Reproductive Health. in refugee situations. an Inter-agency Field Manual

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1 Reproductive Health i refugee situatios a Iter-agecy Field Maual

2 Reproductive Health i refugee situatios a Iter-agecy Field Maual

3 This Iter-agecy Field Maual replaces the above field-test versio. Additioal copies of the Field Maual ca be obtaied from the agecies cited o the back cover. Ay commets ca be directed to the followig: World Health Orgaisatio (WHO) Departmet of Reproductive Health ad Research Uited Natios Fud for Populatio Activities (UNFPA) Emergecy Relief Office, Geeva Uited Natios High Commissioer for Refugees (UNHCR) 1999 Uited Natios High Commissioer for Refugees This documet is issued for geeral distributio. All rights are reserved. Reproductios ad traslatios are authorised, except for commercial purposes, provided the source is ackowledged.

4 Reproductive health is a right; ad like all other huma rights it applies to refugees ad persos livig i refugee-like coditios. To exercise this right, populatios caught up i coflict ad livig i emergecy situatios must have a eablig eviromet ad access to complete reproductive health iformatio ad services so they ca make free ad iformed choices. They also must feel comfortable ad secure i discussig their most private cocers with those who seek to help them. FOREWORD Quality reproductive health services must be based o refugees, particularly wome refugees, eeds. They must also respect refugees various religious ad ethical values ad cultural backgrouds while coformig to uiversally recogised iteratioal huma rights stadards. Therefore, full iformatio o optios, ad access to reproductive health services should be provided, leavig the decisio to the idividual. Reproductive health care covers a wide rage of services. These are defied as follows i the Programme of Actio of the Iteratioal Coferece o Populatio ad Developmet (ICPD) held i Cairo, Egypt, i September 1994: family-plaig cousellig, iformatio, educatio, commuicatio ad services; educatio ad services for preatal care, safe delivery ad post-atal care, ad ifat ad wome s health care; prevetio ad appropriate treatmet of ifertility; prevetio of abortio ad the maagemet of the cosequeces of abortio; treatmet of reproductive tract ifectios, sexually trasmitted diseases, icludig HIV/AIDS; breast cacer ad cacers of the reproductive system, ad other reproductive health coditios; ad active discouragemet of harmful traditioal practices, such as female geital mutilatio. Providig comprehesive ad high-quality reproductive health services requires a multi-sectoral itegrated approach. Protectio, health, utritio, educatio ad commuity service persoel all have a part to play i plaig ad deliverig reproductive health services. The best way to guaratee that reproductive health services meet the eeds of the refugee commuity is to ivolve the commuity i every phase of the developmet of those services: from desigig programmes to lauchig ad maitaiig them to evaluatig their impact. Oly the will refugees beefit from services specifically tailored to their eeds ad demads; ad oly the will they have a stake i the future of those services. This Iter-agecy Field Maual o Reproductive Health i Refugee Situatios is the result of a collaborative effort of may UN agecies, govermetal ad o-govermetal orgaisatios ad refugees themselves. Iformatio i this Maual is based o the ormative, techical guidace of the World Health Orgaizatio. A draft of the Field Maual was first issued i 1996 ad tested extesively i the field. This ew versio ca, ad should, be shaped ad adapted to suit the particular circumstaces ad requiremets of each refugee situatio as it arises ad evolves. We are pleased with the progress already made i meetig the reproductive health eeds of refugees ad persos livig i refugee-like situatios; but we also kow this is o time to lose mometum. We hope the Field Maual will serve to improve the health ad well-beig of refugees ad foster more resposive ad appropriate actios i the field. Gro Harlem Brutlad Director Geeral WHO Nafis Sadik Executive Director UNFPA Sadako Ogata High Commissioer for Refugees UNHCR

5 At a Iter-agecy Symposium o Reproductive Health i Refugee Situatios held i Geeva, Switzerlad i Jue 1995, more tha 50 govermets, o-govermetal orgaisatios (NGOs) ad UN agecies committed themselves to stregtheig reproductive health (RH) services to refugees. Followig the symposium, a Iter-agecy Field Maual o Reproductive Health i Refugee Situatios was produced ad distributed for field-testig aroud the world. PREFACE This 1999 revisio of the Field Maual is the result of two years of field use ad comprehesive field-testig coducted uder the auspices of the Iter-agecy Workig Group o Reproductive Health i Refugee Situatios. More tha 100 experieced staff from 50 agecies workig i refugee situatios i 17 coutries applied the Field Maual i their programmes ad provided commets ad suggestios for improvig the cotet of the publicatio. The Field Maual supports the delivery of quality RH services. Techical stadards icluded i the Field Maual are those set by the World Health Orgaizatio. I several importat areas, the Field Maual provides programmatic directio with frequet referece to additioal resource materials that should be obtaied ad used to esure comprehesive ad reliable RH services for refugees. Field maagers of health services i refugee situatios are the primary audiece for the Field Maual. Commuity-services officers, protectio officers ad others workig to meet the eeds of refugee wome, youg people ad me should also beefit from the guidace offered i the Field Maual. The purposes of the Field Maual are: to serve as a tool to facilitate discussio ad decisio-makig i the plaig, implemetatio, moitorig ad evaluatio of RH itervetios; to guide field staff i itroducig ad/or stregtheig RH itervetios i refugee situatios, based o refugee eeds ad demads ad with full respect for their beliefs ad values; ad to advocate for a multi-sectoral approach to meetig the RH eeds of refugees ad to foster coordiatio amog all parters. Chapter Oe lays the foudatio for the subsequet techical chapters o reproductive health ad provides the guidig priciples for udertakig all RH care. It should be read carefully. The compoets of reproductive health described i the Field Maual are: Miimum Iitial Service Package Safe Motherhood Sexual Violece Sexually Trasmitted Diseases, icludig HIV/AIDS Family Plaig Other Reproductive Health Cocers Reproductive Health of Youg People

6 ACKNOWLEDGMENTS The etities listed cotributed to this Field Maual ad are amog those who believe it will facilitate the delivery of reproductive health services i refugee situatios. The UN, NGO ad Govermet members of the Iter-agecy Workig Group o Reproductive Health i Refugee Situatios (IAWG) are gratefully ackowledged for their cotiuous review of this Field Maual. Actio Cotre la Faim Africa Medical ad Research Foudatio America Refugee Committee CARE Cetre for Research o the Epidemiology of Disasters Cetro de Capacitació e Ecología y Salud para Campesios Ceter for Populatio ad Family Health Columbia Uiversity s Mailma School of Public Health Family Health Iteratioal Iteratioal Cetre for Migratio ad Health Iteratioal Federatio of the Red Cross ad Red Crescet Societies Ipas Iteratioal Plaed Parethood Federatio Iteratioal Rescue Committee Iteratioal Orgaizatio for Migratio JSI Research ad Traiig Istitute Lodo School of Hygiee ad Tropical Medicie Marie Stopes Iteratioal Médecis du Mode Médecis sas Frotières MERLIN (Medical Emergecy Relief Iteratioal) Populatio Coucil Save the Childre Fud UK Uited Natios Childre s Fud Uited Natios High Commissioer for Refugees Uited Natios Joit Programme o AIDS Uited Natios Fud for Populatio Activities U.S. Agecy for Iteratioal Developmet U.S. Ceters for Disease Cotrol ad Prevetio U.S. Departmet of Health ad Huma Services U.S. Departmet of State Wome s Commissio for Refugee Wome ad Childre World Associatio of Girl Guides ad Girl Scouts World Health Orgaizatio

7 Chapters TABLE OF CONTENTS 1 23 Miimum Iitial Service Package (MISP) 11 Fudametal Priciples 1 Safe Motherhood Sexual ad Geder-based Violece 35 Sexually Trasmitted Diseases, Icludig HIV/AIDS Family Plaig 65 Other Reproductive Health Cocers 79 Reproductive Health of Youg People 89 Surveillace ad Moitorig 95 Appedices a1 a2 a3 a4 Iformatio, Educatio, Commuicatio 119 Legal Cosideratios 127 Glossary of Terms 131 Referece Addresses 137 Each collaboratig agecy will implemet the itervetios described i this Field Maual accordig to its madate.

8 Fudametal Priciples 1 Reproductive health (RH) care should be available i all situatios ad be based o the eeds ad expressed demads of refugees, particularly wome, with full respect for the various religious ad ethical values ad cultural backgrouds of the refugees while also coformig with uiversally recogised iteratioal huma rights. The above priciple is the corerstoe of this Field Maual ad should be the basis of all RH itervetios. 1CHAPTER ONE Fudametal Priciples Cotets: Timely Reproductive Health Itervetios The Complexity of Iterveig Guidig Priciples 4 Commuity Participatio 4 Quality of Care 4 Itegratig Services 4 Iformatio, Educatio ad Commuicatio 4 Advocacy for Reproductive Health 4 Coordiatig Activities Needs Assessmet The Structure of the Field Maual Special Notes: a This Field Maual is iteded for use i refugee situatios. It may also be of use i refugee-like situatios, such as i situatios with iterally displaced persos or returee-affected areas. a The term refugee is used herei to describe the beeficiaries of RH care, regardless of their legal status. a UNHCR defies a emergecy as ay situatio i which the life or well-beig of refugees will be threateed uless immediate ad appropriate actio is take ad which demads a extraordiary respose ad exceptioal measures.

9 2 Fudametal Priciples Defiitio of Reproductive Health Reproductive health is a state of complete physical, metal ad social well beig ad ot merely the absece of disease ad ifirmity, i all matters relatig to the reproductive system ad to its fuctios ad processes. Reproductive health therefore implies that people are able to have a satisfyig ad safe sex life ad that they have the capability to reproduce ad the freedom to decide if, whe ad how ofte to do so. Implicit i this last coditio are the rights of me ad wome to be iformed ad to have access to safe, effective, affordable ad acceptable methods of family plaig of their choice, as well as other methods of their choice for regulatio of fertility which are ot agaist the law, ad the right of access to appropriate health-care services that will eable wome to go safely through pregacy ad childbirth ad provide couples with the best chace of havig a healthy ifat. Iteratioal Coferece o Populatio ad Developmet Cairo 1994; Programme of Actio, para 7.2 Timely Reproductive Health Itervetios Providig adequate food, clea water, shelter, saitatio ad primary health care (PHC) are priority activities i ay refugee emergecy. These itervetios help combat the major killers i refugee situatios: malutritio, diarrhoeal diseases, measles, acute respiratory ifectios (ARI) ad malaria (where prevalet). However, RH care is also crucial for the physical, metal ad social well beig of ay idividual. As a itegral part of PHC, RH care is importat i overcomig such problems as: complicatios of pregacy ad delivery, which are leadig causes of death ad disease amog refugee wome of childbearig age; malutritio ad epidemics, which ca further dimiish the physiological reserves of pregat or lactatig wome, thus edagerig their health ad that of their child; ad a absece of law ad order, commoly see i refugee emergecies, which, together with me s loss of power ad status, leads to a icreased risk of sexual violece. Violece agaist refugee wome, rape, sexual abuse, ivolutary prostitutio, eve physical assault durig pregacy have bee foud to be far more widespread tha was previously ackowledged. Some Geeral Facts About Reproductive Health a 585,000 wome die each year oe every miute from pregacy-related causes. Niety-ie per cet of these deaths occur i developig coutries. a Girls aged are twice as likely to die from childbirth as wome i their tweties. Those uder 15 are five times as likely to die from childbirth. a More tha 330 millio ew cases of sexually trasmitted diseases (STDs) occur every year, affectig 1 of every 20 adolescets. a By the year 2000, up to 40 millio people could be HIV-ifected. a 120 millio wome say they do ot wat to become pregat, but are ot usig ay method of family plaig. a 20 millio usafe abortios occur every year 55,000 each day resultig i some 80,000 deaths ad hudreds of thousads of disabilities. Source: WHO World Health Day Safe Motherhood 1998

10 Fudametal Priciples 3 Uquestioably, wome are most affected by reproductive health problems. For refugee wome, this burde is further compouded by the precariousess of their situatio. The Complexity of Iterveig Loss of icome reduces the refugees ability to make free choices. Wome may become solely resposible for the welfare of their families. Fulfillig the role of breadwier ofte represets a great emotioal ad physical burde that is ot adequately compesated by appropriate services. Attetio is ofte focused exclusively o immediate life-savig measures; RH care is ot cosidered a priority. (Hece the developmet of this Field Maual ad the recommedatios for the Miimum Iitial Service Package MISP described i Chapter Two.) CHAPTER ONE 1 It is importat that RH itervetios are ot oly timely but also appropriate ad cosistet with atioal laws ad developmet priorities. RH programmes affect highly persoal aspects of life, so programmes must be particularly sesitive to religious ad ethical values ad cultural backgrouds of the refugee populatio. It may ot always be feasible for oe orgaisatio to implemet the full rage of RH services. Providig comprehesive RH services may require cooperatio ad coordiatio amog agecies. Guidig Priciples for Itervetio The complexities of reproductive health were discussed at the Fourth World Coferece o Wome (Beijig 1995). Participats listed the followig as some of the reasos why may of the world s people do ot beefit from reproductive health:... iadequate levels of kowledge about huma sexuality; iappropriate or poor-quality RH iformatio ad services; the prevalece of high-risk sexual behaviour; discrimiatory social practices; egative attitudes towards wome ad girls; ad the limited power may wome ad girls have over their sexual ad reproductive lives. Platform of Actio, paragraph 7.3 Beijig 1995 A successful RH programme requires adequate ad well-traied staff, sufficiet fudig, ad effective commuity participatio quality of care itegratio of services iclusio of iformatio, educatio ad commuicatio (IEC) activities advocacy for reproductive health coordiatio amog relief agecies. These priciples are applicable to every aspect of RH assistace ad to all subsequet chapters of this Field Maual. Adolescets are particularly vulerable, they cocluded. Commuity Participatio Refugees face eve greater difficulties i obtaiig RH services. Amog them: The breakdow of pre-existig family support etworks meas that youg me ad wome lose their traditioal sources of iformatio, assistace ad protectio. Commuity participatio is essetial at all stages to esure the acceptability, appropriateess ad sustaiability of RH programmes. It is ecessary for empowerig refugees, particularly wome, to have greater cotrol over their lives ad over the services that are provided to them.

