and Demographic and Health Survey (DHS). Gathering this information could be the responsibility of the Headquarters of implementing agencies who may have ready access to these data. § The identification of suitable sites for the future delivery of comprehensive RH serv- ices (as described in the remainder of this Field Manual). It is important to address the following factors when selecting suit- able sites: 4 security both at the point of use and while moving between home and the service delivery point 4 accessibility for all potential users 4 privacy and confidentiality during consultations 4 easy access to water and sanitation facilities 4 appropriate space 4 aseptic conditions § An assessment of the capacity of staff to undertake comprehensive RH services should be made and plans put in place to train/retrain staff. Equipment and supplies for comprehensive RH services should be ordered. This will allow comprehensive services to begin as soon as the situation stabilises. Minimum Initial Service Package 15 C H A P T E R T W O Broad Terms of Reference for a RH Coordinator/ Focal Point Under the auspices of the overall health coordination framework, the RH Coordinator/Focal Point should a be the focal point for RH services and provide technical advice and assistance on reproductive health to refugees and all organisations working in health and other sectors as needed. a liaise with national and regional authorities of the host country when planning and implementing RH activities in refugee camps and among the surrounding population, where appropriate. a liaise with other sectors (protection, community services, camp management, education, etc.) to ensure a multi-sectoral approach to reproductive health. a create/adapt and introduce standardised strategies for reproductive health which are fully integrated within PHC. a initiate and coordinate various audience-specific training sessions on reproductive health (for audiences such as health workers, community services officers, the refugee population, security personnel, etc.). a introduce standardised protocols for selected areas (such as syndromic case man- agement of STDs, referral of obstetric emergencies, medical response to survivors of sexual violence, counselling and family planning services, etc.). a develop/adapt and introduce simple forms for monitoring RH activities during the emer- gency phase that can become more comprehensive once the programme is consolidated. a report regularly to the health coordination team. Material Resources New Emergency Health Kit–98 (NEHK-98) The revised NEHK-98 (for 10,000 people for three months) contains the following supplies to implement the MISP: What is in the NEHK-98 to implement the MISP § Materials for universal precautions for infection control § Equipment, supplies and drugs for deliveries at health centres § Equipment, supplies and drugs for some obstetric emergencies § Equipment, supplies and drugs for post-rape management 16 A booklet-describ- ing the NEHK-98 and how it can be ordered is available from WHO. Reproductive Health Kit A RH Kit for Emergency Situations has been developed by UNFPA, in cooperation with others, for use in refugee situations. It comple- ments the NEHK-98 and should be ordered as needed to launch the MISP and support the referral system. The RH Kit is made up of 12 sub-kits, which can be ordered separately. Materials and supplies in Subkits 3 and 6 are already available in the NEHK-98. To order RH sub-kits from UNFPA, contact the UNFPA Country Director in the country of asylum, the UNFPA Emergency Relief Office in Geneva or the UNFPA Procurement Office in New York. The RH Kit is targeted for use in the initial acute phase of the emergency. Once the situa- tion stabilises, procurement of RH materials and supplies should be done along with other health programme supply and drug ordering. A booklet describing the RH Kit and how it can be ordered is available from UNFPA. (See Appendix Four for contact addresses.) What is in the UNFPA RH Kit § For use at primary health care/health centre level: 10,000 population for three months 0 Training and Administration 1 Condoms 2 Clean delivery sets 3 Post-rape management 4 Oral and injectable contraceptives 5 STD Drugs § For use at health centre or referral level: 30,000 population for three months 6 Professional midwifery delivery kit 7 IUD insertion 8 Management of the complications 8 of unsafe abortion 9 Suture of cervical and vaginal 8 tears 10 Vacuum extraction § For use at the referral level: 150,000 population for three months 11 A – Referral-Level Surgical 11 (reusable equipment) 11 B – Referral-Level Surgical 11 (consumable items and drugs) 12 Transfusion (HIV testing for blood 11 transfusion) Minimum Initial Service Package 17 C H A P T E R T W OMonitoring and Surveillance During the early phase of the emergency, a limited amount of data should be collected to assess the implementation of the MISP. Infor- mation on mortality and morbidity by age and sex should be routinely collected during the early phase of an emergency. Refer to Chapter Nine for more information on these indicators. Consider selecting MISP indicators from the following list. MISP Indicators a Incidence of sexual violence: Monitor the number of cases of sexual violence reported to health services, protection and security officers. a Supplies for universal precautions: Monitor the availability of supplies for universal precau- tions, such as gloves, protective clothing and disposal of sharp objects. a Estimate of condom coverage: Calculate the number of con- doms available for distribution to the population. a Estimate of coverage of clean delivery kits: Calculate the number of clean delivery kits available to cover the estimated births in a given period of time. 18 Checklist for the RH MISP a Collect or estimate basic demographic information § Total population § Number of women of reproductive age § Number of men of reproductive age § Crude birth rate § Age-specific mortality rate § Sex-specific mortality rate § Number of pregnant women § Number of lactating women a Prevent and manage the consequences of sexual and gender-based violence § Systems to prevent sexual violence are in place § Health service able to manage cases of sexual violence § Staff trained (retrained) in prevention and response systems for cases of sexual violence a Prevent HIV transmission § Materials in place for adequate practice of universal precautions § Condoms procured and distributed § Health workers trained/retrained in practice of universal precautions a Prevent excess neonatal and maternal morbidity and mortality § Clean delivery kits available and distributed § UNICEF midwife kits (or equivalent) available at the health centre § Staff competency assessed and retraining undertaken § Referral system for obstetric emergencies functioning a Plan for the provision of comprehensive RH services § Basic information collected (mortality, HIV prevalence, CPR) § Sites identified for future delivery of comprehensive RH services a Identify an organisation(s) and individual(s) to facilitate the MISP § Overall RH Coordinator in place and functioning under the health coordination team § RH focal points in camps and implementing agencies in place § Staff trained and sensitised on technical, cultural, ethical, religious and legal aspects of RH and gender awareness § Materials for the implementation of the MISP available and used C H A P T E R T H R E E Safe Motherhood 19 Contents: n MISP and Safe Motherhood n Safe Motherhood in Stabilised Situations n Providing antenatal, delivery and postpartum care to the mother and immediate care of the neonate n Support for Breastfeeding n Integrating Services and Information, Education and Communication (IEC) n Human Resource Requirements n Monitoring Service Provision Also Included: n Mother-Baby Package Interventions n Checklist for Establishing Safe Motherhood Services n Prototype Home-based Maternal Record n WHO Partograph Safe Motherhood 3 Safe Motherhood programmes are designed to reduce the high numbers of deaths and illnesses resulting from complications of pregnancy and childbirth. In too many countries, maternal mortality is a leading cause of death for women of reproductive age. Most maternal deaths result from haemorrhage, complications of unsafe abortion, pregnancy-induced hypertension, sepsis and obstructed labour. Safe Motherhood programmes seek to address these direct medical causes and undertake related activities to ensure women have access to comprehensive reproductive health services. Causes of Maternal Mortality Globally a Severe bleeding 25% a Indirect causes 20% a Infection 15% a Unsafe abortions 13% a Eclampsia 12% a Obstructed labour 8% a Other direct causes 8% WHO: World Health Day–Safe Motherhood–1998 20 Safe Motherhood In this Field Manual, Safe Motherhood in- cludes antenatal care, delivery care (including skilled assistance for delivery with appropriate referral for women with obstetric complica- tions) and postnatal care, including care of the baby and breastfeeding support. Sexually transmitted disease (STD)/HIV/AIDS preven- tion and management, family planning serv- ices, and other RH concerns should be inte- grated with Safe Motherhood activities and are discussed in Chapters Five, Six and Seven, respectively. MISP and Safe Motherhood Please refer to Chapter Two for the aspects of Safe Motherhood which must be dealt with in the initial phase of a refugee situation. The activities within the MISP related to Safe Motherhood help prevent excess neonatal and maternal morbidity and mortality by: § providing clean delivery kits for use by mothers or birth attendants to promote clean home deliveries; § providing midwife delivery kits (UNICEF or equivalent) to facilitate clean and safe deliveries at the health facility; and by § initiating the establishment of a referral system to manage obstetric emergencies. The individual appointed as RH Coordinator should be responsible for all RH services in- cluding Safe Motherhood, to ensure optimum integration of all the various aspects of repro- ductive health. Safe Motherhood in Stabilised Situations As soon as feasible, comprehensive serv- ices for antenatal, delivery and postpartum care must be organised. Planning for such services should take into account existing facilities for the local population. Both refugee and local population needs should be consid- ered. Services should be able to deal with obstetric and other medical emergencies. For obstetric emergencies, it is preferable to sup- port host-country services rather than estab- lish new and refugee-specific facilities that will not be maintained in the long term. Approximately 15 per cent of pregnant women will develop complications that re- quire essential obstetric care, and up to five per cent of pregnant women will require some type of surgery. The following ratios have been found to be successful in many situations: § one health post/clinic with trained community health workers and tradi- tional birth attendants (TBAs) able to identify problems and refer for every 5,000 people; § one equipped health centre providing ba- sic essential obstetric care for every 30,000-40,000 people; § one operating theatre and staff, capable of performing 24 hour comprehensive es- sential obstetric care, for every 150,000 to 200,000 people. To make sure that the services provided are appropriate and of the highest quality and will be fully used, it is essential to: § identify skilled care providers involved in childbirth (physicians, midwives, experi- enced nurses, trained TBAs); § provide refresher training and close supervision as indicated; § be aware of and discuss community beliefs and practices and health-seeking behaviour related to delivery, such as position for delivery, presence of relatives for support and traditional practices both positive (breastfeeding) and harmful (female genital mutilation); and § ensure that all refugee women and their families know where to obtain assistance for antenatal care and delivery and how to recognise signs of complications. C H A P T E R T H R E E Safe Motherhood 21 Antenatal care The primary objective of antenatal care is to establish contact with the women, and identify and manage current and potential risks and problems. This creates the oppor- tunity for the woman and her health care pro- vider to establish a delivery plan based on her unique needs, resources and circumstances. The delivery plan identifies her intentions about where and with whom she intends to give birth and contingency plans in the event of complications (transport, place of referral, etc.). At least three antenatal visits are recom- mended, ideally with the first visit early in the pregnancy. This number may vary based on national policies. Appropriate antenatal care should include: Assessment of maternal health. This in- cludes not only determining the pregnant woman’s overall health status, but also identi- fying factors which may adversely affect preg- nancy outcome. These factors include: age (younger than 17 or older than 40), grand multipara, significantly short stature, and obstetric history of any previous complica- tions, including surgery. While this screening may help identify some women who will develop complications, it will not identify all of them. Thus it is critically important to identify and manage complications as they arise among all pregnant women. The home-based maternal record at the end of the Chapter should be adapted and used to record care provided to women during pregnancy. Female genital mutilation is a particular risk in some countries (see Chapter Seven). Women who have been subjected to this procedure, especially to infibulation, should be identified during the antenatal period. Detection and management of complica- tions. Special emphasis should be placed on identifying the acute complications of unsafe abortions or ante-partum haemorrhages. Other complications, such as hypertensive dis- eases, anaemia, diabetes, malaria or an STD, are less obvious and require more detailed physical examination. Treatment for existing health conditions should be undertaken. Syphilis testing is recommended at least once during pregnancy, preferably before the third trimester. Systematic testing for syphilis in pregnancy is cost-effective if the prevalence of syphilis is one per cent or more in the general population. Observation and recording of clinical data. Height, blood pressure, search for oedemas, proteinuria and haemoglobin (if indicated by clinical signs), uterine growth, fetal heart rate and presentation should be recorded. Maintenance of maternal nutrition. The rec- ommended minimum nutritional requirements for a pregnant woman have been set at Screening for Syphilis in Pregnancy using RPR Syphilis and other STDs contribute to the transmission of HIV, maternal morbidity and negative pregnancy outcome. In a recent study of 3,591 HIV-negative Malawi women with an active syphilis rate of 3.6 per cent, 21 per cent of perinatal deaths, 26 per cent of stillbirths, 11 per cent of neonatal deaths and 8 per cent of infant deaths were attributable to syphilis. Testing for syphilis in pregnancy can be undertaken at the antenatal clinic by using the RPR (rapid plasma reagin) test. Staff must be trained, but sophisticated laboratory equipment is not needed for routine RPR testing. Periodically, quality control of RPR testing with laboratory verification using Treponema Pallidum Haemagglutination test (TPHA) should be undertaken to ensure accuracy of RPR testing. RPR testing for syphilis in pregnancy has been successfully undertaken in refugee camps in Tanzania. Prevalence of syphilis in pregnancy using RPR ranged from 7 to 20 per cent. 22 2,300 kcal per day of a balanced and culturally acceptable diet. Supplementary food may be required if the basic food ration available or distributed to refugees is inadequate. The offer of supplemental food can be a good incentive to get women to attend for antenatal care. Health care providers should be alert to signs of iron-deficiency anaemia and iodine defi- ciency disorder (IDD). Health education. The following topics should be part of the educational activity related to antenatal care: § choosing the safest place for delivery; § clean delivery; § the major symptoms of complications (bleeding, severe abdominal pain, headache); § where and when to seek care for complications; § exclusive breastfeeding; § maternal nutrition; § STD/HIV/AIDS prevention; § immunisation; and § family planning. Prevention of major diseases. Preventive measures should include: iron folate prophy- laxis (anaemia occurs in about 60 per cent of pregnant women in developing countries); tetanus toxoid immunisation; Vitamin A sup- plements; antimalarials (according to country policies) and antihelminthics (hookworms) in endemic areas. Iodized oil/salt may be given in areas of moderate or severe IDD and following national protocols. Delivery Care This Field Manual does not contain details of how to conduct deliveries. See the Further Reading list for this information. Even with the best possible antenatal screening, any delivery can become a complicated one re- quiring emergency intervention. Therefore, skilled assistance is essential to delivery care. In the absence of midwives or nurses, TBAs (who usually perform home deliveries, often as a source of income) should be trained to identify complications, provide immediate first aid, and know when and where to refer women for addi- tional care. It should also be remembered that: § the first priority for a delivery is to be safe, atraumatic and clean; and § most maternal deaths are due to a fail- ure to get skilled help in time for delivery complications. It is critical to have a well-coordinated system to identify complications and ensure their man- agement with immediate first aid and/or refer- ral. As a rule, the further away the referral facil- ity, the earlier you intervene. Delays in obtaining help may be at the commu- nity level (in identifying and referring women with difficulties); en route to the referral facility (inability to get transport, poor road condi- tions); or on arrival at the referral facility (ab- sence of staff, lack of drugs or other materials). All three possibilities for delay must be mini- mised. Midwives and TBAs should also take care of the newborn by: clearing the airway, keeping the baby warm, providing eye and cord care, Vitamin A Supplementation in Pregnancy Where Vitamin A Deficiency is endemic among children and maternal diets are low in Vitamin A, health workers should provide: § a daily supplement not exceeding 10,000 IU vitamin A during pregnancy or § a weekly supplement not exceeding 25,000 IU Vitamin A after the first trimester. These supplements will benefit the mother and her developing fetus with little risk of harm to either § after the mother gives birth, she should receive 200,000 IU vitamin A. C H A P T E R T H R E E Safe Motherhood 23 helping mothers begin breastfeeding (and not giving any other foods or liquids to the baby), and identifying complications which require re- ferral. Birth weights should also be