3.5 Sexual and reproductive health

Sexual and reproductive health is an important component in a humanitarian response, and providing essential sexual, reproductive health (SRH) services saves lives. “Reproductive health (RH) care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving RH problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases.” – International Conference on Population and Development (ICPD) Programme of Action.

Sexual and Reproductive Health and Rights (SRHR) is a core pillar of CARE’s work in empowering women and girls as well as a core health service defined by Sphere. Our goal in the challenging environments of emergencies, post-conflict and disaster settings is to protect the health and well-being of women, girls, men, and boys and to promote gender equality by increasing access to essential SRHR services and programs across all phases of the emergency continuum (preparedness, response, and transition). For more information on the SRHR strategy within CARE, reference “CARE’s Sexual, Reproductive and Maternal Health and Rights Program Strategy” document.

Effects of a Crisis on Sexual and Reproductive Health

Women and children, who normally comprise 75 – 80% of displaced populations, suffer disproportionately compared to populations living in stable situations.  In crisis situations, we know that forms of gender-based violence frequently increase dramatically in both conflict-related and natural disasters; family planning (FP)/voluntary contraception (VC) and maternal newborn care services including emergency obstetric care (EmOC) are frequently unavailable; the risk of HIV and STI infection continues due to lack of information and access to condoms along with the need to continue treatment and support for those infected with HIV/AIDS.

In a crisis affected population, approximately 4 per cent of the population is estimated to be pregnant. Of the more than 100 million people in need of humanitarian assistance in 2015, an estimated one quarter were women and adolescent girls of reproductive age (SOWP, UNFPA 2015). Approximately 15 per cent of all pregnant women will experience an unpredictable obstetric complication during pregnancy or childbirth that will require emergency obstetric care. Out of this 5 – 15 per cent of all deliveries will require surgery, such as C-section. In order to prevent maternal and newborn mortality and morbidity resulting from complications, skilled birth attendants at all births is a proven best practice, along with basic emergency obstetric care and neonatal resuscitation.  Voluntary contraception services is well proven and time tested intervention that reduces maternal and newborn mortality. Voluntary contraception can prevent approximately 30% of maternal deaths and also prevents maternal to child transmission (PMTCT) of HIV (Saifuddin et.al., 2012). Malnutrition and epidemics, which are common occurrences in humanitarian settings,  increases the risk of pregnancy complications.  Childbirth occurs on the wayside during population movements and lack of access to comprehensive EmONC increases risk of maternal death and neonatal deaths.

For RH services to be comprehensive, it is critical that all of the following elements are implemented at the earliest possible opportunity:

  • Maternal newborn care that includes emergency obstetric and newborn care (EmONC) and post-abortion care (PAC).
  • Voluntary contraception including short acting, long-acting reversible contraception (LARC) as well as emergency contraception (EC).
  • HIV prevention, basic care for those infected with HIV and continued medical treatment for those already on antiretroviral treatment (ART).
  • Prevention and treatment of sexually transmitted infections (STIs).
  • Prevention and treatment of gender-based violence (GBV) including medical, psychosocial and economic care and support; legal services; and security.

Checklist – SRHR Background and MISP readiness checklist

Pre-emergency Basic SRHR Background Information Checklist:

  • Where did women go for delivery services and emergency obstetric and newborn care services?  How was the quality of services?  What is the Maternal Mortality Ratio (MMR)?
  • Where did people go for HIV/AIDS treatment and support? Are people taking antiretrovirals (ARVs)?
  • Do women and men use contraceptive services? What was the contraceptive prevalence rate (CPR)? What were the most commonly used methods?
  • Are there local women’s groups and associations working on GBV prevention, psychosocial care, judicial support and economic reintegration?
  • Are health facility staff trained to provide clinical care for survivors of sexual violence?
  • Is there a focal point within CARE to coordinate and implement the MISP activities for sexual and reproductive health within CARE’s emergency response activities
  • Is there an existing RH coordination mechanism (frequently led by UNFPA) and is CARE coordinating all RH (and health) programming with them

Minimum Initial Service Package (MISP) for RH Checklist:

  • Reduce HIV transmission by:
    • establishing conditions needed to comply with universal precautions
    • making male and female condoms available for free
    • keeping ready and providing free post-exposure prophylaxis (PEP) for any individual who may have had unprotected sex or been raped (sub-kit 3 from UNFPA, see Annex 26.5.12 )
    • ensuring essential PMTCT services (including HIV testing) are available for pregnant women.
  • Reduce HIV mortality by:
    • ensuring that patients already on ART can access their medicines, and that ARVs being provided match existing regimens for the population.
  • Prevent excess neonatal and maternal morbidity and mortality by:
    • providing clean delivery kits for mothers or birth attendants
    • providing midwife delivery kits (UNICEF or UNFPA) to the health facility
    • promoting exclusive breastfeeding for infants up to six months of age
    • establishing a referral system to manage obstetric emergencies
  • Ensure access to voluntary contraception services by:
    • procuring and providing modern contraceptive methods, especially LARC methods
    • ensuring an appropriate method mix including short-acting, long-acting, condoms and emergency contraceptive methods
    • providing safe and confidential contraceptive counselling
    • promoting community awareness of where and how to receive contraceptive services
  • Prevent and manage the consequences of gender-based violence by:
    • assuming that it is happening and asking women how it can be prevented
    • ensuring that women are involved in: leadership positions of food distribution, design and building of latrines and water points, For information on alternative fuels, please go to Annex 26.5.4.
    • working to establish health, and psychosocial and legal response for survivors of violence.
  • Plan for the provision of comprehensive reproductive health services integrated into primary health care, as the situation permits. This includes:
    • collecting background data on maternal, infant and child mortality; HIV/AIDS prevalence (if available); and contraceptive prevalence
    • identifying suitable sites for future delivery of comprehensive reproductive health (RH) services by addressing security problems, accessibility for all potential users, privacy and confidentiality during visits, easy access to water and sanitation, appropriate space for users’ waiting time, and aseptic conditions.
  • Assess the staff capacity to provide comprehensive RH services and put a plan in place for training/retraining of staff. Order equipment and supplies accordingly.

Even in the middle of an urgent crisis situation, women will give birth, nurse their newborns and require medical attention. Despite (or perhaps because of) the sudden loss of home, community, and livelihood options that accompany disasters, people will engage in sexual activities, many with consent but some without consent and as acts of violence. Many people will be coerced into sex against their will so as to survive. Many will be survivors of rape. The conditions that define a complex emergency (conflict, social instability, poverty and powerlessness) favour the rapid spread of HIV/AIDS and other STIs, and put women and adolescent girls in vulnerable situations.

The MISP is a series of activities focused on the sexual and reproductive health needs of populations in the early phase of a crisis. It can be implemented without a needs assessment, because there is documented evidence that it saves lives. The above checklist includes components of the MISP checklist.  For more information on the MISP, MISP checklist, distance learning module on MISP, the Interagency Field Manual for Reproductive Health in Crisis Settings (or Field Manual) and IPPF facilitator’s manual for MISP training see Annex 26.5.5.

Emergency responses have been slow to address the spread through prevention and treatment of HIV, although both are life-saving health interventions.  These trends are changing as implementers begin to understand the importance of addressing HIV at the earliest possible stage of an emergency.

ARV treatment interruption can cause unnecessary increases in morbidity and mortality, and can also lead to drug resistance.  WHO advises that continuation of treatment for those already on ART prior to the crisis should be considered a priority intervention and part of the minimum initial response to HIV even in the acute phase of the emergency.

Prevention of HIV transmission from mother to child (PMTCT) during an emergency should also be a priority intervention, and appropriate national guidelines should be followed to ensure that the risks of vertical transmission are minimal.

Other methods to prevent HIV should be made free and accessible, such as providing condoms (male and female) and post-exposure prophylaxis (PEP). Universal precautions against HIV transmission should be employed.

Both the MISP (Annex 26.5.3) and the IASC’s Guidelines for addressing HIV in humanitarian situations (Annex 26.5.7) should be consulted to develop an HIV response that is contextually appropriate.

Evidence demonstrates that the incidence of gender-based violence (GBV), such as sexual assault, harassment, sexual exploitation and domestic violence, increases during emergencies. There is mounting evidence of increased GBV in post-conflict situations as well. It is important to consider the root causes, contributing factors and examples of GBV when assessing, designing and implementing a GBV program (SPRINT, 2009):

  • Root cases include disrespect for human rights, abuse of power, and gender inequality.
  • Contributing factors include conflict, poverty, lack of education, sexual factors, physical, emotional/mental, economic, harmful traditional practices (HTP), alcohol/drug abuse, lack of police protection and lack of secure domiciles/areas.
  • Examples of GBV include domestic violence, child marriage, dowry abuse, verbal emotional abuse, sexual abuse, FGM, marital rape, verbal emotional abuse based on gender, and rape.