11 4 I a emergecy, refugees are extremely vulerable. It may be easy to overlook their particular eeds i the urgecy of providig services. Their participatio is vital i esurig that this does ot happe, ad that the services are adapted to the users rather tha vice versa. I each situatio it is ecessary to idetify groups ad chaels through which participatio ca be fostered. However, it is also importat to recogise that the leaders may ot be best placed or able to provide the iformatio ad support eeded to successfully adapt RH services to the populatio cocered. Participatio may be best achieved through the family uit. It is oly by takig ito accout the cultural, ecoomic, ethical, legal, liguistic ad religious backgrouds of the refugees ad host coutry populatio that appropriate services ca be offered to ad used by refugees. By actively participatig, refugees develop the sese of owership over programmes that is essetial for sustaiability. It is through commuity participatio that essetial iformatio will be gathered to direct the plaig of services. Such iformatio icludes: idetificatio of the traiig eeds of care providers; selectio of appropriate sites to avoid stigmatisatio of users; aalysis of the appropriate level of privacy ad cofidetiality required by local customs, cultures or beliefs; decisios o whether primarily female staff must be used; ad recogitio of birthig prefereces. A failure to obtai such iformatio may have a egative impact o the use of services, for example, if family members are excluded from a birth whe they have a importat cultural role to play at such times. It is importat that both me ad wome be ivolved i may aspects of the RH programme to promote resposible ad carig attitudes ad behaviour for the beefit of all. Although me may be poorly iformed about RH matters, they are ofte the decisiomakers. Health providers eed to be aware of the roles ad decisio-makig process withi the family so they ca provide services effectively ad i the best iterests of the whole family. Quality of Care Quality RH services require that orgaisatios, programmes ad providers, use appropriate techologies ad have traied staff, respect refugees rights to iformed coset by providig adequate iformatio ad cousellig, ad esure accessible services, privacy, cofidetiality, ad cotiuity of care. These aspects of quality of care are also guidig priciples of medical ethics i the protectio of huma rights. Appropriate Techologies ad Skills Appropriate techologies must be selected accordig to iteratioally accepted stadards. Providers must be adequately traied, equipped ad supervised. Appropriate supplies must be available, clea, ad, whe ecessary, sterile. All ivasive procedures must ivolve ifectio prevetio, proper use of drugs, etc. All itervetios must be safe which requires a sufficietly staffed health facility, techically competet providers, properly fuctioig equipmet, adequate supplies, ad a resposive logistics system. Access Primary health care (PHC) services must be available withi a reasoable distace from all patiets. A referral etwork, icludig trasportatio, to higher-level facilities should be coupled to PHC services. Patiets access to services should ot be cotiget o social or cultural backgrouds or o age, marital sta-

12 Fudametal Priciples 5 tus, parity, umber of male childre, sexual orietatio, or parter or paretal coset. Patiets should ot be required to accept oe service i order to gai access to aother type of service. Iformed Coset A patiet has the right to kow, before ay procedure is performed, what the procedure ivolves as well as its expected beefits, possible risks, duratio of treatmet, ad cost to the patiet or her/his family. This iformatio must be preseted to the patiet i a laguage that s/he ca uderstad. Iformed coset meas that the patiet ot oly has choices, but also ca make a educated decisio amog various optios. To make such a decisio, the patiet must kow her/his coditio ad have ample opportuity to ask questios ad receive aswers from a kowledgeable provider. Privacy Visual ad auditory privacy must be maitaied durig all phases of patiet care from presetatio through diagosis, testig, treatmet, ad cousellig. Examiatio tables should face away from doors ad widows so that a woma will ot risk exposure durig examiatio, particularly durig pelvic examiatio. Widows should be covered, ad partitios placed betwee examiatio areas. Others withi the health facility should ot be able to overhear the iteractio betwee the patiet ad health provider. Cofidetiality All iformatio regardig the patiet, her/his history, treatmet, coditio, circumstaces, ad progosis is discussed oly betwee the patiet, the provider ad supervisors. No staff member should share patiet iformatio with ayoe who is ot directly ivolved i the patiet s care without the patiet s permissio. Medical records should be stored i a locked room or file cabiet to which oly providers ad supervisors have access. Medical records should ever leave the cliic uless required for patiet referral to aother cliic. Respect All health staff should talk with patiets politely ad maage patiet care i a compassioate ad o-judgmetal fashio. Patiets have the right to ask questios ad to expect those questios will be aswered i a timely, complete ad uderstadable maer. Patiets eed to kow how to recogise ad maage commo complicatios of their coditio, sigs ad symptoms idicatig the eed for additioal medical attetio, ad whe ad how to obtai follow-up care. Itegratig Services It is importat to distiguish betwee differet aspects of itegratio. Reproductive health services should be itegrated ito primary health care. Itegratio may occur i relatio to the place at which services are provided or the persoel who provide those services. The potetial to itegrate services provided at ay particular site will deped o the skills ad resources available. It is ureasoable to expect the commuity health worker to provide too wide a rage of services. A health cetre will have greater resources ad more skilled persoel, ad so greater itegratio at oe site becomes possible. The referral-level facility must be able to provide services to meet all eeds. Successful itegratio is depedet o the quality of commuicatio amog the various persoel, at differet levels, withi the overall service. All persoel must be fully aware of how the system operates, what services are provided at each level, ad how those who wat to use the services ca do so. The staff at oe level must be able to provide iformatio about all other levels. Commuicatio must also esure that whe referrals are made betwee levels, adequate iformatio is received about a patiet at both eds of the service. Iformatio must travel i both directios ad must cover both the reasos for a referral ad the evetual cosequeces of ay actio take. CHAPTER ONE

13 6 Good commuicatio amog levels is essetial to deal satisfactorily with issues relatig to support, supervisio ad traiig, all of which are essetial i maitaiig quality. Specific traiig of persoel may be ecessary to esure that the desigated services ca be provided at each level by appropriately skilled persoel. RH services should be cosidered either as optioal or as special projects. They should be itegrated i a timely fashio withi PHC ad commuity service activities. Eve whe the delivery of RH services calls for special arragemets or resources, this caot justify their postpoemet or eglect. Iformatio, Educatio ad Commuicatio (IEC) Reproductive health requires kowledge ad uderstadig about huma sexuality ad appropriate, adequate ad accessible iformatio. It is importat to raise the level of kowledge about reproductio ad sexuality. Wome, me ad adolescets should uderstad how their bodies work ad how they ca maitai good reproductive health. Scietifically validated kowledge should be shared to promote free ad iformed choice ad to couter misperceptios ad harmful practices. IEC activities are essetial for sharig this kowledge. Such activities rage from oe-tooe coversatios betwee service providers ad refugees to highly developed formal campaigs. There are also effective IEC strategies that promote commuity participatio ad idividual commitmet to chagig behaviours. IEC essetials ca be foud i Appedix Oe. Advocacy for Reproductive Health The active promotio of reproductive health should be part of all refugee assistace programmes from the outset. A lack of awareess of the issues ivolved i protectig ad promotig reproductive health may be foud i all groups ivolved i a refugee settig, from the providers of health care to the commuity they serve. This lack of awareess may become a real barrier to improved reproductive health ad resposible sexual behaviour. However, opportuities to promote RH issues may be limited. Ay advocacy that is udertake must demostrate uderstadig of the culture, values ad belief systems of the local populatio. Advocacy that is isesitive or disrespectful may be couterproductive ad prompt rejectio, or eve reprisals, withi the refugee commuity. Coordiatig Activities Amog Relief Agecies Coordiatio is eeded amog: sectors (health, commuity services, protectio), implemetig agecies (govermet, NGOs, UN agecies), ad levels of service providers (doctors, midwives, Traditioal Birth Attedats [TBAs], health assistats). To foster this coordiatio, it is recommeded that a idividual be idetified as RH Coordiator i each refugee situatio. This perso would assume the resposibility for overall orgaisatio ad supervisio of RH activities, as well as the itegratio of these services withi other health services. The issue of sexual violece provides a excellet illustratio of the eed to coordiate amog sectors. To deal with the causes ad cosequeces of violece, health professioals must work closely with staff i the protectio ad commuity services sectors. By doig so, staff ca develop detailed procedures o

14 Fudametal Priciples 7 appropriate care for survivors ad strategies to prevet the occurrece of sexual violece. Coordiatio amog implemetig agecies requires that, although each agecy has its ow expertise ad rage of qualified staff, there should be a stadard approach used by all agecies ivolved. Eve though a agecy may ot provide a full rage of RH services, coordiatio with others would esure that the ed product is complemetary ad comprehesive RH care. Ucoordiated activities result i iappropriate allocatios of scarce resources ad reduced impact of the project. Needs Assessmet RH services must be based o the expressed eeds ad demads of refugees. RH eeds assessmets should be carried out whe the emergecy situatio has stabilised. This Field Maual does ot give detailed guidace o coductig eeds assessmet, but refers the field staff to a set of tools created by the Reproductive Health for Refugees (RHR) Cosortium for this purpose. (See Further Readig) The followig RH eeds assessmet tools have bee developed by the RHR Cosortium: Refugee Leader Questios Group Discussio Questios Survey (for aalysis by computer) Survey (for aalysis by had) Health Facility Questioaire ad Checklist These tools assist relief workers i gatherig iformatio to assess attitudes toward RH practices, local medical practices ad policies, the scope of eeded services ad the degree to which curret services provide what is eeded. The tools, which should be adapted to each situatio, are desiged to be used by people with field maagemet experiece ad/or RH experiece to desig ew RH programmes, assess existig capacity ad moitor services. The refugee commuity should be ivolved i the eeds assessmet process from the begiig. Refugees should participate i: coceptualisig the eeds assessmet framework, site selectio for the assessmet, traslatio/iterpretatio of tools, iterviewig fellow refugees, data aalysis ad iterpretatio, feedback to the commuity, desig or redesig of the RH programme based o the eeds assessmet fidigs. The Structure of the Field Maual The priciples that have bee developed withi this itroductio apply to all chapters throughout the Field Maual. Not all compoets of RH service provisio are appropriate withi the iitial phases of a refugee situatio. This Field Maual is iteded to assist field staff i implemetig such services i phases, movig from miimal to comprehesive services as the situatio gradually stabilises. I recogitio of the urgecy i dealig with some RH issues, Chapter Two of this Field Maual describes i detail the compoets of a Miimum Iitial Service Package (MISP). It is a rage of core RH activities to be carried out from the begiig of the emergecy. The activities outlied withi MISP should be coducted alogside other iitial-phase itervetios that take place i ay ewly idetified refugee or emergecy situatio. A more comprehesive package of RH itervetios must the be provided as the situatio stabilises. These itervetios should be itegrated ito Primary Health Care services. CHAPTER ONE

15 8 The remaiig chapters of the Field Maual ad the mai goal of each are: CHAPTER 2: OVERALL GOAL: CHAPTER 3: OVERALL GOAL: CHAPTER 4: OVERALL GOAL: CHAPTER 5: OVERALL GOAL: 6 7 CHAPTER 6: OVERALL GOAL: CHAPTER 7: OVERALL GOAL: 8 9 CHAPTER 8: OVERALL GOAL: CHAPTER 9: OVERALL GOAL: MISP iitiate selected RH activities as soo as feasible i a emergecy Safe Motherhood prevet excess materal ad peri/eoatal mortality ad morbidity Sexual ad Geder-based Violece prevet ad maage the cosequeces of sexual ad geder-based violece Sexually Trasmitted Diseases (STDs) icludig HIV/AIDS prevet ad treat STDs, reduce the trasmissio of HIV ifectio, ad assist i carig for those affected Family Plaig eable refugees to decide freely the umber ad spacig of their childre Other RH Cocers prevet excess materal morbidity ad mortality due to the complicatios of spotaeous ad usafe abortios ad promote the eradicatio of Female Geital Mutilatio. RH of Youg People promote ad support reproductive health of youg people Moitorig ad Surveillace set objectives, measure progress ad make programmatic decisios based o evidece

16 Fudametal Priciples 9 a1 APPENDIX Oe: OVERALL GOAL: Iformatio, Educatio, Commuicatio promote reproductive health of refugee populatios based o the refugee populatio s eeds ad desires CHAPTER ONE a2 a3 a4 APPENDIX Two: OVERALL GOAL: APPENDIX Three: OVERALL GOAL: APPENDIX Four: OVERALL GOAL: Legal Cosideratios provide iformatio o reproductive rights Glossary of Terms defie importat terms Referece Addresses assist the reader i obtaiig additioal referece documets Each chapter of the Field Maual begis with a overall goal ad provides detailed guidace o the elemets of the RH compoet. These elemets eed to be adapted to each refugee situatio i close collaboratio with host-coutry authorities. A checklist for establishig the particular RH compoet is provided at the ed of each chapter. This list ca also be used for supervisig ad moitorig. Further refereces ca also be foud at the ed of each chapter. This Field Maual does ot address a umber of other issues related to reproductive health, either because they are relatively less sigificat i terms of public health, or because they may be approached as i ormal situatios ad iformatio o the issue is abudat elsewhere. This is the case for most eeds of postmeopausal wome, elective abortio, reproductive tract cacers ad ifertility. Further Readigs Declaratio ad Platform for Actio, Fourth World Coferece o Wome, Beijig, Medical Ethics ad Huma Rights: Guidig Priciples, Commowealth Medical Associatio, Lodo, Programme of Actio, Iteratioal Coferece o Populatio ad Developmet, Cairo, Refugee Reproductive Health Needs Assessmet Field Tools, Reproductive Health for Refugees Cosortium, New York, Refugee Wome ad Reproductive Health Care: Reassessig Priorities, Wome s Commissio for Refugee Wome ad Childre, New York, Reproductive Health Services Durig Coflict ad Displacemet: Guidelies for the Desig ad Maagemet of Reproductive Health Programmes (i preparatio), WHO, Geeva, Reproductive Health Oe ad Five Day Traiig Packages, RHR Cosortium, New York, 1998.