measured. Deliveries outside an equipped health facil- ity. TBAs or family members will often assist deliveries. Therefore, early identification of midwives or TBAs within the community, their training and supervision on the proper use of clean delivery kits (clean place, clean hands, proper cord care) and identification and man- agement of complications (when and where to refer), are essential to prevent excess mater- nal morbidity and mortality. Deliveries in equipped health centres. These health facilities, whether temporary or permanent, should be equipped with the ap- propriate human and material resources to take care of all but surgical cases. Wherever possible, national health facilities should be used and supported. The following basic es- sential obstetric care should be provided and standard protocols used to monitor and man- age labour. These include: § initial assessment, duration, use of a partograph (see Annex 2); § assessment of fetal well being; § episiotomy; § special care for women who have undergone genital mutilation (see Chapter Seven); § use of vacuum extractor; § management of haemorrhage; § management of eclampsia; § multiple birth; § breech delivery; and § procedures for referral to next level of care, if necessary. Protocols must be taught to health staff, pub- licly displayed and made available in all health centres. Basic essential obstetric care should be per- formed at the health-centre level to address, or stabilise before referral, the main complica- tions of delivery, such as ante-partum haemor- rhage, eclampsia, prolonged labour, uterine rup- ture, post-partum haemorrhage, repair of vagi- nal and cervical tears, and retained placenta. These facilities should therefore be equipped with broad spectrum injectable and oral anti- biotics (ampicillin, penicillin, doxycycline, gentamicin, metronidazole), plasma expand- ers, anti-convulsants, oxytocics, ergometrine, analgesics, magnesium sulphate, suturing kits, “high” sterilisation techniques, gloves, syringes and needles, delivery equipment, and materials for universal precautions. These facilities should also be able to provide for resuscitation and basic care of the newborn (e.g., management of hypothermia and hypoglycemia), including measurement of birth weight. A readily available prophylactic to pre- vent neonatal ophthalmia, ideally tetracycline eye ointment, should be given to all newborns. Deliveries at referral hospitals. A referral hospital in which surgical procedures can be performed may exist in some major refugee operations. However, very often, severe com- plications will be managed at the nearest major health facility of the host country. In this case, try to avoid swamping the facility with the de- mands of the refugee population to the detri- ment of the local people. Timely and appropriate support to the local health facility must be given as soon as possi- ble. The agreement and support of the Ministry of Health should be secured in order to formal- ise the integration and coordination of obstetric services between the refugee settlement and the local health facility. The referral hospital should be able to perform safely comprehensive essential obstetric care, such as Caesarean sections, laparotomy, hys- terectomy, repair of cervical and severe (third de- gree) vaginal tears, care for complications due to unsafe abortion, and safe blood transfusion. An appropriate referral system requires refer- ral protocols specifying when and where to re- fer and an adequate record of referred cases. This implies coordination, communication, 24 confidence and understanding between the TBAs and their supervisors (usually midwives) and between the health centre and the hospital with surgical facilities. An effective referral sys- tem will also have to take into account security, geographical and transport constraints. and its birth weight measured. Newborns should be referred to the under-five clinic to start immunisations, growth monitoring and other well-child services. Community Health Workers (CHW) and TBAs should be trained for appropriate referral of postpartum complications, such as haemor- rhage, sepsis, perineal trauma, breastfeeding problems, and newborn complications, such as prematurity or failure to thrive, that may re- quire additional surveillance and/or treatment. Integrating Services and IEC In the stabilisation phase, antenatal and post- natal services should be offered in an appropri- ate environment, in the same location as family planning, STD services, the “baby clinic” and any other services related to primary health care. Some situations may benefit from a “women’s house” which offers peer support, counselling and health promotion in a non-threatening environment. This resource is especially im- portant for adolescent and new mothers. Such a place might also provide a suitable venue for small-scale income-generating or female lit- eracy activities. Effective dissemination of information is vital if women are to enjoy access to available serv- ices. The community’s knowledge and atti- tudes regarding medical care during preg- nancy and childbirth must be assessed. If there is suspicion and fear of medical interven- tions, such as hospital delivery, Caesarean section or blood transfusion, appropriate IEC activities may be necessary. New procedures, such as screening blood for syphilis, should be preceded by educational activities that explain and dispel misconceptions about the proce- dures. Health workers should consider inviting a companion who will be present at the time of delivery to attend antenatal clinics with the pregnant woman. Through TBAs and/or CHWs, the refugee population, as a whole, should be made aware of the warning signs Postpartum Care Since up to 50 per cent of maternal deaths oc- curs after delivery, a midwife or a trained and supervised TBA should visit all mothers as soon as possible within the first 24-48 hours after birth. The midwife or TBA should assess the mother’s general condition and recovery after childbirth and identify any special needs. This attention is particularly important when the woman is alone as head of the family. The postpartum visit provides an occasion for assessing and discussing issues of cleanliness, care of the newborn, breastfeeding and appro- priate methods and timing of family planning (see Chapter Six). Health providers should sup- port early and exclusive breastfeeding, and dis- cuss proper nutrition with the mother. Iron folate tablets should be continued and Vitamin A and iodised oil/salt should be provided when neces- sary. During the postpartum visit, the health and well being of the newborn should also be assessed Essential Obstetric Services Basic Essential Obstetric Care § parenteral antibiotics § parenteral oxytocic drugs § parenteral sedatives for eclampsia § manual removal of placenta § manual removal of retained products Comprehensive Essential Obstetric Care § Basic Care PLUS § surgery § anaesthesia § safe blood transfusion (HIV testing) C H A P T E R T H R E E Safe Motherhood 25 of impending complications in pregnancy and labour and encouraged to plan how to reach the equipped medical facility, if neces- sary. Given that men and older family mem- bers often make the decisions within the fam- ily, it is particularly important that educational activities target these groups. Human Resource Requirements A midwife or an experienced nurse is best suited to organise and supervise the Safe Motherhood programme. A midwife can effec- tively supervise 10 to 15 TBAs for an estimated population of 20,000-30,000. In many societies, TBAs are usually the key people at the community level who will influ- ence maternal and newborn care, although their influence and skills may vary from culture to culture. In general, one TBA can look after 2,000 to 3,000 refugees. With a crude birth rate of three per cent per year, this means roughly five to eight deliveries per month per TBA. With adequate training and supervision, some experienced TBAs can: § identify complications; § refer women with delivery complications to appropriate medical facilities; § provide care for normal pregnancy through labour, delivery and the postpartum period; and § offer family planning information and services. TBAs, however, are no substitute for a more skilled attendant at birth. Bear in mind that female health care provid- ers are usually preferred to attend births. Training and supervision of health workers in Safe Motherhood practices should be evaluated and planned in coordination with the community (both refugee and host), NGOs and UN agen- cies. The nature of the training will vary depend- ing on the services the health worker provides and the skills required for those services. Monitoring Service Provision Services should be continuously reviewed. Ef- forts should be made to collect reliable infor- mation on maternal deaths. Every maternal death should be investigated to determine the cause and action taken and to ensure that the referral system is responding appropriately to obstetric emergencies. Record keeping (adapted to the literacy level of record keepers) is essential for appropriate surveillance. Home-based maternal records (see Annex 1), kept by the mother, have proven advantages. The following is a list of suggested indicators for monitoring Safe Motherhood interventions in refugee situations. Refer to Chapter Nine for further information. Safe Motherhood Indicators a Indicators to be collected from the health-facility level § Crude birth rate § Neonatal mortality rate § Stillbirth ratio § Coverage of antenatal care § Coverage of syphilis screening § Coverage of trained delivery services § Coverage of postpartum care § Incidence of obstetric complications a Indicators collected at the community level The knowledge of the community regarding safe motherhood interventions should be assessed periodically. a Indicators concerning training and quality of care Supervisors should periodically assess the skills of health care providers to ensure quality of care of Safe Motherhood interventions. 26 Support for Breastfeeding Breastfeeding is particularly important in emergency situations because of the increased risk of diarrhoea and other infections, and because the warmth and care which breastfeeding provides is crucial to both mothers and children. In these situations, it may be the only sustainable source of food for infants and young children. The well-known risks associated with bottle feeding and breast milk substitutes are dramatically increased due to poor hygiene, crowding and limited water and fuel. Since breastfeeding is also an important traditional activity for women, it can help uprooted women preserve a sense of their self-worth. For information on HIV and breastfeeding, refer to Chapter Five. Optimal Feeding Practices in Emergencies § Initiate breastfeeding within one hour of birth. § Promote colostrum as a health benefit to newborns, while being sensitive to commonly held beliefs to the contrary. § Implement the “Ten steps to successful breastfeeding” (1989 Joint WHO/UNICEF statement, protecting, promoting and supporting breastfeeding). § Encourage frequent, on-demand feeding (including night feeds). § Promote exclusive breastfeeding. On-demand breastfeeding during the first six months provides 98 per cent contraceptive protection, provided menses has not returned, and no other food is given to the baby. § Surrogate feeding/wet nursing is an alternative for an orphaned child or if the mother is disabled or absent. § Supplement breast milk with appropriate weaning foods starting at six months of age. § Encourage breastfeeding well into the second year of life or beyond. § HIV-positive mothers may need special support and counselling–see Chapter Five. § During a child’s illness, breastfeeding frequency should be increased, as it should after a child’s illness so the child can catch up on its growth. § 2,500 kcal per person per day of culturally appropriate food is recommended as a minimum requirement for lactating women. The distribution of supplementary food to lactating women may be necessary when the diet available to the refugee population is inadequate. Counteracting Common Misconceptions about Breastfeeding in Emergencies MYTH: Women under stress cannot breastfeed. a TRUTH: Women under stress CAN successfully breastfeed. Milk production is stable; but milk release (let down) can be affected by stress. The treatment for poor milk release and for low production is increased suckling and social support. The most effective support for a breastfeeding woman comes from other breastfeeding women. MYTH: Malnourished women don’t produce enough milk. a TRUTH: Malnourished women DO produce enough milk. It is extremely important to distinguish between true cases of insufficient milk production (very rare) and mis- C H A P T E R T H R E E Safe Motherhood 27 taken perceptions. Milk production remains relatively unaffected in quantity and quality except in extremely malnourished women. Malnourished women and chil- dren are best served by feeding the mother and letting her breastfeed the infant. By doing so, you protect the health of both mother and child. Giving supplements to infants decreases suckling and so can reduce milk production. The treatment for insufficient milk production–real or perceived–is to increase suckling frequency and duration, ensure the mother has sufficient food and liquids, and offer reassur- ance from other breastfeeding women. MYTH: Breast milk substitutes are needed during an emergency. a TRUTH: Usually, breast milk substitutes are NOT appropriate. There are good guide- lines on the use of breast milk substitutes and other milk products in emergencies. They include the WHO International Code of Marketing of Breast Milk Substitutes (May 1981), the UNHCR guidelines on the use of milk substitutes (July 1989), and the World Health Assembly resolution 47.5 (May 1994). Under the Code, donors must ensure that any child who receives a breast milk substitute is guaranteed a full, cost-free supply for at least six months. These guidelines include stipulations that breast milk substitutes are: § not used as a sales inducement; § used only for a limited target group of babies (i.e., for orphans in instances where wet nurses are not available); § used under controlled conditions (i.e., for therapeutic feeding; never in general distribution); and § accompanied by additional health care, diarrhoea treatment, water and fuel. In addition, the guidelines assert that feeding bottles and teats should not be provided by relief agencies except under strict supervision; and their use should otherwise be discouraged. These guidelines should be disseminated and followed by all agencies working in emergencies. MYTH: General promotion of breastfeeding is enough. a TRUTH: Breastfeeding women NEED assistance; general promotion of breast-feed- ing is NOT enough. Most health practitioners have little knowledge of breast- feeding and lactation management. Women who are displaced or are in emer- gency situations are at increased risk of breastfeeding problems. They need help, not just motivational messages. Health workers may need to be trained to give practical help to women who have difficulty breastfeeding because of incorrect positioning, cracked nipples or engorgement (see Further Reading). A mother’s fear that she “may not have enough milk” is often a cause of early termination of breastfeeding. This (mis)perception may be intensified by the stress of an emer- gency situation. Health workers should encourage optimal breastfeeding behav- iours, even if they require selective feeding of lactating women. Policies and serv- ices which undermine optimal feeding, such as giving food supplements to infants under six months and using bottles for Oral Rehydration Salts (ORS) delivery, should be avoided. 28 Checklist for Safe Motherhood Services a In Emergency Phase: § Provision of delivery kits: UNICEF midwifery kits for health centres and clean delivery kits for home use § Identification of referral system for obstetric emergencies 4 One health centre for every 30,000-40,000 people 4 One operating theatre and staff for every 150,000 to 200,000 people 4 Skilled health care providers trained and functioning (one midwife for 20,000-30,000 people, one CHW/TBA for 2,000-3,000 people) 4 Community beliefs and practices relating to delivery are known 4 Refugee women are aware of service availability a Antenatal Services are in place: § Record systems in place (clinic and home-based maternal records) § Maternal health assessment routinely conducted § Complications detected and managed § Clinical signs observed and recorded § Maternal nutrition maintained § Syphilis screening in pregnancy undertaken routinely § Educational activity related to antenatal care provision in place § Preventive medication given during antenatal services: iron folate for anaemia, Vitamin A, tetanus toxoid, others as indicated (malaria) § STD prevention and management undertaken § Materials available to implement antenatal care services a Delivery services are in place: § Protocols for managing and referring complications in place and transport system function- ing § Training and supervision of TBAs and midwives undertaken § Complications are detected and managed appropriately § Awareness of warning signs of complications in pregnancy is widespread § Standard protocols are used to manage deliveries § Medical facilities are adequately equipped § Breastfeeding is supported a Postpartum services are in place: § Educational activities undertaken (especially family planning and breastfeeding) § Complications managed appropriately § Iron folate and Vitamin A provided § Newborn weighed and referred for under-five services (e.g., EPI, growth monitoring) C H A P T E R T H R E E Safe Motherhood 29 Ja n- M ar Ap r-J un Ju l-S ep O ct -D ec Ja n- M ar Ap r-J un Ju l-S ep O ct -D ec Ja n- M ar Ap r-J un Ju l-S ep O ct -D ec Ja n- M ar Ap r-J un Ju l-S ep O ct -D ec Ja n- M ar Ap r-J un Ju l-S ep O ct -D ec Ja n- M ar Ap r-J un Ju l-S ep O ct -D ec Ja n- M ar Ap r-J un Ju l-S ep O ct -D ec Breastfeeding Menstruation Pills Injections IUD Surgical Other No methods Very thin Very pale Malaria Other problems fa m ily p la nn in g 19 19 19 19 19 1919 Da te Pr ob le m id en tif ie d He ig ht : Ag e: De at h of c hi ld d ur in g fir st w ee k: Lo w bi rth w ei gh t (l es s t ha n 2 50 0 g ): La bo ur la st in g m or e th an 2 4 ho ur s: Ex ce ss v ag in al b le ed in g af te r d el ive ry : Ab no rm al d el ive rie s: St illb irt hs : Fi ts : O ed em a: Ab or tio ns : Pr ev io us H is to ry n o n o n o n o n o n o n o n o n o ye s ye s ye s ye s ye s ye s ye s ye s ye s 1 2 3 4 0 18 -3 5 be lo w 17 ab ov e 35 le ss th an 14 5 cm Nu m be r o f d el ive rie s: N am e Ad dr es s Da te o f f irs t v isi t AN NE X 1: T h e W H O P ro to ty p e H o m e -b a s e d M a te rn a l R e c o rd * (pa rts 1, 5 an d 6 ) (5) Re m ar ks fr om re fe rr al c en tre (6) Be fo re fi rs t p re gn an cy a nd d ur in g in te rp re gn an cy p er io d (1) M ot he r’s he al th re co rd Ac tio n ta ke n/ Ad vic e 5 or m or e m or e th an 14 5 