CARE has vast experience in addressing root causes and contributing factors to GBV and country offices are encouraged to integrate this work into emergency preparedness, planning and response.   GBV requires a very well coordinated multi-sectoral response that includes the following services: health, psychosocial, legal/justice, and security and protection. This response must result in addressing a protection system in place especially for women and girls, the provision of quality care for survivors, and raising awareness of services available for prevention and treatment. Survivors of sexual assault need access to quality post-rape care that includes post-exposure prophylaxis for HIV, antibiotics for sexually transmitted infections (STIs), emergency contraception, counselling and support. All programs should include a referral system that links survivors with the different services. Referral systems from outreach workers for access to health facility services, protection and legal services need to be established. Coordinate with the protection sector where applicable to create synergies between sectors and overall interventions.

Please refer to Annex 8.5.14 for clinical management guidelines and refer to Chapter 9.1 Gender, for information on how to plan and implement a quality program and for details on the non-health aspects of GBV programming.  To provide these services health worker staff need training and follow-up supervision that is based on the WHO guidelines.  Please refer to Annex 26.5.14 for links to the WHO Clinical Management for Rape Survivors and information on other resources for training in clinical management.

Maternal and newborn deaths and disabilities often increase in emergencies due to lack of available treatment for unexpected medical complications, even when there are trained personnel available. To promote safe deliveries, all visibly pregnant women should be given a clean delivery kit for home use. These kits may frequently be obtained from UNFPA at the country level or ordered from UNFPA (see Annex 26.5.3 for ordering information). These are packages that are used by the woman or her traditional birth attendants (TBAs) during the birth that are managed at home. A referral system for emergency obstetric care that includes transport and communication systems needs to be available 24 hours a day, seven days a week. A local referral facility should be supported with personnel, medical equipment and supplies. If this is not possible, then an appropriate emergency referral facility for the displaced population should be established.

To prevent maternal and newborn deaths, primary health care facilities should provide basic emergency obstetric and newborn care (EmONC) and the referral site should provide comprehensive EmONC. It is important to provide materials and drugs including an orientation to midwives and other skilled birth attendants on using these supplies to safely conduct deliveries, deal with complications and stabilise women before transport to the referral level. Refer to Annex 26.5.12 for MNH and EmONC resources. Supplies for these services are included in the RH kits that may be ordered through UNFPA.

Voluntary contraception is a necessary part of reproductive health service delivery. This is an important part of SRHR interventions to reduce maternal and newborn mortality and morbidity. Access to modern contraception could reduce maternal deaths, STI/HIV transmission, as well as the occurrence of unintended pregnancies and adverse consequences associated with unintended pregnancies. Method mix is essential for the acceptance and continuation of FP/VC use; therefore, services should ensure availability of short-acting (ex. barrier methods and birth control pills), and long-acting reversible (ex. IUD and implants). When the situation transitions to a more stable setting, permanent methods of contraception (such as sterilization) may be offered, based on the demand from the community. This should also include emergency contraception (EC) as a post-coital method of contraception. EC is also critical for post-rape crisis care. See GBV Section.

Contraceptive counselling should emphasize client privacy and confidentiality. Counselling must promote informed choice with description of the methods available as well as effectiveness and potential side effects of them. Full knowledge of side effects (positive and negative) have been linked to higher continuation rate of the chosen method. Currently, contraceptives are included in Kits 1,3,4,5, and 7. Refer to the WHO Medical Eligibility Criteria for Contraceptive Use and the MEC Wheel tool in Annex 26.5.16 to help identify medical conditions that determine the safety of a method based on client’s clinical conditions. The information from the MEC Wheel as well as the client’s own choice determines what contraceptive methods are best for the client.

If possible, activities to encourage community awareness of where and how to seek contraception should occur. This should be inclusive of not only women and adolescents of reproductive age, but also men and boys as well as other potential influencers – determined by analysis of the cultural context. Engaging key community religious, ethnic, or women’s group leadership and sponsoring their support can be incredibly helpful as well.

Voluntary contraception can reduce the demand for abortion; however, there will still be the need for and occurrence of abortions, especially in crisis settings. Access to safe abortion and post abortion care can reduce the occurrence of maternal mortality (UNFPA estimates by up to 50%), especially through the use of manual vacuum aspirators. Manual vacuum aspirators are critical for life-saving procedures for treating complications of abortions, both induced and spontaneous. Almost in all countries, post abortion care is an accepted best practice for managing complications of abortion. There are only a hand-full of countries that have strict regulations on providing access to safe abortion services. Almost all countries provide some conditions where abortion services are legal and life-saving. CO’s must determine their capacity to provide these services as well as their comfort level.

For more information see relevant chapters for the Inter-agency Field Manual on Reproductive Health in Humanitarian Settings in Annex 26.5.6 or additional resources in Annex 26.5.17.