17 10

18 Miimum Iitial Service Package 11 This Chapter describes a series of actios eeded to respod to the reproductive health (RH) eeds of populatios i the early phase of a refugee situatio (which may or may ot be a emergecy). The Miimum Iitial Service Package (MISP) ca be implemeted without ay ew eeds assessmet sice documeted evidece already justifies its use. The MISP is ot just kits of equipmet ad supplies; it is a set of activities that must be implemeted i a coordiated maer by appropriately traied staff. 2CHAPTER TWO Miimum Iitial Service Package (MISP) Cotets: Objectives of the MISP Compoets of the MISP 4 Idetify a orgaisatio(s) ad idividual(s) to facilitate the coordiatio ad implemetatio of the MISP 4 Prevet ad Maage the Cosequeces of Sexual Violece 4 Reduce HIV Trasmissio 4 Prevet excess eoatal ad materal morbidity ad mortality 4 Pla for the provisio of comprehesive RH services, itegrated ito Primary Health Care, as soo as possible Broad Terms of Referece for a RH Coordiator/Focal Poit Material Resources Moitorig ad Surveillace Special Note: a The reader must refer to the relevat chapters i the Maual to properly implemet the MISP.

19 12 Miimum Iitial Service Package (MISP) The major killers i refugee emergecies diarrhoea, measles, acute respiratory ifectios (ARI), malutritio ad malaria, where prevalet are well documeted. Resources should ot be diverted from dealig with these problems. However, there are some aspects of reproductive health that also must be addressed i this iitial phase to reduce mortality ad morbidity, particularly amog wome. Please remember that the compoets of MISP form a miimum requiremet. The expectatio is that the comprehesive services as outlied i the rest of this Field Maual will be provided as soo as the situatio allows. Objectives of the MISP: IDENTIFY a orgaisatio(s) ad idividual(s) to facilitate the coordiatio ad implemetatio of the MISP; PREVENT ad maage the cosequeces of sexual violece; REDUCE HIV trasmissio by 4 eforcig respect for uiversal precautios agaist HIV/AIDS ad 4 guarateeig the availability of free codoms; PREVENT excess eoatal ad materal morbidity ad mortality by 4 providig clea delivery kits for use by mothers or birth attedats to promote clea home deliveries, 4 providig midwife delivery kits (UNICEF or equivalet) to facilitate clea ad safe deliveries at the health facility, ad 4 iitiate the establishmet of a referral system to maage obstetric emergecies; ad PLAN for the provisio of comprehesive RH services, itegrated ito Primary Health Care (PHC), as the situatio permits Compoets of the MISP Idetify a Orgaisatio(s) ad Idividual(s) to Facilitate the Coordiatio ad Implemetatio of the MISP A qualified ad experieced perso should be idetified to coordiate RH activities at the start of the emergecy respose. The overall leadig agecy should be resposible for the desigatio of such a perso, ad the perso appoited should work uder the supervisio of the overall Health Coordiator. RH focal poits should be desigated withi each camp, ad withi each implemetig agecy. These health professioals, experieced i reproductive health, should be i post for a miimum of six moths, as it is likely to take this log to establish comprehesive RH services. All relief orgaisatios should, i accordace with their madates, ad withi the framework of emergecy preparedess ad respose, trai ad sesitise their staff o RH issues ad geder awareess. (See Terms of Referece for the RH Coordiator at the ed of this chapter.) Prevet ad Maage the Cosequeces of Sexual Violece Sexual violece is strogly associated with situatios of forced populatio movemet. I this cotext, it is vital that all actors i the emergecy respose are aware of this issue ad prevetive measures are put i place. The UNHCR Guidelies for Prevetio ad Respose to Sexual Violece agaist Refugees (1995) should be adhered to i the emergecy respose. Measures for assistig refugees who have experieced sexual violece, icludig rape, must also be established i the early phase of a emergecy.

20 Miimum Iitial Service Package 13 Wome who have experieced sexual violece should be referred to the health services as soo as possible after the icidet. Protectio staff should also be ivolved i providig protectio ad legal support to survivors of sexual violece. Key actios to be take durig the emergecy to reduce the risk of sexual violece ad respod to survivors are: desig ad locate refugee camps, i cosultatio with refugees, to ehace physical security esure the presece of female protectio ad health staff ad iterpreters iclude the issues of sexual violece i the health coordiatio meetigs esure refugees are iformed of the availability of services for survivors of sexual violece provide a medical respose to survivors of sexual violece, icludig emergecy cotraceptio, as appropriate idetify idividual or groups who may be particularly at risk to sexual violece (sigle female heads-of-households, uaccompaied miors, etc.) ad address their protectio ad assistace eeds. See Chapter Four for further iformatio o elemets of prevetio ad respose to sexual violece. Reduce HIV Trasmissio Eforce Respect for Uiversal Precautios Agaist HIV/AIDS Uiversal precautios agaist the spread of HIV/AIDS withi the health care settig must be emphasised durig the first meetig of Health Coordiators. Uder the pressure of a emergecy situatio, it is possible that field staff are tempted to take short cuts i procedures which ca jeopardise the safety of patiets ad staff. It is essetial that uiversal precautios be respected. (See Chapter Five for details o uiversal precautios.) Guaratee the Availability of Free Codoms Availability of codoms should be esured from the begiig so that they ca be provided to ayoe who requests them. Sufficiet supplies should be ordered immediately. (See Aex 3, Chapter Five, Prevetio ad Care of Sexually Trasmitted Diseases icludig HIV ad AIDS for calculatig codom supplies.) As well as providig codoms o request, field staff should make sure that refugees are aware that codoms are available ad where they ca be obtaied. Codoms should be made available i health facilities especially whe treatig cases of STDs. Other distributio poits should be established so that those requestig codoms ca obtai them i privacy. Prevet Excess Neoatal ad Materal Morbidity ad Mortality Provide Clea Delivery Kits for Use by Mothers or Birth Attedats to Promote Clea Home Deliveries A refugee populatio will iclude wome who are i the later stages of pregacy, ad who will therefore deliver withi the iitial phase. Simple delivery kits for home use should be made available for wome i the late stages of pregacy. These are very simple kits that the wome, themselves, or traditioal birth attedats (TBAs) ca use. They ca be made up o site ad iclude: oe sheet of plastic, two pieces of strig, oe clea razor blade ad oe bar of soap. UNFPA also supplies this kit. A formula, based upo the Crude Birth Rate (CBR), is used to calculate the supplies ad services required. With a CBR of three to five per cet per year, there would be some births i a three-moth period i a populatio of 10,000. From this, a calculatio ca be made as to how may kits should be ordered. Provide Midwife Delivery Kits (UNICEF or equivalet) to Facilitate Clea ad Safe Deliveries at the Health Facility I the early phase of a emergecy, births will ofte take place outside the health facility with- CHAPTER TWO

21 14 out the assistace of traied health persoel. Approximately 15 per cet of births will ivolve some complicatios. Complicated births should be referred to the health cetre. The supplemetary uit of the New Emergecy Health Kit 98 (NEHK-98) has all the materials eeded to esure safe ad clea ormal deliveries. May obstetric emergecies ca be maaged with the equipmet, supplies ad drugs cotaied i the NEHK-98. Obstetric complicatios that caot be maaged at the health cetre should be stabilised before trasfer to the referral hospital. Iitiate the Establishmet of a Referral System to Maage Obstetric Emergecies Approximately three to seve per cet of deliveries will require Caesarea sectio. Additioal obstetric emergecies may eed to be referred to a hospital that is capable of performig comprehesive essetial emergecy obstetric care. (Refer to Chapters Three ad Seve for iformatio o pregacy ad delivery complicatios.) As soo as the situatio permits, a referral system that maages obstetric complicatios must be available for use by the refugee populatio 24 hours a day. Where feasible, a host-coutry referral facility should be used ad supported to meet the eeds of refugees. If this is ot feasible because of distace or the iability of the hostcoutry facility to meet the icreased demad, the a appropriate refugee-specific referral facility should be provided. I either case, it will be ecessary to coordiate with host-coutry authorities cocerig the policies, procedures ad practices to be followed withi the referral facility. The protocols of the host coutry should be followed, although some variatio may have to be egotiated. Be sure there is sufficiet trasport, qualified staff ad materials to cope with the extra demads. Pla for the Provisio of Comprehesive RH Services, Itegrated Ito Primary Health Care, as Soo as Possible It is essetial to pla for the itegratio of RH activities ito primary health care durig the iitial phase. If ot, the provisio of these services may be delayed uecessarily. Whe plaig, it is importat to iclude the followig activities: The collectio of backgroud iformatio o materal, ifat ad child mortality, available HIV/STD prevalece ad cotraceptive prevalece rates (CPR). This iformatio ca be obtaied from the refugees coutry of origi from such sources as WHO, UNFPA, the World Bak ad Demographic ad Health Survey (DHS). Gatherig this iformatio could be the resposibility of the Headquarters of implemetig agecies who may have ready access to these data. The idetificatio of suitable sites for the future delivery of comprehesive RH services (as described i the remaider of this Field Maual). It is importat to address the followig factors whe selectig suitable sites: 4 security both at the poit of use ad while movig betwee home ad the service delivery poit 4 accessibility for all potetial users 4 privacy ad cofidetiality durig cosultatios 4 easy access to water ad saitatio facilities 4 appropriate space 4 aseptic coditios A assessmet of the capacity of staff to udertake comprehesive RH services should be made ad plas put i place to trai/retrai staff. Equipmet ad supplies for comprehesive RH services should be ordered. This will allow comprehesive services to begi as soo as the situatio stabilises.

22 Miimum Iitial Service Package 15 CHAPTER TWO Broad Terms of Referece for a RH Coordiator/ Focal Poit Uder the auspices of the overall health coordiatio framework, the RH Coordiator/Focal Poit should a be the focal poit for RH services ad provide techical advice ad assistace o reproductive health to refugees ad all orgaisatios workig i health ad other sectors as eeded. a liaise with atioal ad regioal authorities of the host coutry whe plaig ad implemetig RH activities i refugee camps ad amog the surroudig populatio, where appropriate. a liaise with other sectors (protectio, commuity services, camp maagemet, educatio, etc.) to esure a multi-sectoral approach to reproductive health. a create/adapt ad itroduce stadardised strategies for reproductive health which are fully itegrated withi PHC. a iitiate ad coordiate various audiece-specific traiig sessios o reproductive health (for audieces such as health workers, commuity services officers, the refugee populatio, security persoel, etc.). a itroduce stadardised protocols for selected areas (such as sydromic case maagemet of STDs, referral of obstetric emergecies, medical respose to survivors of sexual violece, cousellig ad family plaig services, etc.). a develop/adapt ad itroduce simple forms for moitorig RH activities durig the emergecy phase that ca become more comprehesive oce the programme is cosolidated. a report regularly to the health coordiatio team. Material Resources New Emergecy Health Kit 98 (NEHK-98) The revised NEHK-98 (for 10,000 people for three moths) cotais the followig supplies to implemet the MISP: What is i the NEHK-98 to implemet the MISP Materials for uiversal precautios for ifectio cotrol Equipmet, supplies ad drugs for deliveries at health cetres Equipmet, supplies ad drugs for some obstetric emergecies Equipmet, supplies ad drugs for post-rape maagemet

23 16 A booklet-describig the NEHK-98 ad how it ca be ordered is available from WHO. Reproductive Health Kit A RH Kit for Emergecy Situatios has bee developed by UNFPA, i cooperatio with others, for use i refugee situatios. It complemets the NEHK-98 ad should be ordered as eeded to lauch the MISP ad support the referral system. The RH Kit is made up of 12 sub-kits, which ca be ordered separately. Materials ad supplies i Subkits 3 ad 6 are already available i the NEHK-98. To order RH sub-kits from UNFPA, cotact the UNFPA Coutry Director i the coutry of asylum, the UNFPA Emergecy Relief Office i Geeva or the UNFPA Procuremet Office i New York. The RH Kit is targeted for use i the iitial acute phase of the emergecy. Oce the situatio stabilises, procuremet of RH materials ad supplies should be doe alog with other health programme supply ad drug orderig. What is i the UNFPA RH Kit For use at primary health care/health cetre level: 10,000 populatio for three moths 0 Traiig ad Admiistratio 1 Codoms 2 Clea delivery sets 3 Post-rape maagemet 4 Oral ad ijectable cotraceptives 5 STD Drugs For use at health cetre or referral level: 30,000 populatio for three moths 6 Professioal midwifery delivery kit 7 IUD isertio 8 Maagemet of the complicatios 8 of usafe abortio 9 Suture of cervical ad vagial 8 tears 10 Vacuum extractio For use at the referral level: 150,000 populatio for three moths 11 A Referral-Level Surgical 11 (reusable equipmet) 11 B Referral-Level Surgical 11 (cosumable items ad drugs) 12 Trasfusio (HIV testig for blood 11 trasfusio) A booklet describig the RH Kit ad how it ca be ordered is available from UNFPA. (See Appedix Four for cotact addresses.)