cm O th er h ea lth p ro bl em s: *S ou rc e W HO , r ep ro du ce d by p er m iss io n. Chloroquine tablets 30 Ad vic e o n p lac e o f d eliv ery : La bo ur /D el iv er y Du rat ion : Pr es en tat ion : Ty pe of de live ry: Ex ce ss va gin al ble ed ing : Te tan us to xo id: Ch lor oq uin e t ab let s: Iro n t ab let s: Fo od ad vic e: Ac tio n ta ke n W eig ht in kg : Ur ine -al bu mi n: Ha em og lob in be low 8: BP ab ov e 1 40 /90 : W ea k f eta l m ov em en t: Da te/ Mo nth : Ab no rm al pre se nta tio n: Ve ry lar ge ab do me n: Ve ry thi n: Va gin al ble ed ing ; Pit tin g o ed em a: Se ve re pa llo r n o ye s n or m al br ee ch C/ S ot he r fa ce sh ou ld er br ee ch he adn or m al pr ol on ge d ü in di ca te s do ne ( ) ho m e/ ho sp ita l 1 2 Se x: Da te of de liv ery ; Pla ce of de liv ery ; Co nd uc ted by : Nu mb er of ba bie s: Cr yin g: Bir th we igh t: Br ea thi ng di ffic ult y: Br ea stf ee din g: Co nd itio n o f b ab y: ho m e cli ni c ho sp ita l TB A AN W R el . R N /R M D oc to r m al e fe m al e sin gl e tw in o r m or e im m ed ia te de la ye d m or e th an 2 50 0 g le ss th an 2 50 0 g ye s n o n o ye s al ive st ill- bo rn di ed < 7 da ys di ed 7- 28 da ys B ab y Up to m on th LM P . . . . . . E DD . . . . . (2) P res en t p reg na nc y Ad vic e o n p lac e o f d eliv ery : La bo ur /D el iv er y Du rat ion : Pr es en tat ion : Ty pe of de live ry: Ex ce ss va gin al ble ed ing : Te tan us to xo id: Ch lor oq uin e t ab let s: Iro n t ab let s: Fo od ad vic e: Ac tio n ta ke n W eig ht in kg : Ur ine -al bu mi n: Ha em og lob in be low 8: BP ab ov e 1 40 /90 : W ea k f eta l m ov em en t: Da te/ Mo nth : Ab no rm al pre se nta tio n: Ve ry lar ge ab do me n: Ve ry thi n: Va gin al ble ed ing : Pit tin g o ed em a: Se ve r p all or: n o ye s n or m al br ee ch C/ S ot he r fa ce sh ou ld er br ee ch he adn or m al pr ol on ge d ü in di ca te s do ne ( ) ho m e/ ho sp ita l 1 2 Se x: Da te of de liv ery ; Pla ce of de liv ery ; Co nd uc ted by : Nu mb er of ba bie s: Cr yin g: Bir th we igh t: Br ea thi ng di ffic ult y: Br ea stf ee din g: Co nd itio n o f b ab y: ho m e cli ni c ho sp ita l TB A AN W R el . R N /R M D oc to r m al e fe m al e sin gl e tw in o r m or e im m ed ia te de la ye d m or e th an 2 50 0 g le ss th an 2 50 0 g ye s n o n o ye s al ive st ill- bo rn di ed < 7 da ys di ed 7- 28 da ys B ab y Up to m on th LM P . . . . . . E DD . . . . . Ad vic e o n p lac e o f d eliv ery : La bo ur /D el iv er y Du rat ion : Pr es en tat ion : Ty pe of de live ry: Ex ce ss va gin al ble ed ing : Te tan us to xo id: Ch lor oq uin e t ab let s: Iro n t ab let s: Fo od ad vic e: Ac tio n ta ke n W eig ht in kg : Ur ine -al bu mi n: Ha em og lob in be low 8: BP ab ov e 1 40 /90 : W ea k f eta l m ov em en t: Da te/ Mo nth : Ab no rm al pre se nta tio n: Ve ry lar ge ab do me n: Ve ry thi n: Va gin al ble ed ing : Pit tin g o ed em a: Se ve r p all or: n o ye s n or m al br ee ch C/ S ot he r fa ce sh ou ld er br ee ch he adn or m al pr ol on ge d ü in di ca te s do ne ( ) ho m e/ ho sp ita l 1 2 Se x: Da te of de liv ery ; Pla ce of de liv ery ; Co nd uc ted by : Nu mb er of ba bie s: Cr yin g: Bir th we igh t: Br ea thi ng di ffic ult y: Br ea stf ee din g: Co nd itio n o f b ab y: ho m e cli ni c ho sp ita l TB A AN W R el . R N /R M D oc to r m al e fe m al e sin gl e tw in o r m or e im m ed ia te de la ye d m or e th an 2 50 0 g le ss th an 2 50 0 g ye s n o n o ye s al ive st ill- bo rn di ed < 7 da ys di ed 7- 28 da ys B ab y 3 4 5 6 7 8 9 Up to m on th LM P . . . . . . E D D . . . . . 3 4 5 6 7 8 9 3 4 5 6 7 8 9 (3) P res en t p reg na nc y (4) P res en t p reg na nc y *Source: WHO, used by permission. AN NE X 1: T h e W H O P ro to ty p e H o m e -b a s e d M a te rn a l R e c o rd * (pa rts 2, 3 an d 4 ) C H A P T E R T H R E E Safe Motherhood 31 protein acetone volume Temp °C 180 170 160 150 140 130 120 110 100 90 80 70 60 Drugs given and IV fluids Oxytocin U/L drops/min 5 4 3 2 1 Contractions per 10 mins Liquor Moulding 180 170 160 150 140 130 120 110 100 Fetal heart rate Descent of head [plot 0] Hours 10 9 8 7 6 5 4 3 2 1 0 Time Date of admission hours Name Ruptured membranes Gravida Para. Hospital no. Time of admission Cervix (cm) [plot X] Latent Phase Active Phase Ale rt Ac tio n Pulse and BP {Urine 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Source: WHO, used by permission ANNEX 2: Partograph 32 Mother and Baby Package Interventions 1. Before and During Pregnancy q Information and services for family planning q STD/HIV prevention and management q Tetanus toxoid immunization1 q Antenatal registration and care q Treatment of existing conditions (for example, malaria2 and hookworm), according to country policy q Advice regarding nutrition and diet q Iron/folate supplementation q Recognition, early detection and management of complications (pre-eclampsia/eclampsia, bleeding, abortion, anaemia) 2. During Delivery q Clean and safe (atraumatic) delivery q Recognition, early detection and management of complications at health centre or hospital (for example, haemorrhage, eclampsia, prolonged/obstructed labour) 3. After Delivery: Mother q Management of complications at health centre or hospital (for example, haemorrhage, sepsis and eclampsia) q Postpartum care (promotion and support to breastfeeding and management of breast complications) q Information and services for family planning q STD/HIV prevention and management q Tetanus toxoid immunisation 4. After Delivery: Newborn q Resuscitation q Prevention and management of hypothermia q Early and exclusive breastfeeding q Prevention and management of infections including ophthalmia neonatorum and cord infections q Recording of birth weight and referral of newborn for immunisations and growth monitoring ANNEX 3 Mother and Baby Package Interventions 1. Two doses 2. Malaria prophylaxis to reduce low birth weight in endemic areas Source: WHO C H A P T E R T H R E E Safe Motherhood 33 Further Readings “Breastfeeding Counselling: A Training Course”, WHO/UNICEF, Geneva, 1993. “Care of Mother and Baby at the Health Centre: A Practical Guide”, WHO, Geneva, 1994. “Essential Elements of Obstetric Care at First Referral Level”, WHO, 1991. “HIV and Infant Feeding: Collaborative Statement by UNAIDS/UNICEF/WHO”, UNAIDS, Geneva 1997. “Joint WHO/UNICEF/UNFPA Policy State- ment on Traditional Birth Attendants”, WHO, Geneva, 1992. Klein, Susan. A Book for Midwives, The Hesperian Foundation, 1995. “Life Saving Skills Manual for Midwives”, American College of Nurse-Midwives, 3rd Edition, Washington, DC, 1997. “Mother and Baby Package”, WHO, Geneva, 1994. “Safe Vitamin A Dosage During Pregnancy and Lactation: Recommendations and a Report of a Consultation”, WHO and The Micronutrient Initiative, Geneva, 1998. 34 Sexual and Gender-based Violence 35 C H A P T E R F O U R Contents: n The Nature, Extent and Effects of Sexual Violence n Causes and Circumstances of Sexual Violence n Prevention of Sexual Violence in Refugee Situations n Responding to Sexual Violence n Special Issues n Legal Aspects n Monitoring n Checklist for Sexual Violence Programme Sexual and Gender- based Violence 4 An increase in sexual violence in insecure situations is well recognised. Displacement, uprootedness, the loss of community structures, the need to exchange sex for material goods or protection all lead to distinct forms of violence, particularly sexual violence against women. Special Notes: a This Chapter draws much of its content from “Sexual Violence Against Refugees, Guidelines on Prevention and Re- sponse”, UNHCR, Geneva, 1995. a Though the Chapter concentrates on sexual violence, the guidance given can be applied to other forms of gender- based violence. a The term “victim” is used in some portions of this Chapter as a convenient shorthand despite its negative association with pow- erlessness. The word “survivor” is also used, where appropriate, to convey the meaning that women have survived a vio- lation of their human rights and dignity. 36 Sexual and Gender- based Violence The magnitude of the problem is difficult to determine. Even in normal situations, sexual violence often goes unreported. The factors contributing to under-reporting–fear of retri- bution, shame, powerlessness, lack of sup- port, breakdown or unreliability of public services, and the dispersion of families and communities–are all exacerbated in refugee situations. In general, field staff should act on the as- sumption that sexual violence is a problem, unless they have conclusive proof that this is not the case. Preventive measures should be established, and appropriate protective, medical, psychosocial and legal responses should be organised. The refugees them- selves, especially women, should be fully involved in organising and reviewing protec- tive and preventive measures and appropri- ate responses. This chapter focuses on sexual violence against women. Most reported cases of sexual violence amongst refugees involve female victims and male perpetrators. It is acknowledged that men and young boys may also be vulnerable to sexual violence, particu- larly when they are subjected to detention and torture. Even less is known about the true inci- dence of sexual violence against men and boys than against women and girls in refugee situations. The Nature, Extent and Effects of Sexual Violence There are various forms of sexual violence. Rape, the most often cited form of sexual vio- lence, is defined in many societies as sexual intercourse with another person without his/ her consent. Rape is committed when the vic- tim’s resistance is overwhelmed by force or fear or other coercive means. However, the term sexual and gender-based violence encompasses a wide variety of abuses that includes sexual threats, exploitation, humilia- tion, assaults, molestation, domestic violence, incest, involuntary prostitution (sexual barter- ing), torture, insertion of objects into genital openings and attempted rape. Female genital mutilation and other harmful traditional prac- tices (including early marriage, which sub- stantially increases maternal morbidity and mortality) are forms of sexual and gender- based violence against women which cannot be overlooked nor justified on the grounds of tradition, culture or social conformity. Since perpetrators of sexual and gender- based violence are often motivated by a desire for power and domination, rape is com- mon in situations of armed conflict and inter- nal strife. An act of forced sexual behaviour can threaten the victim’s life. Like other forms of torture, it is often meant to hurt, control and humiliate, while violating a person’s physical and mental integrity. Perpetrators may include fellow refugees, members of other clans, villages, religious or ethnic groups, military personnel, relief work- ers and members of the host population, or family members (for example, when a parent is sexually abusing a child). The enormous pressures of refugee life, such has having to live in closed camps, can often lead to domes- tic violence. In many cases of sexual violence, the victim knows the perpetrator. Because incidents of sexual and gender- based violence are under-reported, the true scale of the problem is unknown. The World Bank estimates that less than 10 per cent of sexual violence cases in non-refugee situa- tions are reported. Two principal types of under-reporting are found in refugee situations: § under-reporting by the victims, which can lead to distorted figures that suggest there is no problem; and § an absence of figures relating to sexual violence within official statistics. (The number of recently reported rape cases in stabilised refugee settings can be found in Table 1.) Sexual and Gender-based Violence 37 C H A P T E R F O U RIt is essential to know that the problem of sexual violence is serious. Reporting and inter- viewing techniques should be adapted to encourage both victims and relief workers to report and document incidents. Reporting and follow-up must be sensitive, discreet and confi- dential so no further suffering is caused and lives are not further endangered. In reporting, it is recommended that definitions (such as confirmed rape cases or sexual vio- lence, in general) are provided and a rate cal- culated (for example, the number of reported cases per 10,000 people over a given period of time). This rate would allow for monitoring of trends and comparisons with other areas. Sexual and gender-based violence has acute physical, psychological and social conse- quences. Survivors often experience psycho- logical trauma: depression, terror, guilt, shame, loss of self-esteem. They may be rejected by spouses and families, ostracised, subjected to further exploitation or to punishment. They may also suffer from unwanted pregnancy, un- safe abortion, sexually transmitted diseases (including HIV), sexual dysfunction, trauma to the reproductive tract, and chronic infections leading to pelvic inflammatory disease and in- fertility. Causes and Circumstances of Sexual Violence Sexual and gender-based violence can occur during all phases of a refugee situation: prior to flight, during flight, while in the country of asylum, during repatriation and reintegration. Prevention and response measures must be adapted to suit the different circumstances of each phase. In conflict situations, sexual violence may be politically motivated–when, for example, mass rape is used to dominate or sexual torture is used as a method of interrogation. It may result from long-standing tensions and feuds and the collapse of traditional societal support. In situations in which the refugees are considered to be materially privileged com- pared to the local population, neighbouring groups may attack the refugees. The psychological strains of refugee life may aggravate aggressive behaviour towards women. Male disrespect towards women may be reinforced in refugee situations where unaccompanied women and girls may be regarded by camp guards and male refugees as common sexual property. 1. It is assumed that the cases reported here are confirmed rapes 2. Actual cases of rapes reported for part of the year and projected for remaining months by taking the average number of rapes per month. TABLE 1 Review of Reported Cases of Rape1 in Refugee Situations Goma-Zaire, Dadaab-Kenya and Ngara, Kibondo-Tanzania 1996 and 1998 Situation Goma Dadaab Ngara Kibondo Population 740,000 109,000 110,000 76,740 a Actual Rape Cases Reported 140 128 24 129 (Number of Months) (7) (12) (12) (12) a Adjusted Number of Rapes for 240 128 24 129 12 month period 2 a Year Reported 1996 1998 1998 1998 a Cases of Rape/10,000 population/year 3.24 11.74 2.16 17.08 38 If men are responsible for distributing goods and necessities, women may be subject to sexual exploitation. Those women without proper per- sonal documentation for collecting food rations or shelter material are especially vulnerable. Women may have to travel to remote distribu- tion points for food, water and fuel; their living quarters may be far from latrines and washing facilities; their sleeping quarters may be un- locked and unprotected. Lack of police protection and lawlessness also contribute to an increase in sexual violence. Police officers, military personnel, relief work- ers, camp administrators or other government officers may themselves be involved in acts of abuse or exploitation. If there are no independ- ent organisations, such as UNHCR or NGOs, to ensure personal security within a camp, the number of attacks often increases. Prevention of Sexual and Gender-based Violence in Refugee Situations A multi-sectoral team approach is required to prevent and respond appropriately to sexual and gender-based violence. A committee or task force should be formed to design, imple- ment and evaluate sexual violence program- ming at the field level. Refugee representa- tives, UNHCR, UN partners, NGOs and gov- ernment authorities should be members of this task force. Each member of the task force, rep- resenting relevant sectors/partners (such as protection, health, education, community serv- ices, security/police, site planning, etc.), should identify his/her role and responsibilities in preventing and responding to sexual and gender-based violence. Involvement of Refugees, Especially Refugee Women The most effective measures require that the refugee community participates in promoting a safe environment for all. Women leaders need to be involved; and women’s refugee commit- tees and groups should be established to rep- resent women’s interests and to help identify and protect those most vulnerable to sexual violence. Traditional birth attendants (TBAs) can be a valuable source of information and a channel for disseminating protection mes- sages. It is important to have at least one trained female protection officer at the site. Host countries and international relief organi- sations have a responsibility to provide the refugee community with funding, technical as- sistance and the safety measures necessary to allow the refugees to design and implement responses to the problem. Experience has shown that community-based groups, commonly called anti-rape or crisis in- tervention teams, should be established. These groups can help raise awareness of the problem, identify preventive measures and be at the forefront of providing assistance to survi- vors. Information, Education and Communication Public information campaigns on the subject of sexual violence should be launched (while re- specting cultural sensitivities). Topics could in- clude preventive measures, seeking assist- ance, laws prohibiting sexual violence, and sanctions and penalties for perpetrators. Pam- phlets, posters, newsletters, radio and other mass media programmes, videos and commu- nity entertainment can all be used to transmit information about preventing sexual violence. The refugee community and health workers must understand the importance of the prob- lem and have the confidence to report all cases of sexual violence as soon as possible. Design, Location and Practical Arrangements Refugee camps can be designed to enhance physical security. Alternatives to closed camps should always be sought. When designing and organising camp facilities, help protect refugees by: Sexual and Gender-based Violence 39 C H A P T E R F O U R§ locating latrines, water points and fuel collection areas in accessible places; § making special arrangements for housing unaccompanied women, girls and lone heads of households; § locking washing facilities; § providing adequate lighting on paths used at night; § providing security patrols; and by § avoiding shared communal living space with unrelated families. Distribution of Food, Materials for Shelter and Assistance Essential items, such as food, non-food and shelter materials, should be distributed directly to women. That way, women will not have to exchange sexual favours for these items. Women should be involved in, if not adminis- ter, the food distribution system. Protection of Detainees Women and men should not be detained to- gether unless they are family members. Appro- priate organisations must be allowed access to detainees to monitor their safety and living conditions. Social and Psychological Factors Life in refugee camps can lead to a breakdown of traditional social structures, frustration, boredom, alcohol and drug abuse, and feel- ings of powerlessness that may contribute to aggression and sexual violence. Therefore, educational, recreational and income-generat- ing activities must be promoted. Responding to Sexual Violence The response to each incident of sexual vio- lence must include protection, medical care and psychosocial treatment. Protection Immediately following an incident of sexual vio- lence, the physical safety of the survivor must be ensured. All actions must be guided by the best interests of the survivor and her wishes must be respected at all times. Wherever pos- sible, the identity of the survivor should be kept secret and all information kept locked and se- cure from outsiders. Health workers should give the survivor as much privacy as she needs and reassure her about her safety. She may want a family mem- ber or friend to accompany her throughout the procedures. She should not be pressured to talk or be left alone for long periods. If the inci- dent occurred recently, medical care may be required. The survivor should then be escorted to the appropriate medical facilities. It also may be necessary to contact the police, if the survi- vor so decides. The likely course of events and all the proce- dures that may follow should be carefully ex- plained to her to ensure informed consent and preparedness. Medical Care The key elements of a medical response to sexual violence are described below. Health care professionals must be specially trained to undertake post-sexual violence medical care. Psychosocial support should begin from the very first encounter with the survivor. A proto- col should be adopted to guide the medical and psychosocial care provided to survivors. Ensure a Same-Sex Health Worker is Present for any Medical Examination and Ensure Privacy and Confidentiality. A doctor (or qualified health worker) of the same sex should conduct the initial examination and follow-up. The survivor should be prepared for the physical examination and perhaps accom- panied (if she so wishes) by a staff member who is familiar with the proceedings, or by a family 40 member or friend. Strict confidentiality is essen- tial. Staff dealing with the survivor must be sen- sitive, discreet and compassionate. Take a Complete History and Do a Physical Examination. The survivor should not shower or bathe, uri- nate or defecate, or change clothes before the medical examination, as evidence may be destroyed. A detailed history of the attack should be docu- mented, including the nature of the penetra- tion, if any, whether ejaculation occurred, recent menstrual and contraceptive history, and the mental state of the survivor. Proce- dures for medical examination after rape should be established and follow national laws, where they exist. The results of the physical examination, the condition of clothing, any foreign material ad- hering to the body, any evidence of trauma, however minor, scratches, bite marks, tender spots, etc., and results of a pelvic examination should be documented. Health workers should collect materials that might serve as evidence, such as hair, fingernail scrapings, sperm, saliva and blood samples. Perform the Tests and Treatments as Indicated The following tests may be indicated to estab- lish pre-existing conditions: syphilis blood test, pregnancy test and HIV test. Treatment for common sexually transmitted diseases (STDs), such as syphilis, gonorrhoea and chlamydia, may be indicated. A tetanus vaccination should be considered. Provide Emergency Contraception, if Appropriate, Along with Comprehensive Counselling. 1. Emergency contraceptive pills (ECPs) can prevent unwanted pregnancies if used within 72 hours of the rape. As described by WHO “emergency contra- ceptive pills (ECPs) work by interrupting a woman’s reproductive cycle–by delaying or inhibiting ovulation, blocking fertilisation or preventing implantation of the ovum. ECPs do not interrupt pregnancy and thus are not considered a method of abortion.” WHO acknowledges that this description does not command consensus and that some believe that ECPs are abortifa- cients. Women and health workers hold- ing such belief may be precluded from using this treatment and women who request this service need to be offered counselling so as to reach an informed decision. ECPs should not be seen as a substitute for regular use of contraceptive methods. Women should be counselled concerning their future contraceptive needs and choices. See Annex 1 for details on using ECPs. 2. Copper-bearing IUDs can be used as a method of emergency contraception. They may be appropriate for some women who wish to retain the IUD for long-term contra- ception and who meet the strict screening requirements for regular IUD use. When in- serted within five days, an IUD is an effec- tive method of emergency contraception. However, IUD insertion requires a much higher degree of training and clinical supervision than ECPs. Clients must be screened to eliminate those who are pregnant, have reproductive tract infections, or are at risk of STDs, includ- ing HIV/AIDS. As for ECPs, some women and health workers may be precluded from using this treatment and women who request this service need to be offered counselling so as to reach an informed decision. Provide Follow-up Medical Care A woman should be counselled to return for fol- low-up examinations one to two weeks after receiving initial medical care. Health care pro- viders should monitor her follow-up care. Fur- Sexual and Gender-based Violence 41 C H A P T E R F O U Rther tests and treatment, such as testing for or treatment of STDs or referral to other RH serv- ices, may be indicated during follow-up. Fur- ther visits may also be required for pregnancy and HIV testing. Psychosocial Care Survivors of sexual violence commonly feel fear, guilt, shame and anger. They may adopt strong defense mechanisms that include for- getting, denial and deep repression of the events. Reactions vary from minor depres- sion, grief, anxiety, phobia, and somatic prob- lems to serious and chronic mental condi- tions. Extreme reactions to sexual violence may result in suicide or, in the case of preg- nancy, physical abandonment or elimination of the child. Children and youth are especially vulnerable to trauma. Health care providers, relief workers and protection officers should devote special attention to their psychosocial needs. Survivors should be treated with empathy, care and support. In the long term, and in most cultural settings, the support of family and friends is likely to be the most important factor in overcoming the trauma of sexual violence. Community-based activities are most effective in helping to relieve trauma. Such activities may include: § identifying and training traditional, community-based support workers, § developing women’s support groups or support groups specifically designed for survivors of sexual violence and their families, and § creating special drop-in centres for survivors where they can receive confidential and compassionate care. See Further Readings. These activities must be culturally appropri- ate and must be developed in close coopera- tion with community members. They will need on-going financial and logistical sup- port and, where appropriate, training and su- pervision. Quality counselling by trained workers, such as counsellors, nurses, social workers, psy- chologists or psychiatrists–preferably from the same background as the survivor–should also be provided as soon after the attack as possi- ble. Reassurance, kindness and total confi- dentiality are vital elements of counselling. Counsellors should also offer support if the survivor experiences any post-traumatic dis- turbances, if she has difficulty dealing with family and community reactions, and as she goes through any legal procedures. The objectives of counselling are to help survivors: § understand what they have experienced, § overcome guilt, § express their anger, § realise they are not responsible for the attack, § know that they are not alone, and § access support networks and services. Special Issues Sexual Violence in Domestic Situations Caution should be exercised before interven- ing in domestic situations because the survi- vor and/or other relatives could be subjected to further harm. If the survivor has to return to the abuser, retaliation may follow, espe- cially if the abuser learns that the matter has been reported. Each situation needs to be in- dividually assessed in close cooperation with colleagues to determine the most appropri- ate response. Health care providers may choose to refer the matter to a disciplinary committee, inform the authorities, or provide discreet advice to the survivor about her options. 42 Children Born as a Result of Rape These children may be mistreated or even abandoned by their mothers and families. They must be closely monitored and support should be offered to the mother. It is important to ensure that the family and the community do not stigmatise either the child or the mother. Foster placement and, later, adoption should be considered if the child is rejected, neglected or otherwise mistreated. Legal Aspects The government on whose territory the sexual attack occurred is responsible for taking reme- dial measures, including conducting a thor- ough investigation into the crime, identifying and prosecuting those responsible and pro- tecting survivors from reprisal. In all cases, the wishes of the survivor should be respected when pursuing the legal aspects of the case. Confidentiality must be ensured. All agencies should advocate the enactment and/or enforcement of national laws against sexual violence in accordance with interna- tional legal obligations. These should include prosecution of offenders and the implementa- tion of legal measures to protect the survivor. The local UNHCR Protection Officer must be familiar with the national criminal and civil law on the subject of rape and sexual violence be- fore an incident occurs so he/she will know what procedural steps should be taken and what advice should be given to survivors. (See Appendix Two.) Sexual Violence Indicators a Indicators to be collected from the health-facility level § Incidence of sexual violence (reported cases/10,000 population) § Coverage of services for survivors § Timely care for survivors a Indicators that might be measured annually § Prosecution of sexual violence offenders § Coverage of health-worker training that serves survivors of sexual violence (Refer to Chapter Nine–Monitoring and Surveillance.) Monitoring Monitoring cases of sexual violence should be a routine task of health care providers, protec- tion officers and others, as appropriate. In addi- tion, there should be regular assessments of the providers’ ability to offer comprehensive medical and psychosocial care for rape survi- vors. Ideally, care should be given as soon af- ter a rape as possible. Sexual and Gender-based Violence 43 C H A P T E R F O U R Emergency Contraceptive Pill Regimens aWhen pills specially packed for emergency contraception are available as supplied in the New Emergency Health Kit 98, or when high-dose pills containing 0.5 mg ethinylestradiol and 0.25 mg of levonorgestrel are available: 4 two pills should be taken as the first dose as soon as convenient but no later than 72 hours after the rape. These should be followed by two more pills 12 hours later. aWhen only low-dose pills containing 0.3 mg ethinylestradiol and 0.15 mg of levonorgestrel are available: 4 four pills should be taken as the first dose as soon as convenient but no later than 72 hours after the rape. These should be followed by four more pills 12 hours later. a Emerging data indicate that alternative hormonal regimes consisting of levonorgestrel-only pills are equally effective and have significantly fewer side effects. When pills containing 0.75 mg levonorgestrel are available: 4 one pill should be taken as the first dose as soon as convenient but no later than 72 hours after the rape. This should be followed by another pill 12 hours later. Managing Side Effects Nausea occurs in about 50 per cent of clients using combined ECPs and 25 per cent for those using levonorgestrel only. Taking the pills with food may reduce nausea. Routine prophylactic use of anti-emetics is not recom- mended in settings with limited resources. If vomiting occurs within two hours of taking ECPs, repeat the dose. Contraindications There are no known medical contraindications to the use of ECPs. The dose of hormones used in ECPs is relatively small and the pills are used for a short time. Contraindications associated with continuous use of hormonal contraceptives do not apply. ECPs should not be given if there is a confirmed pregnancy. ECPs may be given when pregnancy status is unclear and pregnancy testing is not available, as there is no evidence of harm to the woman or to an existing pregnancy. ANNEX 1 Emergency Contraceptive Pill Regimens 44 Key Interventions–Preventing Sexual Violence a Ensure proper documentation for women a Increase availability of female protection officers and interpreters and ensure that all officers have knowledge of UNHCR Protection Guidelines and UN Security Guidelines for Women a Facilitate the use of existing women’s groups or promote the formation of women’s groups to discuss and respond to issues of sexual violence a Improve camp design for increased security for women a Include women in camp decision-making processes, especially in the areas of health, sanitation, reproductive health, food distribution, camp design/location a Distribute essential items such as food, water and fuel directly to women a Train people at all levels (NGO, government, refugee, etc.), to prevent, identify and respond to acts of sexual violence. Key Interventions–Responding to Sexual Violence a Develop/adapt protocols and guidelines that would limit further traumas to survivors of sexual violence a Engage socially and culturally appropriate support personnel as a first contact with people who have been subjected to sexual violence a Provide prompt and culturally appropriate psychosocial support for survivors and their families a Provide medical follow-up immediately after an attack that also addresses STDs, HIV infection and unwanted pregnancy a Establish closer links among protection officers, women’s groups, TBAs and community leaders to discuss issues related to the attacks a Document cases while respecting survivors’ wishes and confidentiality. Checklist for Sexual Violence Programme Sexual and Gender-based Violence 45 C H A P T E R F O U R Adapted from Ngara, Tanzania–HOW TO GUIDE on Crisis Intervention Teams * Code numbers should be used rather than names to ensure confidentiality. Sexual Violence Incident Report Form Camp: Reporting Officer: Date: 1) Affected Person: Code(*): Date of Birth: Sex: Address: Civil Status: If a Minor: Code/Name of Parents/Guardian: 2) Report of Incident: Place: Date: Time: Description of Incident: (Specify type of sexual violence) Persons Involved: 3) Actions Taken: Medical Examination Done: q Yes q No By Whom: Major Findings and Treatments Given: Protection Staff Notified: q Yes q No If no, reasons given: If yes, actions taken: Psychosocial Counselling given: q Yes q No By whom and actions taken 4) Proposed Next Steps 5) Follow-up Plan 5) q Medical Follow-up 5) q Psychosocial Counselling 5) q Legal Proceedings CONFIDENTIAL 46 Further Readings “Emergency Contraception: A Guide for Service Delivery”, WHO, Geneva, 1998. “Emergency Contraception Pills: A Resource Packet for Health Care Providers and Programme Managers”, Consortium for Emergency Contraception, New York, 1997. Heise, Lori L. “Violence Against Women: The Hidden Health Burden”, World Bank Discus- sion Papers, No. 255, The World Bank, Washington, DC, 1994. “How To Guide: Community-based Response to Sexual Violence: Crisis Intervention Teams - Ngara, Tanzania”, UNHCR, Geneva, 1997. “How To Guide: Developing a Team Ap- proach to Prevention and Response to Sexual Violence - Kigoma, Tanzania”, UNHCR, Geneva, 1998. “Mental Health for Refugees”, WHO/UNHCR, Geneva, 1994. “Security Guidelines for Women”, United Nations Security Coordination Office, United Nations, New York, 1995. “Sexual Violence against Refugees: Guide- lines on Prevention and Response”, UNHCR, Geneva, 1995. Sexually Transmitted Diseases, Including HIV/AIDS 47 C H A P T E R F I V E Sexually Transmitted Diseases, Including HIV/AIDS 5 The objectives of any activity in the area of sexually transmitted diseases (STDs), including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), should be to prevent and treat STDs, reduce the transmission of HIV/STD infections, and help care for those affected by AIDS. Contents: n Introduction n Establishing STD/HIV/ AIDS Programmes n Monitoring Also Included: n HIV Testing in Refugee Situations n Mother-to-Child Trans- mission and HIV and Infant Feeding n Formula for Calculating Condom Requirements n STD Treatment Based on Syndromic Case- Management Approach n Flow Chart on Suspected Symptomatic HIV Infections n Essential Drugs for Management of Opportunistic Infections for HIV/AIDS n Alternative Drugs for Treatment of STDs Based on Sensitivity Studies n Estimating Drug Requirements and Costs for Treatment of STDs 48 Sexually Transmitted Diseases, Including HIV/AIDS Introduction STDs, including HIV/AIDS, spread fastest where there is poverty, powerlessness and social instability. The disintegration of com- munity and family life in refugee situations leads to the break-up of stable relationships and the disruption of social norms governing sexual behaviour. Women and children are frequently coerced into having sex to obtain basic needs, such as shelter, security, food and money. In a refugee situation, popu- lations that have different rates of HIV/AIDS prior to becoming refugees may be mixed. Also many refugee situations are like large urban settings and may create conditions that increase the risk of HIV transmission. STDs, which are a major public health prob- lem in most parts of the world, were largely neglected until the appearance of HIV/AIDS. Now, more attention is focused on conven- tional STDs (such as gonorrhoea, syphilis, chlamydia, etc.). They are among the most common, although undiagnosed, causes of ill- ness in the world; and they have far-reaching health, social and economic consequences. STDs substantially increase the risk of HIV in- fection. Preventing and controlling STDs are key strategies in controlling the spread of HIV/ AIDS. The vast majority of HIV infections are sexu- ally transmitted. Between five and ten per cent of HIV infections world-wide are esti- mated to be transmitted through infected blood and blood products, though this per- centage is decreasing as blood for transfu- sions is more regularly tested for HIV. In refu- gee situations, it is essential to ensure that all blood for transfusion is tested and that uni- versal precautions are enforced. Mother-to-child