24 Miimum Iitial Service Package 17 Moitorig ad Surveillace CHAPTER TWO Durig the early phase of the emergecy, a limited amout of data should be collected to assess the implemetatio of the MISP. Iformatio o mortality ad morbidity by age ad sex should be routiely collected durig the early phase of a emergecy. Refer to Chapter Nie for more iformatio o these idicators. Cosider selectig MISP idicators from the followig list. MISP Idicators a Icidece of sexual violece: Moitor the umber of cases of sexual violece reported to health services, protectio ad security officers. a Supplies for uiversal precautios: Moitor the availability of supplies for uiversal precautios, such as gloves, protective clothig ad disposal of sharp objects. a Estimate of codom coverage: Calculate the umber of codoms available for distributio to the populatio. a Estimate of coverage of clea delivery kits: Calculate the umber of clea delivery kits available to cover the estimated births i a give period of time.

25 18 Checklist for the RH MISP a Collect or estimate basic demographic iformatio Total populatio Number of wome of reproductive age Number of me of reproductive age Crude birth rate Age-specific mortality rate Sex-specific mortality rate Number of pregat wome Number of lactatig wome a Prevet ad maage the cosequeces of sexual ad geder-based violece Systems to prevet sexual violece are i place Health service able to maage cases of sexual violece Staff traied (retraied) i prevetio ad respose systems for cases of sexual violece a Prevet HIV trasmissio Materials i place for adequate practice of uiversal precautios Codoms procured ad distributed Health workers traied/retraied i practice of uiversal precautios a Prevet excess eoatal ad materal morbidity ad mortality Clea delivery kits available ad distributed UNICEF midwife kits (or equivalet) available at the health cetre Staff competecy assessed ad retraiig udertake Referral system for obstetric emergecies fuctioig a Pla for the provisio of comprehesive RH services Basic iformatio collected (mortality, HIV prevalece, CPR) Sites idetified for future delivery of comprehesive RH services a Idetify a orgaisatio(s) ad idividual(s) to facilitate the MISP Overall RH Coordiator i place ad fuctioig uder the health coordiatio team RH focal poits i camps ad implemetig agecies i place Staff traied ad sesitised o techical, cultural, ethical, religious ad legal aspects of RH ad geder awareess Materials for the implemetatio of the MISP available ad used

26 Safe Motherhood 19 3 Safe Motherhood programmes are desiged to reduce the high umbers of deaths ad illesses resultig from complicatios of pregacy ad childbirth. I too may coutries, materal mortality is a leadig cause of death for wome of reproductive age. Most materal deaths result from haemorrhage, complicatios of usafe abortio, pregacy-iduced hypertesio, sepsis ad obstructed labour. Safe Motherhood programmes seek to address these direct medical causes ad udertake related activities to esure wome have access to comprehesive reproductive health services. Causes of Materal Mortality Globally CHAPTER THREE Safe Motherhood Cotets: MISP ad Safe Motherhood Safe Motherhood i Stabilised Situatios Providig ateatal, delivery ad postpartum care to the mother ad immediate care of the eoate Support for Breastfeedig Itegratig Services ad Iformatio, Educatio ad Commuicatio (IEC) Huma Resource Requiremets Moitorig Service Provisio Also Icluded: Mother-Baby Package Itervetios Checklist for Establishig Safe Motherhood Services Prototype Home-based Materal Record WHO Partograph a Severe bleedig 25% a Idirect causes 20% a Ifectio 15% a Usafe abortios 13% a Eclampsia 12% a Obstructed labour 8% a Other direct causes 8% WHO: World Health Day Safe Motherhood 1998

27 20 Safe Motherhood I this Field Maual, Safe Motherhood icludes ateatal care, delivery care (icludig skilled assistace for delivery with appropriate referral for wome with obstetric complicatios) ad postatal care, icludig care of the baby ad breastfeedig support. Sexually trasmitted disease (STD)/HIV/AIDS prevetio ad maagemet, family plaig services, ad other RH cocers should be itegrated with Safe Motherhood activities ad are discussed i Chapters Five, Six ad Seve, respectively. MISP ad Safe Motherhood Please refer to Chapter Two for the aspects of Safe Motherhood which must be dealt with i the iitial phase of a refugee situatio. The activities withi the MISP related to Safe Motherhood help prevet excess eoatal ad materal morbidity ad mortality by: providig clea delivery kits for use by mothers or birth attedats to promote clea home deliveries; providig midwife delivery kits (UNICEF or equivalet) to facilitate clea ad safe deliveries at the health facility; ad by iitiatig the establishmet of a referral system to maage obstetric emergecies. The idividual appoited as RH Coordiator should be resposible for all RH services icludig Safe Motherhood, to esure optimum itegratio of all the various aspects of reproductive health. Safe Motherhood i Stabilised Situatios As soo as feasible, comprehesive services for ateatal, delivery ad postpartum care must be orgaised. Plaig for such services should take ito accout existig facilities for the local populatio. Both refugee ad local populatio eeds should be cosidered. Services should be able to deal with obstetric ad other medical emergecies. For obstetric emergecies, it is preferable to support host-coutry services rather tha establish ew ad refugee-specific facilities that will ot be maitaied i the log term. Approximately 15 per cet of pregat wome will develop complicatios that require essetial obstetric care, ad up to five per cet of pregat wome will require some type of surgery. The followig ratios have bee foud to be successful i may situatios: oe health post/cliic with traied commuity health workers ad traditioal birth attedats (TBAs) able to idetify problems ad refer for every 5,000 people; oe equipped health cetre providig basic essetial obstetric care for every 30,000-40,000 people; oe operatig theatre ad staff, capable of performig 24 hour comprehesive essetial obstetric care, for every 150,000 to 200,000 people. To make sure that the services provided are appropriate ad of the highest quality ad will be fully used, it is essetial to: idetify skilled care providers ivolved i childbirth (physicias, midwives, experieced urses, traied TBAs); provide refresher traiig ad close supervisio as idicated; be aware of ad discuss commuity beliefs ad practices ad health-seekig behaviour related to delivery, such as positio for delivery, presece of relatives for support ad traditioal practices both positive (breastfeedig) ad harmful (female geital mutilatio); ad esure that all refugee wome ad their families kow where to obtai assistace for ateatal care ad delivery ad how to recogise sigs of complicatios.

28 Safe Motherhood 21 Ateatal care The primary objective of ateatal care is to establish cotact with the wome, ad idetify ad maage curret ad potetial risks ad problems. This creates the opportuity for the woma ad her health care provider to establish a delivery pla based o her uique eeds, resources ad circumstaces. The delivery pla idetifies her itetios about where ad with whom she iteds to give birth ad cotigecy plas i the evet of complicatios (trasport, place of referral, etc.). At least three ateatal visits are recommeded, ideally with the first visit early i the pregacy. This umber may vary based o atioal policies. Appropriate ateatal care should iclude: Assessmet of materal health. This icludes ot oly determiig the pregat woma s overall health status, but also idetifyig factors which may adversely affect pregacy outcome. These factors iclude: age (youger tha 17 or older tha 40), grad multipara, sigificatly short stature, ad obstetric history of ay previous complicatios, icludig surgery. While this screeig may help idetify some wome who will develop complicatios, it will ot idetify all of them. Thus it is critically importat to idetify ad maage complicatios as they arise amog all pregat wome. The home-based materal record at the ed of the Chapter should be adapted ad used to record care provided to wome durig pregacy. Female geital mutilatio is a particular risk i some coutries (see Chapter Seve). Wome who have bee subjected to this procedure, especially to ifibulatio, should be idetified durig the ateatal period. Detectio ad maagemet of complicatios. Special emphasis should be placed o idetifyig the acute complicatios of usafe abortios or ate-partum haemorrhages. Other complicatios, such as hypertesive diseases, aaemia, diabetes, malaria or a STD, are less obvious ad require more detailed physical examiatio. Treatmet for existig health coditios should be udertake. Syphilis testig is recommeded at least oce durig pregacy, preferably before the third trimester. Systematic testig for syphilis i pregacy is cost-effective if the prevalece of syphilis is oe per cet or more i the geeral populatio. Screeig for Syphilis i Pregacy usig RPR Syphilis ad other STDs cotribute to the trasmissio of HIV, materal morbidity ad egative pregacy outcome. I a recet study of 3,591 HIV-egative Malawi wome with a active syphilis rate of 3.6 per cet, 21 per cet of periatal deaths, 26 per cet of stillbirths, 11 per cet of eoatal deaths ad 8 per cet of ifat deaths were attributable to syphilis. Testig for syphilis i pregacy ca be udertake at the ateatal cliic by usig the RPR (rapid plasma reagi) test. Staff must be traied, but sophisticated laboratory equipmet is ot eeded for routie RPR testig. Periodically, quality cotrol of RPR testig with laboratory verificatio usig Trepoema Pallidum Haemagglutiatio test (TPHA) should be udertake to esure accuracy of RPR testig. RPR testig for syphilis i pregacy has bee successfully udertake i refugee camps i Tazaia. Prevalece of syphilis i pregacy usig RPR raged from 7 to 20 per cet. Observatio ad recordig of cliical data. Height, blood pressure, search for oedemas, proteiuria ad haemoglobi (if idicated by cliical sigs), uterie growth, fetal heart rate ad presetatio should be recorded. Maiteace of materal utritio. The recommeded miimum utritioal requiremets for a pregat woma have bee set at CHAPTER THREE

29 22 2,300 kcal per day of a balaced ad culturally acceptable diet. Supplemetary food may be required if the basic food ratio available or distributed to refugees is iadequate. The offer of supplemetal food ca be a good icetive to get wome to atted for ateatal care. Health care providers should be alert to sigs of iro-deficiecy aaemia ad iodie deficiecy disorder (IDD). Health educatio. The followig topics should be part of the educatioal activity related to ateatal care: choosig the safest place for delivery; clea delivery; the major symptoms of complicatios (bleedig, severe abdomial pai, headache); where ad whe to seek care for complicatios; exclusive breastfeedig; materal utritio; STD/HIV/AIDS prevetio; immuisatio; ad family plaig. Vitami A Supplemetatio i Pregacy Where Vitami A Deficiecy is edemic amog childre ad materal diets are low i Vitami A, health workers should provide: a daily supplemet ot exceedig 10,000 IU vitami A durig pregacy or a weekly supplemet ot exceedig 25,000 IU Vitami A after the first trimester. These supplemets will beefit the mother ad her developig fetus with little risk of harm to either after the mother gives birth, she should receive 200,000 IU vitami A. Prevetio of major diseases. Prevetive measures should iclude: iro folate prophylaxis (aaemia occurs i about 60 per cet of pregat wome i developig coutries); tetaus toxoid immuisatio; Vitami A supplemets; atimalarials (accordig to coutry policies) ad atihelmithics (hookworms) i edemic areas. Iodized oil/salt may be give i areas of moderate or severe IDD ad followig atioal protocols. Delivery Care This Field Maual does ot cotai details of how to coduct deliveries. See the Further Readig list for this iformatio. Eve with the best possible ateatal screeig, ay delivery ca become a complicated oe requirig emergecy itervetio. Therefore, skilled assistace is essetial to delivery care. I the absece of midwives or urses, TBAs (who usually perform home deliveries, ofte as a source of icome) should be traied to idetify complicatios, provide immediate first aid, ad kow whe ad where to refer wome for additioal care. It should also be remembered that: the first priority for a delivery is to be safe, atraumatic ad clea; ad most materal deaths are due to a failure to get skilled help i time for delivery complicatios. It is critical to have a well-coordiated system to idetify complicatios ad esure their maagemet with immediate first aid ad/or referral. As a rule, the further away the referral facility, the earlier you itervee. Delays i obtaiig help may be at the commuity level (i idetifyig ad referrig wome with difficulties); e route to the referral facility (iability to get trasport, poor road coditios); or o arrival at the referral facility (absece of staff, lack of drugs or other materials). All three possibilities for delay must be miimised. Midwives ad TBAs should also take care of the ewbor by: clearig the airway, keepig the baby warm, providig eye ad cord care,