transmission of HIV (MTCT), also called “vertical transmission”, is the most common mode of HIV transmission in chil- dren. More than 90 per cent of HIV-infected infants acquire their HIV infection from their mothers during pregnancy, delivery or during breastfeeding. When there is no intervention, the risk of MTCT ranges from 15 to 25 per cent in industrialised countries and from 25 to 45 per cent in developing countries. Trans- mission is affected by a number of factors, not all of which have been fully examined. These factors include: § high viral-load level in the mother’s blood, § in cervio-vaginal secretions and, in breast milk, decreased maternal immune status, § prolonged rupture of membranes (greater than four hours), § the mode of delivery, and § intra-partum haemorrhage. Studies show an additional 7 to 22 per cent risk of HIV transmission through breast- feeding. Late postnatal transmission after six months of age has been described in a number of studies. (See Annex 2 on MTCT and HIV and Infant Feeding.) Interaction between refugee and local populations is likely to occur. It is therefore vital to liaise with host countries to ensure that comparable services are provided to lo- cal populations. Failure to do so would not only be counterproductive in the effort to pre- vent the spread of STDs and HIV, it could also result in conflict between the two populations. Mandatory HIV testing of refugees is some- times requested in the mistaken belief that this will help prevent HIV transmission. Under no circumstances should mandatory testing be pursued. Mandatory testing for HIV repre- sents a violation of human rights and has no public health justification. (See Annex 1 on HIV testing in refugee situations.) Sexually Transmitted Diseases, Including HIV/AIDS 49 C H A P T E R F I V EEstablishing STD/HIV/AIDS Programmes As described in Chapter Two (Minimum Initial Service Package [MISP]), three activities should be conducted prior to any assessment in any new refugee situation (including an emergency): § Guarantee availability of free condoms § Enforce universal precautions against HIV/AIDS transmission in health-care settings § Identify a person who will coordinate RH activities. Comprehensive prevention, treatment and care services for STDs, including HIV/AIDS, should be made available to refugees at the earliest opportunity. By taking the following steps, you will ensure that the services you provide are effective. Assessment Conduct a situation analysis as soon as possi- ble to help plan an appropriate and compre- hensive prevention and treatment service. The following information should be collected: § the prevalence of STDs and HIV in the host and home country, region or area (this information is available from the national AIDS programmes, UNAIDS and WHO); § the location of specific risk areas within the refugee community (for example, where sexual services are bought and sold, high alcohol-consumption areas, bars), to be tar- geted as priorities for specific activities; and § the cultural and religious beliefs, attitudes, and practices concerning sexuality, repro- ductive health, STDs and AIDS. This infor- mation can be obtained through qualita- tive research using focus groups, inter- views and, if possible, KABP (Knowledge, Attitudes, Behaviour and Practices) sur- veys. It will also be necessary to: § liaise with local health authorities to define a management protocol for STDs; and § identify people in the refugee community who have been trained in HIV/STD prevention. Implementation The situation analysis will indicate what STD and HIV/AIDS interventions are required and what is feasible. The following should be included as basic elements of response to every refugee situation: universal precautions in health-care settings, safe blood transfusion, access to condoms, access to STD care, infor- mation, education and communication (IEC) activities, and comprehensive care for people with HIV/AIDS. Universal Precautions in Health-Care Settings Universal precautions are part of the MISP (Chapter Two) and are essential to prevent the transmission of HIV from patient to patient, health worker to patient and patient to health worker. Because people working under pres- sure are more likely to have work-related acci- dents and to cut corners in sterilisation tech- niques, infection-control measures adopted during crises must be practical to implement and enforce. The guiding principle for the control of infection by HIV and other diseases which may be trans- mitted through blood, blood products and body fluids is that all should be assumed to be po- tentially infectious. The minimum requirements for infection con- trol are as follows: § Facilities for frequent hand washing. Hands should be washed with soap and water, especially after contact with body fluids or wounds. § Availability of gloves for all procedures involving contact with blood or other po- 50 tentially infected body fluids. Gloves should be discarded after each patient, or else washed or sterilised before re-use. Heavy-duty gloves should be worn when materials and sharp objects are taken for disposal. § Availability of protective clothing, such as waterproof gowns or aprons. Masks and eye shields should be worn where there is a possibility of exposure to large amounts of blood. § Safe handling of sharp objects. Punc- ture-resistant containers for sharps dis- posal must be readily available, close at hand and out of the reach of children. Sharp objects should never be thrown into ordinary waste bins or bags. § Disposal of waste materials. People, particularly small children, struggling to survive will scavenge. It is therefore vital to make waste disposal safe. All medical waste materials should be burnt. Those items that still pose a threat, such as sharp objects, should be buried in a deep pit at least 10 metres from a water source. Medical waste should not be disposed of in communal dumps. § Cleaning, disinfecting and sterilising. Pressure-steam sterilisers are recom- mended for cleaning medical instruments between use on different patients. If sterili- sation is not available, or for instruments that are heat sensitive, instruments must be cleaned and high-level disinfected (HLD). HIV can be inactivated by boiling for 20 minutes or by soaking in chemical solutions including a five per cent solution of chlorine bleach for 20 minutes or in a two per cent glutaraldehyde solution for 20 minutes. § Proper handling of corpses. It is advis- able for relief workers to wear gloves and cover any wounds on hands or arms when handling corpses. The relief worker should wash thoroughly with soap and water afterwards. Special caution should be taken with body fluids as they may be potentially infectious. § Treating injuries at work. In cases of injury with a sharp instrument, the wound should be washed thoroughly with soap and water. Splashes of blood or other body fluid into the mouth or eyes should be rinsed thoroughly with water or saline respectively. Further procedures to be followed after an accidental exposure to blood have been developed by Médecins Sans Frontières (MSF). Prophylactic treat- ment against HIV transmission, known as Post Exposure Therapy (PET), may be warranted. Guidelines containing information about poten- tial risks in the environment, how to protect against those risks, and what to do in case of accidents such as needle-stick injuries, cuts or blood splattering should be developed and dis- tributed to field workers. It is equally important to provide clear information about what does not constitute a risk. The guidelines should indicate when it is appropriate to use protective clothing and why. Health workers should also be given guidance on how to avoid unneces- sary injections and other procedures involving sharp instruments. Access to Condoms If consistently and correctly used, condoms offer effective protection against STDs, includ- ing the sexual transmission of HIV. Since many refugees have already been exposed to this message, there may be a demand for con- doms in the early phases of a refugee situa- tion. Condoms are contained in the MISP (See Chapter Two) and should be made freely avail- able for those who seek them. Take every op- portunity to raise awareness and promote con- doms as a method of protection against STDs, including HIV infection. The female condom is not yet widely known; but, if available, it should be used as an additional method of protection. Procurement of good-quality condoms: There are many brands of condoms on the market. If an agency does not have experience in procuring condoms, it may be desirable to contact UNAIDS, UNFPA, UNHCR or WHO to facilitate the purchase of bulk quantities of Sexually Transmitted Diseases, Including HIV/AIDS 51 C H A P T E R F I V Egood-quality condoms at low cost. Annex 3 shows how to calculate the number of con- doms required. Good-quality condoms are es- sential for the protection of the consumer and the credibility of the relief programme. Condom distribution: To ensure ongoing access in refugee situations, a system of distri- bution must be in place. The system should include the following: § Condoms and instructions for their use should be available on request in health facilities (especially where STDs are treated) and distribution centres (such as food and non-food item distribution areas). Staff should be trained in the pro- motion, distribution and use of condoms. § Promotional campaigns should be launched at football matches, mass ral- lies, dance parties, theatres, group dis- cussions, etc., to promote the use of con- doms and inform the public on how and where to obtain them. § Contacts between the refugee and local populations are likely to occur. Therefore, condoms must also be made available to the wider host community. This requires liaison with groups involved in AIDS pre- vention and family-planning activities in the area. § Once the situation has stabilised, health workers must decide whether or not to continue free distribution of condoms. The introduction of some form of partial cost- recovery (social marketing) may be con- sidered in situations where this is feasible and appropriate. When possible, the con- dom-distribution network can be extended to community agents, shops, bars, youth and women’s groups, etc. Social market- ing strategies in the host country or in the country of origin could be extended into the refugee situation. Safe Blood Transfusion Blood transfusions must not be done if the fa- cilities for safe transfusion, including screening for HIV testing, do not exist. Safe blood trans- fusion can be organised within the refugee set- tlement in major operations or should be arranged with local health facilities following appropriate discussions with the Ministry of Health. Should local health facilities be used, support to these structures must be assured by the refugee programme. The likehood of becoming infected with HIV through transfusion of infected blood is well over 90 per cent. Measures to ensure the safety of blood transfusion in refugee situa- tions are extremely important. The main recommendations for preventing HIV infection and other blood-borne diseases through blood transfusion are to: § Transfuse only previously tested blood and only when clinically necessary. § Use blood substitutes, such as simple crystalloid (physiological saline solution for intravenous administration) and col- loids whenever possible. § Collect blood from donors identified as being least likely to transmit infectious agents in their blood. Selection of safe do- nors can be promoted by giving clear in- formation to potential donors on when it is appropriate or inappropriate to give blood and by using a blood-donor questionnaire. Voluntary, non-remunerated blood donors are safer sources than paid donors. Per- sonal information given by the donor must be treated as strictly confidential. § Provide reagents to perform HIV testing of donated blood. Screening for HIV and other infectious agents should be carried out using the most appropriate assays. § Develop clear policies and protocols/ guidelines concerning the appropriate use of blood for transfusion, the recruitment and care of donors and the safe disposal of waste products, such as blood bags, needles and syringes. § Appoint an experienced person to be re- sponsible for refugee-specific blood trans- fusion services. 52 Access to STD Care Because the risk of HIV transmission is greatly increased in the presence of other STDs, early establishment and integration of STD services within general health care services is a priority. STDs and their complications, such as infertil- ity and congenital syphilis, are a major cause of ill health and are usually grossly under-re- ported. The prevention of STDs involves the promotion of safer sex as well as early and ef- fective case finding, advise on notification of partners and case management. STD services should be user-friendly, private and confidential. Special arrangements may be necessary to ensure that women and young people feel comfortable using these services. In many societies, women will not seek treat- ment if the health professionals at the clinic are all male, particularly if a physical examination is required. In these situations, female health workers should provide services for women. Appropriate and effective case management involves the following: § training health care providers § providing guidelines for case manage- ment, including case definition and management protocol § consistent availability of appropriate drugs § consistent supply of condoms § monitoring § identifying secondary or informal providers of STD care Training health care providers. Health care providers, including volunteer workers, should receive training in prevention of STD/HIV/ AIDS, be provided with information materials and serve as channels for the distribution of condoms. Professional health workers should be trained in the syndromic approach to STD management. Health worker training should include the following topics: § syndrome recognition and diagnosis § effective treatment based on observed syndromes § importance of confidentiality § education for prevention/counselling focused on specific population groups § condom promotion and provision § partner notification and management § monitoring STD Case Management. Treatment of symptomatic cases should be standardised on the basis of syndromes and not depend- ent on laboratory analysis. A treatment pro- tocol (consistent with national protocols) based on syndromic case management should be prepared and adopted. (See examples in Annexes 4 and 5.) The most ef- fective drugs should be used at the first en- counter. Initial drug requirements should be based on available data from the country of origin or esti- mated as indicated in Annex 8. Monitoring ac- tivities will then serve to review real needs. If IEC efforts are effective, if services are user- friendly and people from outside the camp are attending the health facilities, the need for drugs may increase rapidly. Partners of patients with an STD are likely to be infected themselves and should be treated. Each patient should be provided with contact slip(s) to be given to his/her sexual partner(s). On the basis of these slips, partners should have access to the same treatment as the pa- tient who presented first. The process should be confidential, voluntary and non-coercive and include all sexual partners of each STD patient. Applying a syndromic approach to STD case management allows effective care for symp- tomatic cases without the need for laboratory support. The exception to this is systematic testing for syphilis in pregnant women. This type of testing is cost effective even in sites where the prevalence of syphillis in the gen- eral population is as low as one per cent. Sexually Transmitted Diseases, Including HIV/AIDS 53 C H A P T E R F I V EInformation, Education and Communication (IEC) Information, education and communication activities are central to a successful HIV/ AIDS and STD strategy in all situations. IEC includes a variety of activities at different lev- els, from intensive person-to-person educa- tion to mass dissemination of information. (For further information on IEC, refer to Ap- pendix One.) Comprehensive Care for People with HIV/AIDS Comprehensive care for people with HIV-re- lated illnesses should be seen as a component of basic care in any refugee situation. This is especially important when refugees come from an area where HIV-related illnesses are a major cause of morbidity and mortality. (The WHO flow chart for suspected symptomatic HIV infection for the purpose of clinical man- agement is provided in Annex 6.) The elements of comprehensive care include: § clinical management, involving early di- agnosis of HIV-related illnesses, rational treatment and planning for follow-up care; § supportive care to promote and maintain hygiene and nutrition; § education of individuals and families on HIV prevention and care; § counselling to help individuals make informed decisions on HIV testing, reduce stress and anxiety and promote safer sex; and § social support, including information and referral to support groups, welfare serv- ices and legal advice. § A home-based care system, to which people with advanced HIV infection/AIDS- related illnesses can be discharged from inpatient care, should be established early in refugee situations. The introduction of comprehensive care for HIV/AIDS in refugee situations involves: § sensitising health workers to HIV-related illnesses and AIDS; § developing a policy on the role of volun- tary and confidential HIV tests (with related pre- and post-test counselling) for clinical diagnosis (see Annex 1). If host countries offer voluntary counselling and testing services to the local population, ini- tiate discussions to determine the possi- bility of extending these services to refu- gee populations; § adapting existing clinical and nursing guidelines for case management of HIV- related illnesses in primary and secondary care in refugee settings. This should include guidelines on discharge and refer- ral of people with HIV-related problems, either for more sophisticated care or to home-based care; § drawing up an essential drug list for care of HIV-related illnesses and establishing mechanisms to ensure the procurement and supply of these drugs; § training health care workers in the use of the clinical guidelines; § introducing counselling training for health and lay workers and developing guide- lines for counselling. This can be inte- grated into counselling for other problems related to the refugee situation. It will be helpful if staff involved in this activity are not subject to frequent rotation; § including those people living with HIV/ AIDS in training programmes; § ensuring that HIV-related care is fully inte- grated into basic curative services and that prevention components (such as sup- ply of condoms) and STD treatment are provided; § developing community support for AIDS care by: – exploring community potential for stigma and discrimination; – exploring community capacities and commitment; 54 – encouraging the development and training of self-help and other community-based support groups; and – starting community-based care and support activities, using the self-help groups that have been established. Monitoring Data on the number of STD and HIV/AIDS cases presenting for treatment or detected in health services are essential for planning serv- ices and as indicators of trends in STD preva- lence in the community. Always suspect un- der-reporting of STDs and HIV/AIDS. Manag- ers of health care programmes may want to check for the presence of informal networks of treatment for STDs, such as in local markets. The following is a list of suggested indicators for monitoring and evaluating HIV/AIDS and STD interventions in refugee situations: STD/HIV/AIDS Indicators a Indicators to be collected from the health-facility level § percentage of blood screened for HIV before transfusion and per cent found positive for HIV § incidence of STDs § practice of universal precautions a Indicators collected at the community level § outlets for condoms distribution § knowledge of correct condom use § condom use a Indicators concerning training and quality of care § training of health workers in syndromic case management § quality of STD case management (Refer to Chapter Nine–Surveillance and Monitoring.) Sexually Transmitted Diseases, Including HIV/AIDS 55 C H A P T E R F I V E Checklist for STD/HIV/AIDS Programmes From MISP q Guarantee availability of free condoms q Enforce universal precautions aHIV/STD/AIDS situational analysis is undertaken aTrained people from refugee community are identified aInformation, education and communication programmes are in place aUniversal precautions in health settings are practiced aFree good-quality condoms are regularly available and accessible aSystem of condom distribution is in place aSafe blood transfusion services are in place, guidelines disseminated, HIV test kits available, staff trained aManagement protocols for STDs are defined and disseminated aDrugs for STD treatment are on hand aStaff are trained/retrained on syndromic case management aSystem for partner notification and treatment are instituted aVoluntary counselling and testing (VCT) services are in place (as appropriate) aHome-based care for people with AIDS is in place aCounselling and support services for people with HIV/AIDS are in place 56 HIV Testing in Refugee Situations Available resources for HIV testing should be devoted, first and foremost, to ensuring a safe blood supply for transfusions. A voluntary HIV testing and counselling (VCT) programme is a lower priority in a refugee situation but should not be ruled out if resources are available and if these services are available in the host country or were available in the country of origin. HIV testing to diagnose HIV-related illness may be indicated, but only if two conditions are met: § consent, pre- and post-test counselling and confidentiality can be assured; and § a confirmatory testing procedure is undertaken as outlined in UNAIDS Policy on HIV Testing and Counselling. People known to be HIV infected or to have AIDS should remain within their communities or within the refugee settlements, where they should have equal access to all available care and support. UNAIDS/WHO Position on Mandatory HIV Testing in Refugee Situations Mandatory HIV testing in refugee circumstances, with the single exception of testing blood for transfusion, is not justified. WHO and UNAIDS have determined that such testing should not be pursued as a matter of policy. a Identifying people with HIV/AIDS through mandatory testing does nothing to stop the spread of the virus. a Mandatory testing is a violation of human rights, and it leaves those who are identified as HIV-positive open to discrimination and persecution. a No negative HIV test can be assumed to have excluded the possibility of HIV infection in the person tested. There is a latent period of several weeks following infection, during which the HIV test can come up negative, but the person is still capable of transmitting the infection through unprotected sexual contact or blood. Occasionally, too, tests have shown false negative results. a A negative HIV test offers no assurance that the person tested will not be exposed to HIV and become infected soon thereafter. a A negative HIV test is, therefore, no reason to relax the universal precautions that health workers need to observe at all times; nor does a negative HIV test give any reason to feel that sterile procedures during medical interventions are any less important. In practice, every patient should be regarded as a potential carrier of HIV, Hepatitis B or other blood-borne infections, since testing removes none of the potential for transmitting these diseases. a UNHCR and International Organization on Migration (IOM) issued a joint policy in 1990 which strictly opposes the use of mandatory HIV screening, and any restrictions based on a refugee’s HIV status. Nevertheless, some States have adopted mandatory HIV testing for refugees and exclude those who test positive. Other States place restrictions on the admission of persons whom they know to be HIV positive or have AIDS. Although some countries have established waiver procedures, resettlement cases of refugees who are HIV positive or have AIDS are certain to be more complex than most resettlement cases. a Resettlement considerations of refugees living with HIV are difficult and must be given special attention to avoid placing these persons at greater risk for discrimination, refoulement, and institutionalisation. ANNEX 1 HIV Testing in Refugee Situations Sexually Transmitted Diseases, Including HIV/AIDS 57 C H A P T E R F I V E Mother-to-Child Transmission and HIV and Infant Feeding Primary prevention of HIV in girls and women of reproductive age remains the most important component of any strategy or programme to prevent mother-to-child transmission (MTCT). For women who are HIV negative or of unknown status, breastfeeding should be protected, promoted and supported. (See Chapter Three-Safe Motherhood) For HIV-infected pregnant women, the only interventions proven to reduce significantly MTCT of HIV are the use of antiretroviral therapy (ARV) and the avoidance of breastfeeding. Women who are known to be HIV positive should be counselled about the possibility of avoiding breastfeeding. They should consider using commercial infant formula, home- prepared formula, or a modified form of breastfeeding, such as expressing and heat treating their own breast milk. They could also breastfeed for a shorter time than usual, or find an HIV-negative wet nurse. However, most of these options are usually impractical. Studies are continuing on the effectiveness and service delivery implications of providing short-course ARV treatment which may represent a feasible intervention in some settings and for some circumstances. In some settings, consideration could be given to providing HIV-positive mothers with breast milk substitutes and supporting its safe use. The supply of the substitute should be guaran- teed for at least six months. The acquisition and distribution of breast-milk substitutes should be in compliance with the International Code of Marketing of Breast-milk Substitutes. Considerable resources are required to prepare formula, whether commercial or home made. The mother needs water to clean equipment and prepare feeds; she needs adequate fuel to boil water to sterilise equipment and make feeds safe. She must do this six times a day, or prepare six feeds at one time and keep them cool for up to 24 hours to prevent spoilage. This is not often practical when normal life is disrupted. If feeds cannot be mixed correctly, if equipment cannot be adequately cleaned and sterilised, or if prepared feeds cannot be stored to prevent spoilage, the risks of sickness and death to the infant may be greater than the risk of transmission of HIV through breastfeeding. Bear in mind these considerations when counselling women. Health care providers should support women and, when possible, their families, in making the best decision on how to feed their infant given their particular circumstances. Breastfeeding may be the most appropriate and safest option. For more information on HIV and Infant Feeding refer to the “HIV and Infant Feeding Packet” produced by UNAIDS, UNICEF and WHO, Geneva, 1998. Also refer to “Nutrition and HIV/ AIDS”, Sub-committee on Nutrition News, Number 17, WHO, Geneva, 1998. ANNEX 2 Mother-to-Child Transmission and HIV and Infant Feeding 58 Formula for Calculating Condom Requirements Condom needs can be calculated if you can estimate the following: § The size of the target population (i.e., refugee population and adjoining areas). Roughly 20 per cent of this number represents the size of the sexually active male population. § The percentage of males using condoms. Results from previous knowledge, attitudes, behaviour and practices (KAPB) studies can be used when they exist. If they do not exist, plan from data provided by the most reliable source and adapt according to needs. § Plan for about 12 condoms per sexually active male per month. § Add to the above figure 20 per cent for wastage and loss. a Example: A baseline calculation for procuring one month’s supply of condoms for an estimated refugee and adjoining population of 10,000 people, with 20 per cent of sexually active males using condoms, is as follows: 2,000 sexually active males 2,000 20/100 20 per cent using condoms x 0.2 = 400 12 condoms per month x 12.0 = 4,800 20% wastage/loss + 0.2 = 960 total condoms per month 4,800 total wastage/loss + 960 Estimated total needs for one month: 5,760 condoms Condoms usually come in boxes of 144, called a gross. Quantities of follow-on supplies should be modified according to the field situation (demographic profiles in refugee camps may be very different from the normal demographic profile; use rates of condoms may also vary). To avoid shortages, make sure a three-month reserve supply is available. ANNEX 3 Formula for Calculating Condom Requirements Sexually Transmitted Diseases, Including HIV/AIDS 59 C H A P T E R F I V E ANNEX 4 STD Treatment Based on Syndromic Approach STD Treatment Based on Syndromic Approach Syndrome Treat For Urethral discharge Gonorrhoea and chlamydia Genital ulcers Syphilis and chancroid Vaginal discharge1 Gonorrhoea, chlamydia and trichomonas Lower abdominal pain Gonorrhoea, chlamydia and anaerobes Inguinal bubo as for chlamydia Scrotal swelling Gonorrhoea and chlamydia Neonatal eye discharge Neonate gonorrhoea and chlamydia 1. If a woman complains of vaginitis (itching)–treat for candidiasis. 60 Drugs for Treatment of STDs (Choice of drugs should be based on antibiotic sensitivity studies in a specific area) Treat For Drugs – Depending on Adult Dose (for uncomplicated Sensitivity Studies or early infections) Gonorrhoea Ciprofloxacin1 500 mg - single dose - oral Spectinomycin 2 g - single dose - IM Cefixime 400 mg - single dose - oral Ceftriaxone 250 mg - single dose - IM Kanamycin 2 g - single dose - IM Sulfamethoxazole/Trimethoprim 400mg/80mg - 10 tabs once daily for 3 days Chlamydia Doxycycline1 100 mg - twice daily for 7 days - oral Tetracycline1 500 mg - four times a day for 7 days - oral Erythromycin 500 mg - four times a day for 7 days - oral Sulfafurazole 500 mg - four times a say for 10 days - oral Syphilis Benzathine penicillin G 2.4 MUs - single dose - IM Procaine penicillin G 1.2 MUs - daily for 10 days - IM Tetracycline(1,2) 500 mg - four times a day for 15 days - oral Doxycycline(1,2) 100 mg - twice daily for 15 days - oral Erythromycin2 500 mg - four times a day for 15 days - oral Chancroid Erythromycin 500 mg - three times a day for 7 days - oral Ciprofloxacin1 500 mg - single dose - oral Ceftriaxone 250 mg - single dose - IM Spectinomycin 2 gm - single dose - IM Sulfamethoxazole/Trimethoprim 800mg/160mg - twice daily for 7 days - oral Donovanosis Sulfamethoxazole/Trimethoprim 800mg/160mg - twice daily for 14 days - oral Doxycycline1 100 mg - twice daily for 7 days Tetracycline1 500 mg - four times a day for 7 days Chloramphenicol 500 mg - four times a day for 2 days Trichomononas Metronidazole3 2 g - single dose - oral Candidosis Nystatin pessaries 100,000 IU - twice intravaginally for 14 days Clotrimazole or miconazole pessaries 200 mg - once intravaginally for 3 days Miconazole 500 mg - intravaginally - single dose Bacterial Metronidazole3 400-500 mg - twice a day for 7 days - oral vaginosis or 2 g - single dose - oral ANNEX 5 Drugs for Treatment of STDs 1–Contraindicated in pregnancy 2–For persons allergic to penicillin, but may be less effective. Close follow up is necessary to ensure a cure. 3–Contraindicated in first trimester of pregnancy Based on: Management of STDs– WHO/GPA/TEM/94.1 and WHO Model Prescribing Information: Drugs Used in STDs and HIV Infections– WHO 1997 NOTE: Drugs for treatment of STDs are continuously revised. Health care providers should rely on the most up-to-date recommendations. Sexually Transmitted Diseases, Including HIV/AIDS 61 C H A P T E R F I V E Two or more characteristic findings? (c) One characteristic finding? (c) 1.1.1.1.1. Two associated findings? (d) Positive lab test for HIV? Three or more associated findings? (d) 4.4.4.4.4. Two or more associated findings? (d) Any cardinal findings (b) 2.2.2.2.2. 3.3.3.3.3. 5.5.5.5.5. 7.7.7.7.7. 6.6.6.6.6. Any epidemiological risk factors? (e) 8.8.8.8.8. Symptomatic: HIV infections nonononono yesyesyesyesyes yesyesyesyesyes yesyesyesyesyes yesyesyesyesyes yesyesyesyesyes yesyesyesyesyes Symptomatic: not HIV related yesyesyesyesyes yesyesyesyesyes Suspected Symptomatic HIV Infection (a) nonononono nonononono nonononono nonononono nonononono nonononono 1. Kaposi sarcoma is a cardinal finding only when: (i) intraoral lesions are present; (ii) lesions are generalised; or (iii) lesions are rapidly progressive or invasive. 2. If no other obvious cause of immunosuppression is evident. 3. The combination of fever, weight loss and cough is characteristic of both tuberculosis and AIDS. 4. Neurological complaints or findings associated with HIV infection include seizures (especially focal), peripheral neuropathy (motor or sensory), focal central motor or sensory deficits, dementia and progressively worsening headache. Adapted from WHO/GPA/IDS/ HCS/91.6 “Guidelines for the Clinical Management of HIV Infection in Adults”, December 1991. Annotations: a) The purpose is to help the health care provider to recognize the patient with symptomatic HIV infection, as an aid to clinical management. HIV testing, when available and affordable, can be used to substantiate the clinical diagnosis. b) Cardinal Findings: § Kaposi sarcoma1 § Pneumocystis carinii pneumonia § Toxoplasma encephalitis § Oesophageal candidiasis § Cytomegalovirus retinitis c) Characteristic Findings2: § Oral thrush (in patient not taking antibiotics) § Hairy leukoplakia § Cryptococcal meningitis (may be a cardinal finding in Africa) § Miliary, extrapulmonary or noncavitary pulmonary tuberculosis3 § Herpes zoster, present or past, particularly multidermatomal, age 50 years § Severe prurigo § Kaposi sarcoma (other than as cardinal finding) § High-grade B-cell extranodal lymphoma d) Associated Findings²: § Weight loss (recent unexplained) of more than 10% of baseline body weight, if assessable³ § Fever (continuous or intermittent) for more than 1 month³ § Diarrhoea (continuous or intermittent) for more than 1 month § Ulcers (genital or perianal) for more than 1 month § Cough for more than 1 month³ § Neurological complaints or findings4 § Generalised lymphadenopathy (extrainguinal) § Drug reactions (previously not seen), e.g. to thiacetazone or sulfonamides § Skin infections (severe or recurrent), e.g. warts, dermatophytes, folliculitis e) Epidemiological Risk Factors: § Present or past high-risk behaviour: – drug injecting – multiple sex partners – sex partner(s) with known AIDS or HIV infection – sex partner(s) with known epidemiological risk factor or from an area with a high prevalence of HIV infection – males having penetrative sexual intercourse with males § Recent history of genital ulcer disease. § History of transfusion after 1975 of unscreened blood, plasma or clotting factor; or (even if screened) from an area with a high prevalence of HIV infection. § History of scarification, tattooing, ear piercing or circumcision using non-sterile instruments. ANNEX 6 Suspected Symptomatic HIV Infections WHO Flow Chart 62 ANNEX 7 WHO Essential Drugs for HIV/AIDS Management 1 Ketoconazole is expensive, therefore only limited supplies should be considered and only if there are enforceable criteria for its use. 2 The appropriate use of anti- depressant medicine should be considered in situations where clinical depression is diagnosed. 3 Given the possibility of overdose, tricyclics should perhaps be prescribed only in 5 or less at a time and by a physician. 