30 Safe Motherhood 23 helpig mothers begi breastfeedig (ad ot givig ay other foods or liquids to the baby), ad idetifyig complicatios which require referral. Birth weights should also be measured. Deliveries outside a equipped health facility. TBAs or family members will ofte assist deliveries. Therefore, early idetificatio of midwives or TBAs withi the commuity, their traiig ad supervisio o the proper use of clea delivery kits (clea place, clea hads, proper cord care) ad idetificatio ad maagemet of complicatios (whe ad where to refer), are essetial to prevet excess materal morbidity ad mortality. Deliveries i equipped health cetres. These health facilities, whether temporary or permaet, should be equipped with the appropriate huma ad material resources to take care of all but surgical cases. Wherever possible, atioal health facilities should be used ad supported. The followig basic essetial obstetric care should be provided ad stadard protocols used to moitor ad maage labour. These iclude: iitial assessmet, duratio, use of a partograph (see Aex 2); assessmet of fetal well beig; episiotomy; special care for wome who have udergoe geital mutilatio (see Chapter Seve); use of vacuum extractor; maagemet of haemorrhage; maagemet of eclampsia; multiple birth; breech delivery; ad procedures for referral to ext level of care, if ecessary. Protocols must be taught to health staff, publicly displayed ad made available i all health cetres. Basic essetial obstetric care should be performed at the health-cetre level to address, or stabilise before referral, the mai complicatios of delivery, such as ate-partum haemorrhage, eclampsia, prologed labour, uterie rupture, post-partum haemorrhage, repair of vagial ad cervical tears, ad retaied placeta. These facilities should therefore be equipped with broad spectrum ijectable ad oral atibiotics (ampicilli, peicilli, doxycyclie, getamici, metroidazole), plasma expaders, ati-covulsats, oxytocics, ergometrie, aalgesics, magesium sulphate, suturig kits, high sterilisatio techiques, gloves, syriges ad eedles, delivery equipmet, ad materials for uiversal precautios. These facilities should also be able to provide for resuscitatio ad basic care of the ewbor (e.g., maagemet of hypothermia ad hypoglycemia), icludig measuremet of birth weight. A readily available prophylactic to prevet eoatal ophthalmia, ideally tetracyclie eye oitmet, should be give to all ewbors. Deliveries at referral hospitals. A referral hospital i which surgical procedures ca be performed may exist i some major refugee operatios. However, very ofte, severe complicatios will be maaged at the earest major health facility of the host coutry. I this case, try to avoid swampig the facility with the demads of the refugee populatio to the detrimet of the local people. Timely ad appropriate support to the local health facility must be give as soo as possible. The agreemet ad support of the Miistry of Health should be secured i order to formalise the itegratio ad coordiatio of obstetric services betwee the refugee settlemet ad the local health facility. The referral hospital should be able to perform safely comprehesive essetial obstetric care, such as Caesarea sectios, laparotomy, hysterectomy, repair of cervical ad severe (third degree) vagial tears, care for complicatios due to usafe abortio, ad safe blood trasfusio. A appropriate referral system requires referral protocols specifyig whe ad where to refer ad a adequate record of referred cases. This implies coordiatio, commuicatio, CHAPTER THREE

31 24 cofidece ad uderstadig betwee the TBAs ad their supervisors (usually midwives) ad betwee the health cetre ad the hospital with surgical facilities. A effective referral system will also have to take ito accout security, geographical ad trasport costraits. Essetial Obstetric Services Basic Essetial Obstetric Care pareteral atibiotics pareteral oxytocic drugs pareteral sedatives for eclampsia maual removal of placeta maual removal of retaied products Comprehesive Essetial Obstetric Care Basic Care PLUS surgery aaesthesia safe blood trasfusio (HIV testig) Postpartum Care Sice up to 50 per cet of materal deaths occurs after delivery, a midwife or a traied ad supervised TBA should visit all mothers as soo as possible withi the first hours after birth. The midwife or TBA should assess the mother s geeral coditio ad recovery after childbirth ad idetify ay special eeds. This attetio is particularly importat whe the woma is aloe as head of the family. The postpartum visit provides a occasio for assessig ad discussig issues of clealiess, care of the ewbor, breastfeedig ad appropriate methods ad timig of family plaig (see Chapter Six). Health providers should support early ad exclusive breastfeedig, ad discuss proper utritio with the mother. Iro folate tablets should be cotiued ad Vitami A ad iodised oil/salt should be provided whe ecessary. Durig the postpartum visit, the health ad well beig of the ewbor should also be assessed ad its birth weight measured. Newbors should be referred to the uder-five cliic to start immuisatios, growth moitorig ad other well-child services. Commuity Health Workers (CHW) ad TBAs should be traied for appropriate referral of postpartum complicatios, such as haemorrhage, sepsis, perieal trauma, breastfeedig problems, ad ewbor complicatios, such as prematurity or failure to thrive, that may require additioal surveillace ad/or treatmet. Itegratig Services ad IEC I the stabilisatio phase, ateatal ad postatal services should be offered i a appropriate eviromet, i the same locatio as family plaig, STD services, the baby cliic ad ay other services related to primary health care. Some situatios may beefit from a wome s house which offers peer support, cousellig ad health promotio i a o-threateig eviromet. This resource is especially importat for adolescet ad ew mothers. Such a place might also provide a suitable veue for small-scale icome-geeratig or female literacy activities. Effective dissemiatio of iformatio is vital if wome are to ejoy access to available services. The commuity s kowledge ad attitudes regardig medical care durig pregacy ad childbirth must be assessed. If there is suspicio ad fear of medical itervetios, such as hospital delivery, Caesarea sectio or blood trasfusio, appropriate IEC activities may be ecessary. New procedures, such as screeig blood for syphilis, should be preceded by educatioal activities that explai ad dispel miscoceptios about the procedures. Health workers should cosider ivitig a compaio who will be preset at the time of delivery to atted ateatal cliics with the pregat woma. Through TBAs ad/or CHWs, the refugee populatio, as a whole, should be made aware of the warig sigs

32 Safe Motherhood 25 of impedig complicatios i pregacy ad labour ad ecouraged to pla how to reach the equipped medical facility, if ecessary. Give that me ad older family members ofte make the decisios withi the family, it is particularly importat that educatioal activities target these groups. Huma Resource Requiremets A midwife or a experieced urse is best suited to orgaise ad supervise the Safe Motherhood programme. A midwife ca effectively supervise 10 to 15 TBAs for a estimated populatio of 20,000-30,000. I may societies, TBAs are usually the key people at the commuity level who will ifluece materal ad ewbor care, although their ifluece ad skills may vary from culture to culture. I geeral, oe TBA ca look after 2,000 to 3,000 refugees. With a crude birth rate of three per cet per year, this meas roughly five to eight deliveries per moth per TBA. With adequate traiig ad supervisio, some experieced TBAs ca: idetify complicatios; refer wome with delivery complicatios to appropriate medical facilities; provide care for ormal pregacy through labour, delivery ad the postpartum period; ad offer family plaig iformatio ad services. TBAs, however, are o substitute for a more skilled attedat at birth. Bear i mid that female health care providers are usually preferred to atted births. Traiig ad supervisio of health workers i Safe Motherhood practices should be evaluated ad plaed i coordiatio with the commuity (both refugee ad host), NGOs ad UN agecies. The ature of the traiig will vary depedig o the services the health worker provides ad the skills required for those services. Moitorig Service Provisio Services should be cotiuously reviewed. Efforts should be made to collect reliable iformatio o materal deaths. Every materal death should be ivestigated to determie the cause ad actio take ad to esure that the referral system is respodig appropriately to obstetric emergecies. Record keepig (adapted to the literacy level of record keepers) is essetial for appropriate surveillace. Home-based materal records (see Aex 1), kept by the mother, have prove advatages. The followig is a list of suggested idicators for moitorig Safe Motherhood itervetios i refugee situatios. Refer to Chapter Nie for further iformatio. Safe Motherhood Idicators a Idicators to be collected from the health-facility level Crude birth rate Neoatal mortality rate Stillbirth ratio Coverage of ateatal care Coverage of syphilis screeig Coverage of traied delivery services Coverage of postpartum care Icidece of obstetric complicatios a Idicators collected at the commuity level The kowledge of the commuity regardig safe motherhood itervetios should be assessed periodically. a Idicators cocerig traiig ad quality of care Supervisors should periodically assess the skills of health care providers to esure quality of care of Safe Motherhood itervetios. CHAPTER THREE

33 26 Support for Breastfeedig Breastfeedig is particularly importat i emergecy situatios because of the icreased risk of diarrhoea ad other ifectios, ad because the warmth ad care which breastfeedig provides is crucial to both mothers ad childre. I these situatios, it may be the oly sustaiable source of food for ifats ad youg childre. The well-kow risks associated with bottle feedig ad breast milk substitutes are dramatically icreased due to poor hygiee, crowdig ad limited water ad fuel. Sice breastfeedig is also a importat traditioal activity for wome, it ca help uprooted wome preserve a sese of their self-worth. For iformatio o HIV ad breastfeedig, refer to Chapter Five. Optimal Feedig Practices i Emergecies Iitiate breastfeedig withi oe hour of birth. Promote colostrum as a health beefit to ewbors, while beig sesitive to commoly held beliefs to the cotrary. Implemet the Te steps to successful breastfeedig (1989 Joit WHO/UNICEF statemet, protectig, promotig ad supportig breastfeedig). Ecourage frequet, o-demad feedig (icludig ight feeds). Promote exclusive breastfeedig. O-demad breastfeedig durig the first six moths provides 98 per cet cotraceptive protectio, provided meses has ot retured, ad o other food is give to the baby. Surrogate feedig/wet ursig is a alterative for a orphaed child or if the mother is disabled or abset. Supplemet breast milk with appropriate weaig foods startig at six moths of age. Ecourage breastfeedig well ito the secod year of life or beyod. HIV-positive mothers may eed special support ad cousellig see Chapter Five. Durig a child s illess, breastfeedig frequecy should be icreased, as it should after a child s illess so the child ca catch up o its growth. 2,500 kcal per perso per day of culturally appropriate food is recommeded as a miimum requiremet for lactatig wome. The distributio of supplemetary food to lactatig wome may be ecessary whe the diet available to the refugee populatio is iadequate. Couteractig Commo Miscoceptios about Breastfeedig i Emergecies MYTH: Wome uder stress caot breastfeed. a TRUTH: Wome uder stress CAN successfully breastfeed. Milk productio is stable; but milk release (let dow) ca be affected by stress. The treatmet for poor milk release ad for low productio is icreased sucklig ad social support. The most effective support for a breastfeedig woma comes from other breastfeedig wome. MYTH: Malourished wome do t produce eough milk. a TRUTH: Malourished wome DO produce eough milk. It is extremely importat to distiguish betwee true cases of isufficiet milk productio (very rare) ad mis-

34 Safe Motherhood 27 take perceptios. Milk productio remais relatively uaffected i quatity ad quality except i extremely malourished wome. Malourished wome ad childre are best served by feedig the mother ad lettig her breastfeed the ifat. By doig so, you protect the health of both mother ad child. Givig supplemets to ifats decreases sucklig ad so ca reduce milk productio. The treatmet for isufficiet milk productio real or perceived is to icrease sucklig frequecy ad duratio, esure the mother has sufficiet food ad liquids, ad offer reassurace from other breastfeedig wome. CHAPTER THREE MYTH: Breast milk substitutes are eeded durig a emergecy. a TRUTH: Usually, breast milk substitutes are NOT appropriate. There are good guidelies o the use of breast milk substitutes ad other milk products i emergecies. They iclude the WHO Iteratioal Code of Marketig of Breast Milk Substitutes (May 1981), the UNHCR guidelies o the use of milk substitutes (July 1989), ad the World Health Assembly resolutio 47.5 (May 1994). Uder the Code, doors must esure that ay child who receives a breast milk substitute is guarateed a full, cost-free supply for at least six moths. These guidelies iclude stipulatios that breast milk substitutes are: ot used as a sales iducemet; used oly for a limited target group of babies (i.e., for orphas i istaces where wet urses are ot available); used uder cotrolled coditios (i.e., for therapeutic feedig; ever i geeral distributio); ad accompaied by additioal health care, diarrhoea treatmet, water ad fuel. I additio, the guidelies assert that feedig bottles ad teats should ot be provided by relief agecies except uder strict supervisio; ad their use should otherwise be discouraged. These guidelies should be dissemiated ad followed by all agecies workig i emergecies. MYTH: Geeral promotio of breastfeedig is eough. a TRUTH: Breastfeedig wome NEED assistace; geeral promotio of breast-feedig is NOT eough. Most health practitioers have little kowledge of breastfeedig ad lactatio maagemet. Wome who are displaced or are i emergecy situatios are at icreased risk of breastfeedig problems. They eed help, ot just motivatioal messages. Health workers may eed to be traied to give practical help to wome who have difficulty breastfeedig because of icorrect positioig, cracked ipples or egorgemet (see Further Readig). A mother s fear that she may ot have eough milk is ofte a cause of early termiatio of breastfeedig. This (mis)perceptio may be itesified by the stress of a emergecy situatio. Health workers should ecourage optimal breastfeedig behaviours, eve if they require selective feedig of lactatig wome. Policies ad services which udermie optimal feedig, such as givig food supplemets to ifats uder six moths ad usig bottles for Oral Rehydratio Salts (ORS) delivery, should be avoided.