4 The use of anxiolytics (Diazepan - Benzodiazepine family) may also be considered for temporary management of severe anxiety reactions where respiration is not impaired (e.g., pneumocystis carinii pneumonia). Sources: WHO Model Prescribing – Drugs used in HIV Infections, WHO/ EDM 1999. Standard treatments and essential drugs for HIV-related conditions WHO/DAP Dec. 1997. UNAIDS Technical Update “Access to drugs” October 1998. WHO Essential Drugs HIV/AIDS Management IndicationsIndicationsIndicationsIndicationsIndications Dehydration Diarrhoea Bacterial Infections Fungal Infections Parasitic Infections Palliative Care and Pain Management Tuberculosis Clinical Depression2 DrugsDrugsDrugsDrugsDrugs Oral Rehydration Salts Loperamide Cotrimoxazole Amoxicillin Ciprofloxacin Ceftriaxone Miconazole Nystatin (oral and ointment) Ketoconazole1 Metronidazole (oral) Codeine Isoniazid Rifampicin Pyrazinamide Ethambutol Tricyclics3 Benzodiazepine Family4 Sexually Transmitted Diseases, Including HIV/AIDS 63 C H A P T E R F I V E ANNEX 8 Sexually Transmitted Diseases 5 %5 %5 %5 %5 % 20% of (1)(1)(1)(1)(1) 50% of (1)(1)(1)(1)(1) 5% of (1)(1)(1)(1)(1) 25% of (1)(1)(1)(1)(1) 55555 000000000000000 1 000 2 500 250 1 250 5 000 x 12 = 60 000 benzathine benzyl- penicillin 2.4 MU 1 dose plusplusplusplusplus erythromycin, 500mg 3/day x 7 days ciprofloxacin, 500mg x 1 plus plus plus plus plus doxycyclin, 100mg 2/day x 7 days ciprofloxacin, 500mg plus plus plus plus plus doxycyclin, 100mg 2/day x 7 days metronidazole, 2gr plus plus plus plus plus nystatin 2p/day x 14 days 0.24 plus 1.68 = 1.92 1.72 plus 0.17 = 1.89 1.89 0.04 plus 0.50 = 0.79 US$5.40 per 144 pieces 1 920 4 725 473 988 2 250 10,35610,35610,35610,35610,356 Cost perCost perCost perCost perCost per treatment intreatment intreatment intreatment intreatment in US$US$US$US$US$ TreatmentTreatmentTreatmentTreatmentTreatment ProtocolProtocolProtocolProtocolProtocol Total costTotal costTotal costTotal costTotal cost ininininin US$US$US$US$US$ 100100100100100 000000000000000 TOTAL US$TOTAL US$TOTAL US$TOTAL US$TOTAL US$ Population 15-44 yearsPopulation 15-44 yearsPopulation 15-44 yearsPopulation 15-44 yearsPopulation 15-44 years 50% of total population50% of total population50% of total population50% of total population50% of total population Expected % of STD (1)Expected % of STD (1)Expected % of STD (1)Expected % of STD (1)Expected % of STD (1) Expected % of genital ulcers Expected % of urethal discharge Expected % of cervicitis Expected % of vaginitis Condoms estimate during STD management Sexually Transmitted Diseases: Example for estimating of drug requirements and costs for a population of 200,000 64 Further Readings “Essential AIDS Information Resources”, WHO/ AHRTAG, Geneva/London, 1994. “Guidelines for HIV Interventions in Emergency Set- tings”, UNHCR/ WHO/UNAIDS, Geneva, 1996. “Working with Young People: A Guide to Preventing HIV/AIDS and STDs”, Commonwealth Secretariat, WHO/UNICEF, London, 1996. On universal precautions “A Practical Guide to Infection Control: How to Use Universal Precautions and Plan for Essential Sup- plies”, WHO, Geneva, 1995. “Guidelines on Disinfection and Sterilisation”, Médecins sans Frontières (MSF), Brussels, 1994. “Guidelines on Procedures to be Followed after an Ac- cidental Exposure to Blood”, MSF, Brussels, 1997. On access to condoms “Managing Condom Supply Manual”, WHO, Geneva, 1994. “Specifications and Guidelines for Condom Procure- ment”, WHO, Geneva, 1995. “The Female Condom: An information pack”, WHO/ UNAIDS, Geneva. “The Female Condom and AIDS” UNAIDS Point of View, Geneva, 1998. “The Male Latex Condom” WHO/UNAIDS, Geneva, 1998. On safe blood transfusion “Blood Needs in Disaster Situations: Practical Advice for Emergencies”, Transfusion International, No.59, March 1993. “Blood Safety” UNAIDS Point of View, Geneva “Blood Safety” UNAIDS Technical Update, Geneva “Guide for Planning Operations for Refugees, Dis- placed Persons and Returnees: from Emergency Re- sponse to Solutions”, International Federation of Red Cross and Red Crescent Societies, Geneva, 1993. “Guidelines for the Appropriate Use of Blood”, WHO, Geneva, 1989. “Use of Blood Plasma Substitutes and Plasma in Developing Countries”, WHO, Geneva, 1989. On HIV testing and counselling “Counselling and HIV/AIDS” UNAIDS Technical Up- date, Geneva, 1997. “Guidelines for Blood Donor Counselling on Human Immunodeficiency Virus (HIV)” International Federa- tion of Red Cross and Red Crescent Societies/WHO/ GPA Geneva 1994 (WHO/GPA/TCO/HCS/94.2) “Policy of HIV Testing and Counselling” UNAIDS, UNAIDS/97.1 “Recommendations for the Selection and Use of HIV Antibody Tests”, WHO Weekly Epidemiological Record, No. 20:145-9, Geneva, 1997. “Voluntary Counselling and Testing” UNAIDS Tech- nical Update, Geneva,1999. On the management of STDs Adler, M., and S. Foster, J. Richens, and H. Slavin. “STD Infections: Guidelines for Prevention and Treat- ment”, ODA/DFID Occasional Paper, London 1996. “Management of Sexually Transmitted Diseases”, WHO, Geneva, 1994. “Prescribing Information: Drugs Used in Sexually Transmitted Diseases and HIV infection”, WHO, Ge- neva, 1995. “Sexually transmitted diseases: policies and principles for prevention and care” UNAIDS/WHO Geneva,1997. “STD Case Management Workbooks” WHO/ GPTCO/PMT/95.18A, Geneva, 1995. “The public health approach to STD control” UNIADS Technical Update, Geneva, 1998. On comprehensive care “AIDS Home Care Handbook”, WHO, Geneva, 1993. “Guidelines for the Clinical Management of HIV In- fection in Adults”, WHO, Geneva 1991. “Guidelines for the Clinical Management of HIV In- fection in Children”, WHO, Geneva 1993. “HIV/AIDS Counselling: A Key to Caring: Guidelines for Policy Makers and Planners”, WHO, Geneva 1995. On standard treatment and essential drugs for HIV/AIDS management “Access to drugs”, UNAIDS Technical Update, Geneva, 1998. “Standard treatments and essential drugs for HIV- related conditions”, WHO/DAP, Geneva,1997. “WHO Model Prescribing – Drugs used in HIV Infec- tions”, WHO/EDM, Geneva,1999. Family Planning 65 C H A P T E R S I X Contents: n Preliminary Considerations n Assessment of Needs n Implementation of Family Planning Services n Examples of Contraceptive Methods that May Be Provided in Refugee Settings n Male Involvement in Family Planning Programmes n Monitoring Family Planning 6 Family planning helps save women’s and children’s lives and preserves their health by preventing untimely and unwanted pregnancies, reducing women’s exposure to the health risks of childbirth and abortion and giving women, who are often the sole caregivers, more time to care for their children and themselves. All couples and individuals have the right to decide freely and responsibly the number and spacing of their children and to have access to the information, education and means to do so. 66 Family Planning Refugee women and men should be involved in all aspects of family planning programmes; and the programmes should be conducted with full respect for the various religious and ethical values and cultural backgrounds within the refugee community. From the earliest stages of an operation, relief organisations should be able to respond to refugees’ demand for contraceptives. As the situation stabilises, a range of safe and effec- tive modern methods of family planning, approved by WHO, should be available. The provision of family planning services requires appropriately trained staff and a reliable sup- ply of material and financial resources. Preliminary Considerations The situation in the refugees’ country of origin will be an important factor influencing expecta- tions, perceived needs and demand for family planning. Laws, infrastructure, religious and ethical values and cultural backgrounds and the training of health-care providers from the host country also have an important affect on the services that can be offered. Some women may want to continue using a contraceptive method that they used before displacement. These women’s demands for continued family planning should be met as soon as possible. Given the risk of pregnancy and exposure to sexually transmitted diseases (STDs), in- cluding HIV, that often prevails in refugee situations, condoms should be available as early as possible. (See Chapter Two – MISP.) Counselling services should also be available. Providing a full range of family planning serv- ices will usually not be feasible until the situa- tion has stabilised somewhat. A refugee situa- tion is considered “stabilised” when the crude mortality rate falls below one in 10,000 per day, when there are no major epidemics, and when the “settled” refugee population is not expected to repatriate or relocate within six months. Protocols used to manage family planning services in the country of origin may be differ- ent than those used in the host country. To the extent possible, host country protocols should be followed, although some negotiation may be necessary where differences exist. Most family planning methods are used by women. Women have the right to confidentiality and privacy about their choice of methods. But frequently men are the decision-makers within the family unit. Where appropriate, men should be given appropriate information and encour- aged to take an active role in the family planning decision-making process. This will help ensure that joint responsibility is taken for family plan- ning decisions and will maximise acceptance of the programme within the community. Assessment of Needs Background information on reproductive health (RH) in the country of origin should be available from pre-existing data. Sources for this information include UNAIDS, UNFPA, WHO and other governmental and non-gov- ernmental agencies that work in reproductive health and family planning. Headquarters and regional offices should be able to provide this information to field operations. A review of the national or other (UNFPA, NGO, bilateral, etc.) family planning programmes of the host country must be conducted to find ways and means for collaboration and to identify any differences in protocols which must be re- solved. If services are made available to refu- gees, they should also be available to the sur- rounding local population on request. The following activities will help assess the demand for family planning within a refugee population: § Carry out an investigation of attitudes held by the refugee population concern- ing contraception. § Assess attitudes and knowledge of providers from the refugee population, Family Planning 67 C H A P T E R S I Xincluding those involving traditional methods. § Gather information on contraceptive prevalence by method in the country of origin. § Verify in-country availability of supplies and continuity of supplies. § Determine if refugees can use existing facilities in the host country. The support of community, social and religious leaders should be sought before setting up family planning services. Without this support, only those willing to risk community censure may use the services. For example, in some traditional cultures, talk of women’s reproduc- tive rights may provoke opposition. But support may be given for an information, education and communication (IEC) campaign emphasising child spacing, safe motherhood and the health of women. Discussions should be held with individual women (including leaders and traditional birth attendants [TBAs]) and women’s organisations to obtain their advice on the location of service points, the timing of services at the health facilities and the level of privacy and confiden- tiality that will ensure maximum use. Implementation of Family Planning Services To ensure an appropriate and effective family planning programme, the following compo- nents must be integrated, according to the findings of the assessment: High-Quality Family Planning Services All RH services should be of the highest quality possible. High-quality contraceptive care in- volves providing women and men with safe and appropriate methods to meet individuals’ and couples’ needs at every stage of their reproductive lives. Accurate and complete information should be provided, allowing women and men to select freely a method that suits their needs. High quality means that: § the needs of clients are assessed; § an appropriate range of methods is provided; § complete and accurate information about all methods is offered, thus ensuring informed choice; § a mix of methods matches the needs of all potential clients; § providers have the necessary technical skills to offer the methods safely (i.e., providers screen women for medical contraindications, assess STD/HIV risks, and can medically manage side effects); § providers are trained in technically accurate and culturally appropriate counselling techniques and use them effectively; § services are convenient, accessible and acceptable to clients; § follow-up care to ensure continuity of services is provided; and § an adequate logistics system ensures a continuity of supplies. Procurement of Contraceptives and Logistics of Distribution It is not possible to provide quality services unless an uninterrupted supply of contraceptives is ensured and staff are appropriately trained. Local supply channels should be investigated. If these are inadequate, supplies should be ob- tained through reliable suppliers or with support from UNFPA, UNHCR or WHO. These agencies can facilitate the purchase of bulk quantities of good-quality contraceptives at low cost. The following are the basic steps required to manage stocks of contraceptives: § Select contraceptives. Selection should be based on past use within the refugee 68 community, the providers’ skills, and con- sideration for the laws, procedures and practices of the host country. Negotiation maybe necessary to resolve any differ- ences. § Estimate quantities to be procured. Es- timates should initially be based on data from the country of origin and, later, on data generated within the refugee situa- tion. § Set up a system for record keeping. See section below on monitoring. § Set up procedures for efficiently man- aging the procurement, distribution and inventory of contraceptives. Under- or over-supply may be avoided by careful organisation, primarily by appointing an individual who will assume this specific responsibility. Planning Outlets and Opportunities for Family Planning Services Family planning delivery sites should be ac- cessible and convenient. Ideally, family plan- ning services should be available at health centres, outreach health posts and through community-based distribution channels, when appropriate. Some groups, such as adoles- cents, unmarried women and men, may need special consideration so they feel comfortable using the services and so they can avoid the risk of stigmatisation by the community. Con- traceptives should be available at the consulta- tion point; the client should not be referred to a central pharmacy to obtain the selected method. Counselling and family planning methods should be systematically offered to refugees after providing services related to post-abor- tion care, STDs or after childbirth. Human Resource Needs Family planning programmes should be organ- ised and supervised by an experienced nurse, midwife or doctor and maximum use should be made of qualified or experienced refugees or local staff. If lay workers are used for commu- nity-based distribution, they must be trained in appropriate skills and attitudes and must be supervised. Those involved in providing family planning services must show respect for the client’s opinion and for the need for confidentiality. To increase use, the provider may need to be of the same sex and cultural background as the user and have strong communication skills. To ensure administrative, technical and refer- ral support, there must be coordination and cooperation with the host country’s family plan- ning programme and with NGOs or UN agen- cies, such as UNFPA. Such cooperation will also increase the chances of sustainability of the refugee family planning programme. Preparation of the information, education and communication (IEC) component Counselling should always be an integral part of family planning services. Appropriate, culturally acceptable IEC materials help individuals and couples make free contraceptive choices. Infor- mation must include the benefits and con- straints of different methods, and how to use them. (See Appendix One–The Essentials of IEC Programmes.) Preparation of an adequate training programme for service providers In many situations, there will be trained provid- ers among the refugee population. These peo- ple should be employed to the fullest extent possible. All staff involved in providing family planning services must have adequate training on contraceptive methods and counselling, as indicated in the list below. This training should be supplemented by periodic refresher courses. On-the-job training and supervised practice are essential to ensure adequate per- formance and must be integral components of the supervisory programme. Family Planning 69 C H A P T E R S I XThe elements of an adequate training pro- gramme for service providers include: § Technical Competence – description of methods (including advantages and effectiveness) – mode of action, side-effects, complications, danger signs – appropriate groups of users and instructions for use or administration – contraindications and drug interactions – technical skills relating to the provision of each method (e.g., insertion of IUD or hormonal implant) – follow-up and re-supply requirements, including ordering supplies – record keeping For methods that require specific techni- cal skills–such as implants, IUDs, volun- tary sterilisation and the diaphragm–pro- viders need hands-on training in method provision and close supervision. § Interpersonal Skills – communication and counselling skills – appropriate attitudes towards users and non-users and respect for their choices – appropriate responses to rumours and misconceptions – respect for dignity, privacy, confidentiality – understanding of the needs of specific groups, such as adolescents, single women and men § Communication Skills It is important for providers to be trained in culturally sensitive, unbiased communica- tion techniques that encourage open, in- teractive relationships with clients. Skills necessary for this kind of communication include listening, clarifying, encouraging clients to speak, acknowledging client feelings, and summarising what has been said. In addition, providers should be taught strategies for effective counselling of clients about method choices in a lim- ited time period. Providers should also be trained to use visual and other support materials and to identify clients with spe- cial needs, such as those with a high risk of STDs, post-abortion clients, breast- feeding women, adolescents, etc. § Administrative Skills Many family planning providers must also perform routine administrative and mana- gerial tasks, such as record keeping, re- ferrals and inventory control, and should therefore be trained in these activities. Training should emphasise not only the specific skills necessary to carry out these functions, but also why they are important. Plan protocols to be used during the family planning consultation First contact involves: – registration and taking an individual RH history; – physical, gynaecological and pelvic examination when indicated (for exam- ple, to ascertain whether a woman is pregnant, to investigate unexplained vaginal bleeding, to determine the pres- ence of an STD); – counselling regarding available methods and the user’s preferred choice accord- ing to her/his STD/HIV risk; – provision of the contraceptive method supply, as indicated; – counselling on when and how to use the contraceptives; – counselling on possible side effects and reassurance that she/he can return to the health facility at any time and change methods; – scheduling a follow-up visit. See Annex 2 for an example of the decision- making process during a first visit. Annex 3 70 shows an example of a checklist used at a first visit to screen female refugees for contra- indications against the use of various methods. Host-country checklists may exist for each method and should be used where appropriate. For a new user, frequent follow-up (at one month, three months and six months) gives the client opportunities to ask questions about use and any side-effects which she/he may have experienced. As the user becomes familiar with a method, he/she no longer needs frequent fol- low-up visits. With some methods, such as pills, condoms, and injectables, clients must make regular visits to obtain the contraceptives, so follow-up is more automatic. Whatever the fre- quency of follow-up visits, the user should be assured of immediate access if she/he experi- ences any difficulties. When arranging follow-up visits, providers must be sensitive to the literacy and numeracy of the client. Examples of Methods That May Be Provided in Refugee Settings Providers and users must be aware of the par- ticularities of each method, its effectiveness, safety, side effects. They should also know its effect on the risk of STD transmission, its ap- propriateness for breastfeeding women and the usual length of time between discontinua- tion of the method and return to normal fertility. Information