35 28 Checklist for Safe Motherhood Services a I Emergecy Phase: Provisio of delivery kits: UNICEF midwifery kits for health cetres ad clea delivery kits for home use Idetificatio of referral system for obstetric emergecies 4 Oe health cetre for every 30,000-40,000 people 4 Oe operatig theatre ad staff for every 150,000 to 200,000 people 4 Skilled health care providers traied ad fuctioig (oe midwife for 20,000-30,000 people, oe CHW/TBA for 2,000-3,000 people) 4 Commuity beliefs ad practices relatig to delivery are kow 4 Refugee wome are aware of service availability a Ateatal Services are i place: Record systems i place (cliic ad home-based materal records) Materal health assessmet routiely coducted Complicatios detected ad maaged Cliical sigs observed ad recorded Materal utritio maitaied Syphilis screeig i pregacy udertake routiely Educatioal activity related to ateatal care provisio i place Prevetive medicatio give durig ateatal services: iro folate for aaemia, Vitami A, tetaus toxoid, others as idicated (malaria) STD prevetio ad maagemet udertake Materials available to implemet ateatal care services a Delivery services are i place: Protocols for maagig ad referrig complicatios i place ad trasport system fuctioig Traiig ad supervisio of TBAs ad midwives udertake Complicatios are detected ad maaged appropriately Awareess of warig sigs of complicatios i pregacy is widespread Stadard protocols are used to maage deliveries Medical facilities are adequately equipped Breastfeedig is supported a Postpartum services are i place: Educatioal activities udertake (especially family plaig ad breastfeedig) Complicatios maaged appropriately Iro folate ad Vitami A provided Newbor weighed ad referred for uder-five services (e.g., EPI, growth moitorig)

36 Safe Motherhood 29 (1) Mother s health record Name Address Date of first visit below 17 above 35 Age: less tha 145 cm Height: Previous History CHAPTER THREE ANNEX 1: The WHO Prototype Home-based Materal Record* (parts 1, 5 ad 6) (5) Remarks from referral cetre (6) Before first pregacy ad durig iterpregacy period Date Problem idetified Breastfeedig Mestruatio Pills Ijectios IUD Surgical Other No methods Very thi Very pale Malaria Other problems Chloroquie tablets family plaig Ja-Mar Apr-Ju Jul-Sep Oct-Dec Ja-Mar Apr-Ju Jul-Sep Oct-Dec Ja-Mar Apr-Ju Jul-Sep Oct-Dec Ja-Mar Apr-Ju Jul-Sep Oct-Dec Ja-Mar Apr-Ju Jul-Sep Oct-Dec Ja-Mar Apr-Ju Jul-Sep Oct-Dec Ja-Mar Apr-Ju Jul-Sep Oct-Dec Number of deliveries: yes o Abortios: yes o Oedema: yes o Fits: yes o Stillbirths: yes o Abormal deliveries: yes o Excess vagial bleedig after delivery: yes o Labour lastig more tha 24 hours: yes o Low birth weight (less tha 2500 g): o yes Death of child durig first week: Other health problems: Actio take/advice more tha 145 cm 5 or more *Source WHO, reproduced by permissio

37 30 *Source: WHO, used by permissio. ANNEX 1: The WHO Prototype Home-based Materal Record* (parts 2, 3 ad 4) (2) Preset pregacy Severe pallor Pittig oedema: Vagial bleedig; Very thi: Very large abdome: Abormal presetatio: Weak fetal movemet: Date/Moth: BP above 140/90: Haemoglobi below 8: Urie-albumi: Weight i kg: Actio take Food advice: Iro tablets: Chloroquie tablets: Tetaus toxoid: Advice o place of delivery: LMP... EDD... Up to moth ( üidicates doe ) 1 2 home/hospital (3) Preset pregacy (4) Preset pregacy Sever pallor: Pittig oedema: Vagial bleedig: Very thi: Very large abdome: Abormal presetatio: Weak fetal movemet: Date/Moth: BP above 140/90: Haemoglobi below 8: Urie-albumi: Weight i kg: Actio take Food advice: Iro tablets: Chloroquie tablets: Tetaus toxoid: Advice o place of delivery: LMP... EDD... Up to moth ( üidicates doe ) 1 2 home/hospital Sever pallor: Pittig oedema: Vagial bleedig: Very thi: Very large abdome: Abormal presetatio: Weak fetal movemet: Date/Moth: BP above 140/90: Haemoglobi below 8: Urie-albumi: Weight i kg: Actio take Food advice: Iro tablets: Chloroquie tablets: Tetaus toxoid: Advice o place of delivery: LMP... EDD... Up to moth ( üidicates doe ) 1 2 home/hospital Labour/Delivery Duratio: Presetatio: Type of delivery: Excess vagial bleedig: ormal prologed head breech shoulder face ormal breech C/S other o yes Labour/Delivery Duratio: Presetatio: Type of delivery: Excess vagial bleedig: ormal prologed head breech shoulder face ormal breech C/S other o yes Labour/Delivery Duratio: Presetatio: Type of delivery: Excess vagial bleedig: ormal prologed head breech shoulder face ormal breech C/S other o yes Baby Date of delivery; Baby Date of delivery; Baby Date of delivery; Place of delivery; Coducted by: Sex: Number of babies: Cryig: Birth weight: Breathig difficulty: Breastfeedig: Coditio of baby: home cliic hospital TBA Rel. ANW RN/RM Doctor male female sigle twi or more immediate delayed more tha 2500 g less tha 2500 g o yes yes o alive still-bor died <7 days died 7-28 days Place of delivery; Coducted by: Sex: Number of babies: Cryig: Birth weight: Breathig difficulty: Breastfeedig: Coditio of baby: home cliic hospital TBA Rel. ANW RN/RM Doctor male female sigle twi or more immediate delayed more tha 2500 g less tha 2500 g o yes yes o alive still-bor died <7 days died 7-28 days Place of delivery; Coducted by: Sex: Number of babies: Cryig: Birth weight: Breathig difficulty: Breastfeedig: Coditio of baby: home cliic hospital TBA Rel. ANW RN/RM Doctor male female sigle twi or more immediate delayed more tha 2500 g less tha 2500 g o yes yes o alive still-bor died <7 days died 7-28 days

38 Safe Motherhood 31 ANNEX 2: Partograph Name Date of admissio Fetal heart rate Liquor Mouldig Cervix (cm) [plot X] Gravida Para. Hospital o. Time of admissio Ruptured membraes hours CHAPTER THREE Active Phase Alert Actio 6 5 Descet of head [plot 0] Latet Phase 1 Hours0 Time Cotractios 4 per 3 10 mis 2 1 Oxytoci U/L drops/mi Drugs give ad IV fluids Pulse ad BP Temp C protei Urie { acetoe volume Source: WHO, used by permissio

39 32 ANNEX 3 Mother ad Baby Package Itervetios Mother ad Baby Package Itervetios 1. Before ad Durig Pregacy q Iformatio ad services for family plaig q STD/HIV prevetio ad maagemet q Tetaus toxoid immuizatio 1 q Ateatal registratio ad care q Treatmet of existig coditios (for example, malaria 2 ad hookworm), accordig to coutry policy q Advice regardig utritio ad diet q Iro/folate supplemetatio q Recogitio, early detectio ad maagemet of complicatios (pre-eclampsia/eclampsia, bleedig, abortio, aaemia) 2. Durig Delivery q Clea ad safe (atraumatic) delivery q Recogitio, early detectio ad maagemet of complicatios at health cetre or hospital (for example, haemorrhage, eclampsia, prologed/obstructed labour) 3. After Delivery: Mother q Maagemet of complicatios at health cetre or hospital (for example, haemorrhage, sepsis ad eclampsia) q Postpartum care (promotio ad support to breastfeedig ad maagemet of breast complicatios) q Iformatio ad services for family plaig q STD/HIV prevetio ad maagemet q Tetaus toxoid immuisatio 1. Two doses 2. Malaria prophylaxis to reduce low birth weight i edemic areas 4. After Delivery: Newbor q Resuscitatio q Prevetio ad maagemet of hypothermia q Early ad exclusive breastfeedig q Prevetio ad maagemet of ifectios icludig ophthalmia eoatorum ad cord ifectios q Recordig of birth weight ad referral of ewbor for immuisatios ad growth moitorig Source: WHO

40 Safe Motherhood 33 Further Readigs CHAPTER THREE Breastfeedig Cousellig: A Traiig Course, WHO/UNICEF, Geeva, Care of Mother ad Baby at the Health Cetre: A Practical Guide, WHO, Geeva, Essetial Elemets of Obstetric Care at First Referral Level, WHO, HIV ad Ifat Feedig: Collaborative Statemet by UNAIDS/UNICEF/WHO, UNAIDS, Geeva Joit WHO/UNICEF/UNFPA Policy Statemet o Traditioal Birth Attedats, WHO, Geeva, Klei, Susa. A Book for Midwives, The Hesperia Foudatio, Life Savig Skills Maual for Midwives, America College of Nurse-Midwives, 3rd Editio, Washigto, DC, Mother ad Baby Package, WHO, Geeva, Safe Vitami A Dosage Durig Pregacy ad Lactatio: Recommedatios ad a Report of a Cosultatio, WHO ad The Microutriet Iitiative, Geeva, 1998.

41 34

42 Sexual ad Geder-based Violece 35 4 A icrease i sexual violece i isecure situatios is well recogised. Displacemet, uprootedess, the loss of commuity structures, the eed to exchage sex for material goods or protectio all lead to distict forms of violece, particularly sexual violece agaist wome. CHAPTER FOUR Sexual ad Gederbased Violece Cotets: The Nature, Extet ad Effects of Sexual Violece Causes ad Circumstaces of Sexual Violece Prevetio of Sexual Violece i Refugee Situatios Respodig to Sexual Violece Special Issues Legal Aspects Moitorig Checklist for Sexual Violece Programme Special Notes: a This Chapter draws much of its cotet from Sexual Violece Agaist Refugees, Guidelies o Prevetio ad Respose, UNHCR, Geeva, a Though the Chapter cocetrates o sexual violece, the guidace give ca be applied to other forms of gederbased violece. a The term victim is used i some portios of this Chapter as a coveiet shorthad despite its egative associatio with powerlessess. The word survivor is also used, where appropriate, to covey the meaig that wome have survived a violatio of their huma rights ad digity.

43 36 Sexual ad Gederbased Violece The magitude of the problem is difficult to determie. Eve i ormal situatios, sexual violece ofte goes ureported. The factors cotributig to uder-reportig fear of retributio, shame, powerlessess, lack of support, breakdow or ureliability of public services, ad the dispersio of families ad commuities are all exacerbated i refugee situatios. I geeral, field staff should act o the assumptio that sexual violece is a problem, uless they have coclusive proof that this is ot the case. Prevetive measures should be established, ad appropriate protective, medical, psychosocial ad legal resposes should be orgaised. The refugees themselves, especially wome, should be fully ivolved i orgaisig ad reviewig protective ad prevetive measures ad appropriate resposes. This chapter focuses o sexual violece agaist wome. Most reported cases of sexual violece amogst refugees ivolve female victims ad male perpetrators. It is ackowledged that me ad youg boys may also be vulerable to sexual violece, particularly whe they are subjected to detetio ad torture. Eve less is kow about the true icidece of sexual violece agaist me ad boys tha agaist wome ad girls i refugee situatios. The Nature, Extet ad Effects of Sexual Violece There are various forms of sexual violece. Rape, the most ofte cited form of sexual violece, is defied i may societies as sexual itercourse with aother perso without his/ her coset. Rape is committed whe the victim s resistace is overwhelmed by force or fear or other coercive meas. However, the term sexual ad geder-based violece ecompasses a wide variety of abuses that icludes sexual threats, exploitatio, humiliatio, assaults, molestatio, domestic violece, icest, ivolutary prostitutio (sexual barterig), torture, isertio of objects ito geital opeigs ad attempted rape. Female geital mutilatio ad other harmful traditioal practices (icludig early marriage, which substatially icreases materal morbidity ad mortality) are forms of sexual ad gederbased violece agaist wome which caot be overlooked or justified o the grouds of traditio, culture or social coformity. Sice perpetrators of sexual ad gederbased violece are ofte motivated by a desire for power ad domiatio, rape is commo i situatios of armed coflict ad iteral strife. A act of forced sexual behaviour ca threate the victim s life. Like other forms of torture, it is ofte meat to hurt, cotrol ad humiliate, while violatig a perso s physical ad metal itegrity. Perpetrators may iclude fellow refugees, members of other clas, villages, religious or ethic groups, military persoel, relief workers ad members of the host populatio, or family members (for example, whe a paret is sexually abusig a child). The eormous pressures of refugee life, such has havig to live i closed camps, ca ofte lead to domestic violece. I may cases of sexual violece, the victim kows the perpetrator. Because icidets of sexual ad gederbased violece are uder-reported, the true scale of the problem is ukow. The World Bak estimates that less tha 10 per cet of sexual violece cases i o-refugee situatios are reported. Two pricipal types of uder-reportig are foud i refugee situatios: uder-reportig by the victims, which ca lead to distorted figures that suggest there is o problem; ad a absece of figures relatig to sexual violece withi official statistics. (The umber of recetly reported rape cases i stabilised refugee settigs ca be foud i Table 1.)

44 Sexual ad Geder-based Violece 37 It is essetial to kow that the problem of sexual violece is serious. Reportig ad iterviewig techiques should be adapted to ecourage both victims ad relief workers to report ad documet icidets. Reportig ad follow-up must be sesitive, discreet ad cofidetial so o further sufferig is caused ad lives are ot further edagered. I reportig, it is recommeded that defiitios (such as cofirmed rape cases or sexual violece, i geeral) are provided ad a rate calculated (for example, the umber of reported cases per 10,000 people over a give period of time). This rate would allow for moitorig of treds ad comparisos with other areas. Sexual ad geder-based violece has acute physical, psychological ad social cosequeces. Survivors ofte experiece psychological trauma: depressio, terror, guilt, shame, loss of self-esteem. They may be rejected by spouses ad families, ostracised, subjected to further exploitatio or to puishmet. They may also suffer from uwated pregacy, usafe abortio, sexually trasmitted diseases (icludig HIV), sexual dysfuctio, trauma to the reproductive tract, ad chroic ifectios leadig to pelvic iflammatory disease ad ifertility. Causes ad Circumstaces of Sexual Violece Sexual ad geder-based violece ca occur durig all phases of a refugee situatio: prior to flight, durig flight, while i the coutry of asylum, durig repatriatio ad reitegratio. Prevetio ad respose measures must be adapted to suit the differet circumstaces of each phase. I coflict situatios, sexual violece may be politically motivated whe, for example, mass rape is used to domiate or sexual torture is used as a method of iterrogatio. It may result from log-stadig tesios ad feuds ad the collapse of traditioal societal support. I situatios i which the refugees are cosidered to be materially privileged compared to the local populatio, eighbourig groups may attack the refugees. The psychological strais of refugee life may aggravate aggressive behaviour towards wome. Male disrespect towards wome may be reiforced i refugee situatios where uaccompaied wome ad girls may be regarded by camp guards ad male refugees as commo sexual property. CHAPTER FOUR TABLE 1 Review of Reported Cases of Rape 1 i Refugee Situatios Goma-Zaire, Dadaab-Keya ad Ngara, Kibodo-Tazaia 1996 ad 1998 Situatio Goma Dadaab Ngara Kibodo Populatio 740, , ,000 76,740 a Actual Rape Cases Reported (Number of Moths) (7) (12) (12) (12) a Adjusted Number of Rapes for moth period 2 a Year Reported a Cases of Rape/10,000 populatio/year It is assumed that the cases reported here are cofirmed rapes 2. Actual cases of rapes reported for part of the year ad projected for remaiig moths by takig the average umber of rapes per moth.

45 38 If me are resposible for distributig goods ad ecessities, wome may be subject to sexual exploitatio. Those wome without proper persoal documetatio for collectig food ratios or shelter material are especially vulerable. Wome may have to travel to remote distributio poits for food, water ad fuel; their livig quarters may be far from latries ad washig facilities; their sleepig quarters may be ulocked ad uprotected. Lack of police protectio ad lawlessess also cotribute to a icrease i sexual violece. Police officers, military persoel, relief workers, camp admiistrators or other govermet officers may themselves be ivolved i acts of abuse or exploitatio. If there are o idepedet orgaisatios, such as UNHCR or NGOs, to esure persoal security withi a camp, the umber of attacks ofte icreases. Prevetio of Sexual ad Geder-based Violece i Refugee Situatios A multi-sectoral team approach is required to prevet ad respod appropriately to sexual ad geder-based violece. A committee or task force should be formed to desig, implemet ad evaluate sexual violece programmig at the field level. Refugee represetatives, UNHCR, UN parters, NGOs ad govermet authorities should be members of this task force. Each member of the task force, represetig relevat sectors/parters (such as protectio, health, educatio, commuity services, security/police, site plaig, etc.), should idetify his/her role ad resposibilities i prevetig ad respodig to sexual ad geder-based violece. Ivolvemet of Refugees, Especially Refugee Wome The most effective measures require that the refugee commuity participates i promotig a safe eviromet for all. Wome leaders eed to be ivolved; ad wome s refugee committees ad groups should be established to represet wome s iterests ad to help idetify ad protect those most vulerable to sexual violece. Traditioal birth attedats (TBAs) ca be a valuable source of iformatio ad a chael for dissemiatig protectio messages. It is importat to have at least oe traied female protectio officer at the site. Host coutries ad iteratioal relief orgaisatios have a resposibility to provide the refugee commuity with fudig, techical assistace ad the safety measures ecessary to allow the refugees to desig ad implemet resposes to the problem. Experiece has show that commuity-based groups, commoly called ati-rape or crisis itervetio teams, should be established. These groups ca help raise awareess of the problem, idetify prevetive measures ad be at the forefrot of providig assistace to survivors. Iformatio, Educatio ad Commuicatio Public iformatio campaigs o the subject of sexual violece should be lauched (while respectig cultural sesitivities). Topics could iclude prevetive measures, seekig assistace, laws prohibitig sexual violece, ad sactios ad pealties for perpetrators. Pamphlets, posters, ewsletters, radio ad other mass media programmes, videos ad commuity etertaimet ca all be used to trasmit iformatio about prevetig sexual violece. The refugee commuity ad health workers must uderstad the importace of the problem ad have the cofidece to report all cases of sexual violece as soo as possible. Desig, Locatio ad Practical Arragemets Refugee camps ca be desiged to ehace physical security. Alteratives to closed camps should always be sought. Whe desigig ad orgaisig camp facilities, help protect refugees by:

46 Sexual ad Geder-based Violece 39 locatig latries, water poits ad fuel collectio areas i accessible places; makig special arragemets for housig uaccompaied wome, girls ad loe heads of households; lockig washig facilities; providig adequate lightig o paths used at ight; providig security patrols; ad by avoidig shared commual livig space with urelated families. Distributio of Food, Materials for Shelter ad Assistace Essetial items, such as food, o-food ad shelter materials, should be distributed directly to wome. That way, wome will ot have to exchage sexual favours for these items. Wome should be ivolved i, if ot admiister, the food distributio system. Protectio of Detaiees Wome ad me should ot be detaied together uless they are family members. Appropriate orgaisatios must be allowed access to detaiees to moitor their safety ad livig coditios. Social ad Psychological Factors Life i refugee camps ca lead to a breakdow of traditioal social structures, frustratio, boredom, alcohol ad drug abuse, ad feeligs of powerlessess that may cotribute to aggressio ad sexual violece. Therefore, educatioal, recreatioal ad icome-geeratig activities must be promoted. Respodig to Sexual Violece The respose to each icidet of sexual violece must iclude protectio, medical care ad psychosocial treatmet. Protectio Immediately followig a icidet of sexual violece, the physical safety of the survivor must be esured. All actios must be guided by the best iterests of the survivor ad her wishes must be respected at all times. Wherever possible, the idetity of the survivor should be kept secret ad all iformatio kept locked ad secure from outsiders. Health workers should give the survivor as much privacy as she eeds ad reassure her about her safety. She may wat a family member or fried to accompay her throughout the procedures. She should ot be pressured to talk or be left aloe for log periods. If the icidet occurred recetly, medical care may be required. The survivor should the be escorted to the appropriate medical facilities. It also may be ecessary to cotact the police, if the survivor so decides. The likely course of evets ad all the procedures that may follow should be carefully explaied to her to esure iformed coset ad preparedess. Medical Care The key elemets of a medical respose to sexual violece are described below. Health care professioals must be specially traied to udertake post-sexual violece medical care. Psychosocial support should begi from the very first ecouter with the survivor. A protocol should be adopted to guide the medical ad psychosocial care provided to survivors. Esure a Same-Sex Health Worker is Preset for ay Medical Examiatio ad Esure Privacy ad Cofidetiality. A doctor (or qualified health worker) of the same sex should coduct the iitial examiatio ad follow-up. The survivor should be prepared for the physical examiatio ad perhaps accompaied (if she so wishes) by a staff member who is familiar with the proceedigs, or by a family CHAPTER FOUR

47 40 member or fried. Strict cofidetiality is essetial. Staff dealig with the survivor must be sesitive, discreet ad compassioate. Take a Complete History ad Do a Physical Examiatio. The survivor should ot shower or bathe, uriate or defecate, or chage clothes before the medical examiatio, as evidece may be destroyed. A detailed history of the attack should be documeted, icludig the ature of the peetratio, if ay, whether ejaculatio occurred, recet mestrual ad cotraceptive history, ad the metal state of the survivor. Procedures for medical examiatio after rape should be established ad follow atioal laws, where they exist. The results of the physical examiatio, the coditio of clothig, ay foreig material adherig to the body, ay evidece of trauma, however mior, scratches, bite marks, teder spots, etc., ad results of a pelvic examiatio should be documeted. Health workers should collect materials that might serve as evidece, such as hair, figerail scrapigs, sperm, saliva ad blood samples. Perform the Tests ad Treatmets as Idicated The followig tests may be idicated to establish pre-existig coditios: syphilis blood test, pregacy test ad HIV test. Treatmet for commo sexually trasmitted diseases (STDs), such as syphilis, goorrhoea ad chlamydia, may be idicated. A tetaus vacciatio should be cosidered. Provide Emergecy Cotraceptio, if Appropriate, Alog with Comprehesive Cousellig. 1. Emergecy cotraceptive pills (ECPs) ca prevet uwated pregacies if used withi 72 hours of the rape. As described by WHO emergecy cotraceptive pills (ECPs) work by iterruptig a woma s reproductive cycle by delayig or ihibitig ovulatio, blockig fertilisatio or prevetig implatatio of the ovum. ECPs do ot iterrupt pregacy ad thus are ot cosidered a method of abortio. WHO ackowledges that this descriptio does ot commad cosesus ad that some believe that ECPs are abortifaciets. Wome ad health workers holdig such belief may be precluded from usig this treatmet ad wome who request this service eed to be offered cousellig so as to reach a iformed decisio. ECPs should ot be see as a substitute for regular use of cotraceptive methods. Wome should be couselled cocerig their future cotraceptive eeds ad choices. See Aex 1 for details o usig ECPs. 2. Copper-bearig IUDs ca be used as a method of emergecy cotraceptio. They may be appropriate for some wome who wish to retai the IUD for log-term cotraceptio ad who meet the strict screeig requiremets for regular IUD use. Whe iserted withi five days, a IUD is a effective method of emergecy cotraceptio. However, IUD isertio requires a much higher degree of traiig ad cliical supervisio tha ECPs. Cliets must be screeed to elimiate those who are pregat, have reproductive tract ifectios, or are at risk of STDs, icludig HIV/AIDS. As for ECPs, some wome ad health workers may be precluded from usig this treatmet ad wome who request this service eed to be offered cousellig so as to reach a iformed decisio. Provide Follow-up Medical Care A woma should be couselled to retur for follow-up examiatios oe to two weeks after receivig iitial medical care. Health care providers should moitor her follow-up care. Fur-

48 Sexual ad Geder-based Violece 41 ther tests ad treatmet, such as testig for or treatmet of STDs or referral to other RH services, may be idicated durig follow-up. Further visits may also be required for pregacy ad HIV testig. Psychosocial Care Survivors of sexual violece commoly feel fear, guilt, shame ad ager. They may adopt strog defese mechaisms that iclude forgettig, deial ad deep repressio of the evets. Reactios vary from mior depressio, grief, axiety, phobia, ad somatic problems to serious ad chroic metal coditios. Extreme reactios to sexual violece may result i suicide or, i the case of pregacy, physical abadomet or elimiatio of the child. Childre ad youth are especially vulerable to trauma. Health care providers, relief workers ad protectio officers should devote special attetio to their psychosocial eeds. Survivors should be treated with empathy, care ad support. I the log term, ad i most cultural settigs, the support of family ad frieds is likely to be the most importat factor i overcomig the trauma of sexual violece. Commuity-based activities are most effective i helpig to relieve trauma. Such activities may iclude: idetifyig ad traiig traditioal, commuity-based support workers, developig wome s support groups or support groups specifically desiged for survivors of sexual violece ad their families, ad creatig special drop-i cetres for survivors where they ca receive cofidetial ad compassioate care. See Further Readigs. These activities must be culturally appropriate ad must be developed i close cooperatio with commuity members. They will eed o-goig fiacial ad logistical support ad, where appropriate, traiig ad supervisio. Quality cousellig by traied workers, such as cousellors, urses, social workers, psychologists or psychiatrists preferably from the same backgroud as the survivor should also be provided as soo after the attack as possible. Reassurace, kidess ad total cofidetiality are vital elemets of cousellig. Cousellors should also offer support if the survivor experieces ay post-traumatic disturbaces, if she has difficulty dealig with family ad commuity reactios, ad as she goes through ay legal procedures. The objectives of cousellig are to help survivors: uderstad what they have experieced, overcome guilt, express their ager, realise they are ot resposible for the attack, kow that they are ot aloe, ad access support etworks ad services. Special Issues Sexual Violece i Domestic Situatios Cautio should be exercised before iterveig i domestic situatios because the survivor ad/or other relatives could be subjected to further harm. If the survivor has to retur to the abuser, retaliatio may follow, especially if the abuser lears that the matter has bee reported. Each situatio eeds to be idividually assessed i close cooperatio with colleagues to determie the most appropriate respose. Health care providers may choose to refer the matter to a discipliary committee, iform the authorities, or provide discreet advice to the survivor about her optios. CHAPTER FOUR

49 42 Childre Bor as a Result of Rape These childre may be mistreated or eve abadoed by their mothers ad families. They must be closely moitored ad support should be offered to the mother. It is importat to esure that the family ad the commuity do ot stigmatise either the child or the mother. Foster placemet ad, later, adoptio should be cosidered if the child is rejected, eglected or otherwise mistreated. Moitorig Moitorig cases of sexual violece should be a routie task of health care providers, protectio officers ad others, as appropriate. I additio, there should be regular assessmets of the providers ability to offer comprehesive medical ad psychosocial care for rape survivors. Ideally, care should be give as soo after a rape as possible. Legal Aspects The govermet o whose territory the sexual attack occurred is resposible for takig remedial measures, icludig coductig a thorough ivestigatio ito the crime, idetifyig ad prosecutig those resposible ad protectig survivors from reprisal. I all cases, the wishes of the survivor should be respected whe pursuig the legal aspects of the case. Cofidetiality must be esured. All agecies should advocate the eactmet ad/or eforcemet of atioal laws agaist sexual violece i accordace with iteratioal legal obligatios. These should iclude prosecutio of offeders ad the implemetatio of legal measures to protect the survivor. The local UNHCR Protectio Officer must be familiar with the atioal crimial ad civil law o the subject of rape ad sexual violece before a icidet occurs so he/she will kow what procedural steps should be take ad what advice should be give to survivors. (See Appedix Two.) Sexual Violece Idicators a Idicators to be collected from the health-facility level Icidece of sexual violece (reported cases/10,000 populatio) Coverage of services for survivors Timely care for survivors a Idicators that might be measured aually Prosecutio of sexual violece offeders Coverage of health-worker traiig that serves survivors of sexual violece (Refer to Chapter Nie Moitorig ad Surveillace.)