on the common methods is pre- sented here. “In no cases should abortion be promoted as a method of family planning” (ICPD para 8.25). Barrier Methods In most refugee situations, the most important barrier method will be male latex condoms. Con- sistent and correct use of condoms can play the dual role of protection against STD and HIV in- fection and prevention of conception. They can be used alone or in combination with another method to increase effectiveness. Only water- based lubricants should be used with condoms. Other barrier methods, such as spermicides and female condoms, may be requested by refugees who are familiar with these methods from their country of origin. If requested, every effort should be made to supply these methods. Hormonal Contraceptives Oral Contraceptive Pills should include at least: § one combined oral contraceptive (COC): ethinyl oestradiol < 0.035 mg and levonorgestrel 0.15 mg; § one progestogen-only oral contraceptive (POP): levonorgestrel 0.03 mg or norethisterone 0.35 mg. Injectable Contraceptives could include depot- medroxyprogesterone acetate (DMPA, Depo- provera), one injection every three months, norethisterone enatharem (NET-EN) one injection every 2 months, or Cyclofem, one injection per month. Trained health profession- als should administer injectables. It is recom- mended that only one injectable method should be used to avoid confusion and misun- derstanding over the schedule for reinjection. Supportive counselling and continued reassur- ance during follow-up visits will help clients tol- erate common side effects, such as changed patterns of menstrual bleeding. See Chapter Four for details about the provi- sion of Emergency Contraceptive Pills (ECPs). National policies and the demands of well- informed users should guide the use of ECPs in refugee situations. Copper IUDs (Intra-Uterine Devices) IUD insertion, like sterilisation and implants, requires special training, facilities and equip- ment that must be in place before these meth- ods are provided. Women known to be infected or at high risk for an STD, including HIV, should not have an IUD inserted. For nulliparous women, an IUD is not the method of first choice. Family Planning 71 C H A P T E R S I XNatural Family Planning (NFP) Methods Natural Family Planning methods include the basal body temperature method, the cervical mucus or ovulation method, the calendar method and the sympto-thermal method. NFP is particularly appropriate for people who do not wish to use other methods for medical rea- sons or because of religious or personal be- liefs. Counselling must be provided to both partners when choosing these methods and when practising them. The methods require initial training and regular follow-up until confi- dence is achieved in detecting fertility signs. Teaching these methods to potential users is relatively time consuming, and requires sepa- rate sessions for those refugees who wish to use them. Breastfeeding Breastfeeding is effective as a contraceptive method if a woman is exclusively breast- feeding on demand her infant (no other food being given to the baby), she is not menstruat- ing and her infant is less than six months old. If any one this these three criteria are not met, then an additional method of contraception is advised. Family planning methods recommended for breastfeeding mothers are: § from delivery up to six weeks postpartum: barrier methods, postpartum IUD insertion and sterilisation; § from six weeks to six months postpartum: barrier methods, progestin-only methods (pills, injectables, implants), IUDs, and sterilisation; § after six months postpartum: COCs and combined injectables, and natural family planning methods. Hormonal Implants An implant is a long-lasting progestogen-only contraceptive. The most widely used types (Norplant and Norplant 2) consist, respectively, of six or two silastic capsules containing the progestogen levonorgestrel. The capsules, in- serted under the skin of the arm, slowly release the progestogen. These implants are effective for five years. They should only be inserted or removed by properly trained personnel. Before using any long-term contraceptive within a refugee situation, service providers must be sure that the necessary facilities and skilled personnel exist in the country of origin to reverse or remove the method, since refu- gees may return home at any time. If such facilities do not exist in the country of origin, the method should not be used. Voluntary Surgical Contraception Both male (vasectomy) and female sterilisation are desirable methods of contraception for some clients. As a surgical method, sterilisation should only be performed in safe conditions, with the formal consent of the user and by trained per- sonnel with the necessary equipment. Sterilisa- tion should not be excluded especially if it is familiar to the refugees from their country of ori- gin and is allowed within the host country. Male Involvement in Family Planning Programmes Men must be involved in family planning pro- grammes to increase recognition of other RH issues, such as the prevention of STDs/HIV/ AIDS, and to increase acceptance within the community. Activities might include couples counselling, condom promotion, special health facility times for men, peer-group ses- sions and social groups. Consideration of men’s perspectives and motivation must be integral to programme activities. Contracep- tive use by men enables them to share the responsibility of family planning with their female partners. Some services may need to be specifically tailored to meet the needs of male users. 72 Monitoring Providers should maintain a daily activity regis- ter and individual forms to help them record information and offer effective follow-up. The following information should be recorded: § date § user name–or, if required for confidentiality, only a number § user information (age, parity, address) § method selected (and brand name) § side effects experienced § type of user (new, repeat, etc.) § reason for discontinuation–dropout or changed to other method § date of next visit (for follow-up). Record-keeping forms should be simple and appropriate to the information gathered and to staff literacy levels. All staff should receive training in how to maintain appropriate records and be informed of how the information being collected will be useful to users and providers. Family Planning Indicators a Indicators to be collected at the health-facility level Contraceptive Prevalence Rate (CPR). CPR is the percentage of women who are using (or whose partner is using) a method of contraception at a given point in time. a Indicators to be collected at the community level Community-based surveys could be carried out to assess the knowledge, attitudes and practices of refugees concerning family planning services. a Indicators concerning training and quality of care Regular skills training and assessments. Health personnel implementing family planning programmes should be trained and their skills assessed regularly. An indicator of this competency should be monitored at least once a year. A possible indicator to assess the skills of family planning workers is the proportion of health workers appropriately implementing family planning services. (Refer to Chapter Nine–Monitoring and Surveillance.) Family Planning 73 C H A P T E R S I X Further Readings “Pocket Guide for Family Planning Service Providers”, Blumenthal, P. et al. JHPIEGO, Baltimore, MD, 1995. “Contraceptive Logistic Guidelines for Refu- gee Settings”, Family Planning Logistics Man- agement Project, John Snow, Inc., Arlington, VA, 1996. Hatcher, R. and W. Rinehart, R. Blackburn, and J. Geller. “The Essentials of Contraceptive Technology”, a joint WHO/USAID publication, Population Information Program, Centre for Communication Programs, The Johns Hopkins School of Public Health, Baltimore, MD, 1997. “Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contra- ceptive Use”, WHO, Geneva, 1996. “Medical and Service Delivery Guidelines for Family Planning”, WHO, IPPF, AVSC, Second Edition, 1997. Checklist for Establishing Family Planning Services aAssessment of attitudes of different groups undertaken aContraceptive prevalence in country of origin known aFamily planning services sites established with participation of refugees aContraceptives procured and logistics system in place aHealth and community workers trained in family planning service delivery aFamily planning record keeping system in place aInvolvement of male community undertaken Technical and Managerial Guidelines on Family Planning, WHO, Geneva ¡ Barrier Methods and Spermicides: Their Role in Family Planning Care, 1987. ¡ Natural Family Planning - A Guide for Provision of Services, 1988. ¡ Norplant Contraceptive Implants: Managerial and Technical Guidelines, 1990. ¡ Injectable Contraceptives: Their Role in Family Planning Care, 1991. ¡ Guidelines for Community-based Distribution of Contraceptives, 1994. ¡ Emergency Contraception: A Guide Service Delivery, 1998. ¡ Female Sterilisation: A Guide to the Provision of Services, 1992. ¡ Technical and Managerial Guidelines for Vasectomy Services, 1988. ¡ Intrauterine Devices: Technical and Managerial Guidelines for Services, 1997. WHO Brochures: What Health Workers Need to Know ¡ Natural Family Planning ¡ Providing an Appropriate Contracep- tive Method Choice ¡ Female Sterilisation ¡ Vasectomy ¡ Breastfeeding and Child Spacing ¡ IUDs ¡ Injectable Contraceptives 74 ANNEX 1 Appropriate Family Planning Methods at Different Stages in a Woman’s Reproductive Life Perimenopausal women IUDs Condomsa Diaphragm/cap Vaginal spermicidesa Women who wish to delay their first birth Implants Combined oral contra- ceptives Injectablesb Condomsa Diaphragm/cap Vaginal spermicidesa Natural family planninga Adolescents Combined oral contraceptives Condomsa Vaginal spermicidesa Women not breastfeeding who wish to space birthsd Implants Combined oral contracep- tives Injectablesb IUDs Condomsa Diaphragm/cap Vaginal spermicidesa Natural family planninga Appropriate Family Planning Methods at Different Stages in a Woman’s Reproductive Life Couples who wish to terminate child-bearing Vasectomy Female steriliza- tion Implants IUDs Breastfeeding women who wish to space birthsc Nonhormonal methods: - IUDs - condoms - diaphragm/cap - vaginal spermicides Progesterone-only hormonal methods: - minipills - implants - DMPA/NET-EN a less than 90% effective b return to fertility may be delayed after use of injectables c exclusive breastfeeding alone has a significant contraceptive effect if other criteria are also met: complete amenorrhea and a period of less than 6 months since delivery d including post-abortion clients Source: “Providing an appropriate contraceptive method choice”, WHO, 1993. Used by permission. Family Planning 75 C H A P T E R S I X ANNEX 2 Contraceptive Choice Decision Tree for Refugees Who Desire More Children Is th e cli en t b re as tfe ed in g? Do es th e cli en t d es ire a m et ho d th at d oe s no t r eq ui re fre qu en t u se o r r es up pl y? Di sc us s th e su ita bi lity o f: – m on th ly in jec tab les – co m bi ne d or al co n tra ce pt ive s – ba rri er m et ho ds – n at ur al fa m ily pl an ni ng Di sc us s th e su ita bi lity o f: – ba rri er m et ho d – n at ur al fa m ily pl an ni ng Di sc us s th e su ita bi lity o f ba rri er m et ho ds Ad vis e th e cli en t t ha t s he m ay b e ad eq ua te ly pr ot ec te d fro m p re gn an cy bu t s ho ul d re tu rn fo r co nt ra ce pt io n as s oo n as on e of th e th re e cr ite ria ab ov e is m et . Di sc us s th e su ita bi lity o f: – IU Ds – ba rri er m et ho ds – im pl an ts – m in ip ills – DM PA /N ET -E N Is th e cli en t a t r isk o f cir cu la to ry d ise as e? Di sc us s th e su ita bi lity o f: – im pl an ts – IU Ds – DM PA /N ET -E N Th e cli en t i s no t a de qu at el y pr ot ec te d fro m p re gn an cy a nd re qu ire s a co m pl em en ta ry m et ho d. Th e cli en t i s ad eq ua te ly pr ot ec te d fro m p re gn an cy Do es th e cli en t w ish to ad op t a c on tra ce pt ive m et ho d to c om pl em en t br ea st fe ed in g, o r i s sh e u n lik el y to re tu rn fo r se rv ic es ? Is th e cli en t m or e th an s ix w ee ks p os t p ar tu m ? Is th e cli en t m en st ru at in g? Is th e ch ild g ive n fo od s up pl em en ts in a dd itio n to b re as tfe ed in g? Ha s th e cli en t b ee n br ea st fe ed in g fo r m or e th an s ix m on th s? N O N O N O N O AL L “N O ” O NE O R M O RE “ YE S” YE S YE S N O YE S YE S YE S So ur ce : W HO , u se d by p er m iss io n. 76 ANNEX 3 Family Planning Consultation Card Ca m p: Ad dr es s: N O YE S IU D CO C PO P IN J* o o (–) + + – o o (–) - + + o o (–) + + + o o (–) + + + o o (–) + + + o o + – + + o o (–) + + + o o – – – – o o + (–) (–) + o o + – + (–) o o (–) + + + o o (–) + + + o o + – – – o o + – – – o o – + + + o o + – + (–) o o + – – – o o + – + + o o – – – – o o – + + + 1. N ul lip ar a 2. Po st p ar tu m < 6 w ee ks 3. Po st a bo rtu m < 6 w ee ks 4. Ca es ar ea n se ct io n < 6 m on th s 5. Di ab et es n ot u nd er s ur ve ill an ce 6. Tw o o f t he fo llo w in g: ag e > 3 5 ye ar s o he av y sm ok er o o be si ty o 7. H yp er m en or rh ea /d ys m en or rh ea 8. M et ro rr ha gi a 9. M ed ic in al tr ea tm en t w hi ch c ou ld in te rfe re w ith ef fic ie nc y of o ra l c on tra ce pt iv es 1. Ph le bi tis , a rte ria l t hr om bo si s, e m bo lis m 2. Ex tra -u te rin e pr eg na nc y 3. Up pe r g en ita l i nf ec tio n 4. Re ce nt li ve r d is ea se (< 6 mo nth s) 1. Ye llo w c on jun cti va (li ve r m alf un cti on ) 2. Ca rd ia c va lv ul ar p at ho lo gy 3. Bl oo d pr es su re a bo ve 1 4/ 9 4. M am m ar y tu m ou r 5. Ph le bi tis , i m po rta nt v ar ic os e ve in s 6. Pr eg na nc y 7. Up pe r o r l ow er g en ita l i nf ec tio n Da te : __ / __ / __ Si gn at ur e QU AL IF IC AT IO N A. AN AM NE SI S B .H IS TO RY C. G EN ER AL A ND G YN AE CO LO G IC AL EX AM IN AT IO N Av ai la bl e m et ho ds M et ho d de sir ed : M et ho d(s ) a lre ad y u se d: La st m en st ru al p er io d: D at e _ _ /_ _ /_ _ D ur at io n: Af flu en ce : Ag e of y ou ng es t l ivi ng c hi ld : W ish es to S PA CE : d ur at io n: W ish es to L IM IT : Pr eg na nc ie s: Bi rth s: D es ire d: Li vin g Ch ild re n: Ed uc at io n: N am e: Ag e: N um be r: M ET HO D RE TA IN ED RE CO M M EN DE D M ET HO D( S) CO NC LU SI O N: Po ss ib le c om pl em en ta ry e xa m s: N AM E * IU D (in tra -ut eri ne de vic e) CO C (co mb ine d o ral co nt ra ce pt ive p ill) PO P (pr og es ter on e-o nly pi ll) IN J (in jec tab le) Family Planning 77 C H A P T E R S I X ANNEX 4 Calculating Contraceptive Requirements Example of needs for one year in Two Camps: A and B Po pu la tio n Ca m p A 10 0 00 0 20 0 00 4 00 0 57 6 00 0 20 0 00 3 00 0 wo m en 1 95 0 wo m en or 7 8 00 d os es 90 0 wo m en o r 11 70 0 cy cle s 15 0 wo m en o r 15 0 IU Ds Po pu la tio n Ca m p B 50 0 00 10 0 00 2 00 0 28 8 00 0 10 0 00 1 50 0 wo m en 97 5 wo m en or 3 9 00 d os es 45 0 wo m en o r 5 85 0 cy cle s 75 w om en o r 75 IU Ds Ite m s CO ND O M S Ta rg et g ro up (m ale s): 20 % of po pu la tio n Us er s: 2 0% o f t he ta rg et gr ou p 12 c on do m s pe r u se r p er m o n th CO NT RA CE PT IV ES Ta rg et g ro up (w om en 15 -44 yr s): 20 % of po pu la tio n Co nt ra ce pt ive Pr ev al en ce R at e: 1 5% 65 % o f t he u se rs p re fe r de po pr ov er a (4 pe r y ea r) 30 % o f t he u se rs p re fe r p ills (13 cy cle s p er ye ar) 5% o f t he u se rs p re fe r IU D To ta l (bo th ca mp s) 86 4 00 0 (+2 0% w as tag e) 11 70 0 do se s (+1 0% w as tag e) 19 3 00 c yc le s (+1 0% w as tag e) 22 5 IU Ds Un it co st s ($) av er ag e $5 .40 pe r 14 4 pi ec es $1 .5 pe r v ial $6 0 p er 10 0 cy cle s $1 .2 pe r I UD To ta l c os ts ($) pe r y ea r 39 0 00 19 3 00 11 60 0 27 0 $7 0 1 70 W he n or de rin g co nt ra ce pt ive s, a lw ay s ke ep in m in d th e tim e it w ill ta ke b et we en th e da te o f y ou r o rd er a nd ac tu al re ce ip t o f t he co nt ra ce pt ive s (us ua lly 2 to 3 m on th s). 78 Other Reproductive Health Concerns 79 C H A P T E R S E V E N Contents: n Post-Abortion Care 1 4 Emergency Manage- ment of Post-Abortion Complications 4 Post-Abortion Family Planning 4 Links to Other RH Services 4 Monitoring and Surveillance n Female Genital Mutilation 2 4 Scope and Definition 4 WHO classification 4 Prevention of Female Genital Mutilation in Refugee Situations 4 Care of Women with Female Genital Mutilation in Refugee Situations 4 Strategies to Eliminate Harmful Traditional Practices Other Reproductive Health Concerns 7 This Chapter does not include a discussion of all remaining reproductive health (RH) issues. It deals with two particularly serious aspects of reproductive health: managing complications of spontaneous and unsafe abortion, and eliminating the practice of female genital mutilation and caring for women who have undergone this procedure. 1. This section draws heavily on WHO’s Clinical Management of Abortion Complications: A Practical Guide, WHO’s Complications of Abortion, Technical and Managerial Guidelines for Prevention and Treatment and the Post-abortion Care: A Reference Manual for Improving Quality of Care, Post-abortion Care Consortium 1995. 2. This section draws heavily upon “Female Genital Mutilation”, WHO Information Kit and the WHO Manage- ment of Pregnancy, Childbirth and the Postpartum Period in the Presence of Female Genital Mutilation. 80 Other Reproductive Health Concerns Introduction Complications of Spontaneous and Unsafe Abortion Health professionals should be able to recog- nise and manage the complications of sponta- neous and unsafe abortions, which are major public health concerns as recognised in both the International Conference on Population and Development (ICPD) in Cairo (1994) and The Fourth World Conference on Women in Beijing (1995). The following statement from the ICPD under- pins the guidance offered in this Chapter: “In no cases should abortion be promoted as a method of family planning. All Gov- ernments and relevant intergovernmental and non-governmental organisations are urged to strengthen their commitment to women’s health, to deal with the health im- pact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and im- proved family planning services. Preven- tion of unwanted pregnancy must always be given the highest priority and every at- tempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and com- passionate counselling.where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. Post-abortion counselling, education and family planning services should be offered promptly, which will also help to avoid repeat abortions.” Cairo, ICPD, 1994, paragraph 8.25 Unsafe abortion contributes significantly to the morbidity and mortality of women of repro- ductive age throughout the world. WHO defines unsafe abortion as “a procedure for terminating unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking minimal medical stand- ards or both.” Every day, an estimated 55,000 unsafe abortions take place, resulting in the deaths of 200 women daily. WHO reports that up

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