50 Sexual ad Geder-based Violece 43 CHAPTER FOUR Emergecy Cotraceptive Pill Regimes a Whe pills specially packed for emergecy cotraceptio are available as supplied i the New Emergecy Health Kit 98, or whe high-dose pills cotaiig 0.5 mg ethiylestradiol ad 0.25 mg of levoorgestrel are available: ANNEX 1 Emergecy Cotraceptive Pill Regimes 4 two pills should be take as the first dose as soo as coveiet but o later tha 72 hours after the rape. These should be followed by two more pills 12 hours later. a Whe oly low-dose pills cotaiig 0.3 mg ethiylestradiol ad 0.15 mg of levoorgestrel are available: 4 four pills should be take as the first dose as soo as coveiet but o later tha 72 hours after the rape. These should be followed by four more pills 12 hours later. a Emergig data idicate that alterative hormoal regimes cosistig of levoorgestrel-oly pills are equally effective ad have sigificatly fewer side effects. Whe pills cotaiig 0.75 mg levoorgestrel are available: 4 oe pill should be take as the first dose as soo as coveiet but o later tha 72 hours after the rape. This should be followed by aother pill 12 hours later. Maagig Side Effects Nausea occurs i about 50 per cet of cliets usig combied ECPs ad 25 per cet for those usig levoorgestrel oly. Takig the pills with food may reduce ausea. Routie prophylactic use of ati-emetics is ot recommeded i settigs with limited resources. If vomitig occurs withi two hours of takig ECPs, repeat the dose. Cotraidicatios There are o kow medical cotraidicatios to the use of ECPs. The dose of hormoes used i ECPs is relatively small ad the pills are used for a short time. Cotraidicatios associated with cotiuous use of hormoal cotraceptives do ot apply. ECPs should ot be give if there is a cofirmed pregacy. ECPs may be give whe pregacy status is uclear ad pregacy testig is ot available, as there is o evidece of harm to the woma or to a existig pregacy.

51 44 Checklist for Sexual Violece Programme Key Itervetios Prevetig Sexual Violece a Esure proper documetatio for wome a Icrease availability of female protectio officers ad iterpreters ad esure that all officers have kowledge of UNHCR Protectio Guidelies ad UN Security Guidelies for Wome a Facilitate the use of existig wome s groups or promote the formatio of wome s groups to discuss ad respod to issues of sexual violece a Improve camp desig for icreased security for wome a Iclude wome i camp decisio-makig processes, especially i the areas of health, saitatio, reproductive health, food distributio, camp desig/locatio a Distribute essetial items such as food, water ad fuel directly to wome a Trai people at all levels (NGO, govermet, refugee, etc.), to prevet, idetify ad respod to acts of sexual violece. Key Itervetios Respodig to Sexual Violece a Develop/adapt protocols ad guidelies that would limit further traumas to survivors of sexual violece a Egage socially ad culturally appropriate support persoel as a first cotact with people who have bee subjected to sexual violece a Provide prompt ad culturally appropriate psychosocial support for survivors ad their families a Provide medical follow-up immediately after a attack that also addresses STDs, HIV ifectio ad uwated pregacy a Establish closer liks amog protectio officers, wome s groups, TBAs ad commuity leaders to discuss issues related to the attacks a Documet cases while respectig survivors wishes ad cofidetiality.

52 Sexual ad Geder-based Violece 45 CONFIDENTIAL Sexual Violece Icidet Report Form CHAPTER FOUR Camp: Reportig Officer: Date: 1) Affected Perso: Code(*): Date of Birth: Sex: Address: Civil Status: If a Mior: Code/Name of Parets/Guardia: 2) Report of Icidet: Place: Date: Time: Descriptio of Icidet: (Specify type of sexual violece) Persos Ivolved: 3) Actios Take: Medical Examiatio Doe: q Yes q No By Whom: Major Fidigs ad Treatmets Give: Protectio Staff Notified: q Yes q No If o, reasos give: If yes, actios take: Psychosocial Cousellig give: q Yes q No By whom ad actios take 4) Proposed Next Steps 5) Follow-up Pla 5) q Medical Follow-up 5) q Psychosocial Cousellig 5) q Legal Proceedigs Adapted from Ngara, Tazaia HOW TO GUIDE o Crisis Itervetio Teams * Code umbers should be used rather tha ames to esure cofidetiality.

53 46 Further Readigs Emergecy Cotraceptio: A Guide for Service Delivery, WHO, Geeva, Emergecy Cotraceptio Pills: A Resource Packet for Health Care Providers ad Programme Maagers, Cosortium for Emergecy Cotraceptio, New York, Heise, Lori L. Violece Agaist Wome: The Hidde Health Burde, World Bak Discussio Papers, No. 255, The World Bak, Washigto, DC, How To Guide: Commuity-based Respose to Sexual Violece: Crisis Itervetio Teams - Ngara, Tazaia, UNHCR, Geeva, How To Guide: Developig a Team Approach to Prevetio ad Respose to Sexual Violece - Kigoma, Tazaia, UNHCR, Geeva, Metal Health for Refugees, WHO/UNHCR, Geeva, Security Guidelies for Wome, Uited Natios Security Coordiatio Office, Uited Natios, New York, Sexual Violece agaist Refugees: Guidelies o Prevetio ad Respose, UNHCR, Geeva, 1995.

54 Sexually Trasmitted Diseases, Icludig HIV/AIDS 47 5 The objectives of ay activity i the area of sexually trasmitted diseases (STDs), icludig Huma Immuodeficiecy Virus (HIV) ad Acquired Immue Deficiecy Sydrome (AIDS), should be to prevet ad treat STDs, reduce the trasmissio of HIV/STD ifectios, ad help care for those affected by AIDS. CHAPTER FIVE Sexually Trasmitted Diseases, Icludig HIV/AIDS Cotets: Itroductio Establishig STD/HIV/ AIDS Programmes Moitorig Also Icluded: HIV Testig i Refugee Situatios Mother-to-Child Trasmissio ad HIV ad Ifat Feedig Formula for Calculatig Codom Requiremets STD Treatmet Based o Sydromic Case- Maagemet Approach Flow Chart o Suspected Symptomatic HIV Ifectios Essetial Drugs for Maagemet of Opportuistic Ifectios for HIV/AIDS Alterative Drugs for Treatmet of STDs Based o Sesitivity Studies Estimatig Drug Requiremets ad Costs for Treatmet of STDs

55 48 Sexually Trasmitted Diseases, Icludig HIV/AIDS Itroductio STDs, icludig HIV/AIDS, spread fastest where there is poverty, powerlessess ad social istability. The disitegratio of commuity ad family life i refugee situatios leads to the break-up of stable relatioships ad the disruptio of social orms goverig sexual behaviour. Wome ad childre are frequetly coerced ito havig sex to obtai basic eeds, such as shelter, security, food ad moey. I a refugee situatio, populatios that have differet rates of HIV/AIDS prior to becomig refugees may be mixed. Also may refugee situatios are like large urba settigs ad may create coditios that icrease the risk of HIV trasmissio. STDs, which are a major public health problem i most parts of the world, were largely eglected util the appearace of HIV/AIDS. Now, more attetio is focused o covetioal STDs (such as goorrhoea, syphilis, chlamydia, etc.). They are amog the most commo, although udiagosed, causes of illess i the world; ad they have far-reachig health, social ad ecoomic cosequeces. STDs substatially icrease the risk of HIV ifectio. Prevetig ad cotrollig STDs are key strategies i cotrollig the spread of HIV/ AIDS. The vast majority of HIV ifectios are sexually trasmitted. Betwee five ad te per cet of HIV ifectios world-wide are estimated to be trasmitted through ifected blood ad blood products, though this percetage is decreasig as blood for trasfusios is more regularly tested for HIV. I refugee situatios, it is essetial to esure that all blood for trasfusio is tested ad that uiversal precautios are eforced. Mother-to-child trasmissio of HIV (MTCT), also called vertical trasmissio, is the most commo mode of HIV trasmissio i childre. More tha 90 per cet of HIV-ifected ifats acquire their HIV ifectio from their mothers durig pregacy, delivery or durig breastfeedig. Whe there is o itervetio, the risk of MTCT rages from 15 to 25 per cet i idustrialised coutries ad from 25 to 45 per cet i developig coutries. Trasmissio is affected by a umber of factors, ot all of which have bee fully examied. These factors iclude: high viral-load level i the mother s blood, i cervio-vagial secretios ad, i breast milk, decreased materal immue status, prologed rupture of membraes (greater tha four hours), the mode of delivery, ad itra-partum haemorrhage. Studies show a additioal 7 to 22 per cet risk of HIV trasmissio through breastfeedig. Late postatal trasmissio after six moths of age has bee described i a umber of studies. (See Aex 2 o MTCT ad HIV ad Ifat Feedig.) Iteractio betwee refugee ad local populatios is likely to occur. It is therefore vital to liaise with host coutries to esure that comparable services are provided to local populatios. Failure to do so would ot oly be couterproductive i the effort to prevet the spread of STDs ad HIV, it could also result i coflict betwee the two populatios. Madatory HIV testig of refugees is sometimes requested i the mistake belief that this will help prevet HIV trasmissio. Uder o circumstaces should madatory testig be pursued. Madatory testig for HIV represets a violatio of huma rights ad has o public health justificatio. (See Aex 1 o HIV testig i refugee situatios.)

56 Sexually Trasmitted Diseases, Icludig HIV/AIDS 49 Establishig STD/HIV/AIDS Programmes As described i Chapter Two (Miimum Iitial Service Package [MISP]), three activities should be coducted prior to ay assessmet i ay ew refugee situatio (icludig a emergecy): Guaratee availability of free codoms Eforce uiversal precautios agaist HIV/AIDS trasmissio i health-care settigs Idetify a perso who will coordiate RH activities. Comprehesive prevetio, treatmet ad care services for STDs, icludig HIV/AIDS, should be made available to refugees at the earliest opportuity. By takig the followig steps, you will esure that the services you provide are effective. Assessmet Coduct a situatio aalysis as soo as possible to help pla a appropriate ad comprehesive prevetio ad treatmet service. The followig iformatio should be collected: the prevalece of STDs ad HIV i the host ad home coutry, regio or area (this iformatio is available from the atioal AIDS programmes, UNAIDS ad WHO); the locatio of specific risk areas withi the refugee commuity (for example, where sexual services are bought ad sold, high alcohol-cosumptio areas, bars), to be targeted as priorities for specific activities; ad the cultural ad religious beliefs, attitudes, ad practices cocerig sexuality, reproductive health, STDs ad AIDS. This iformatio ca be obtaied through qualitative research usig focus groups, iterviews ad, if possible, KABP (Kowledge, Attitudes, Behaviour ad Practices) surveys. It will also be ecessary to: liaise with local health authorities to defie a maagemet protocol for STDs; ad idetify people i the refugee commuity who have bee traied i HIV/STD prevetio. Implemetatio The situatio aalysis will idicate what STD ad HIV/AIDS itervetios are required ad what is feasible. The followig should be icluded as basic elemets of respose to every refugee situatio: uiversal precautios i health-care settigs, safe blood trasfusio, access to codoms, access to STD care, iformatio, educatio ad commuicatio (IEC) activities, ad comprehesive care for people with HIV/AIDS. Uiversal Precautios i Health-Care Settigs Uiversal precautios are part of the MISP (Chapter Two) ad are essetial to prevet the trasmissio of HIV from patiet to patiet, health worker to patiet ad patiet to health worker. Because people workig uder pressure are more likely to have work-related accidets ad to cut corers i sterilisatio techiques, ifectio-cotrol measures adopted durig crises must be practical to implemet ad eforce. The guidig priciple for the cotrol of ifectio by HIV ad other diseases which may be trasmitted through blood, blood products ad body fluids is that all should be assumed to be potetially ifectious. The miimum requiremets for ifectio cotrol are as follows: Facilities for frequet had washig. Hads should be washed with soap ad water, especially after cotact with body fluids or wouds. Availability of gloves for all procedures ivolvig cotact with blood or other po- CHAPTER FIVE

57 50 tetially ifected body fluids. Gloves should be discarded after each patiet, or else washed or sterilised before re-use. Heavy-duty gloves should be wor whe materials ad sharp objects are take for disposal. Availability of protective clothig, such as waterproof gows or apros. Masks ad eye shields should be wor where there is a possibility of exposure to large amouts of blood. Safe hadlig of sharp objects. Pucture-resistat cotaiers for sharps disposal must be readily available, close at had ad out of the reach of childre. Sharp objects should ever be throw ito ordiary waste bis or bags. Disposal of waste materials. People, particularly small childre, strugglig to survive will scavege. It is therefore vital to make waste disposal safe. All medical waste materials should be burt. Those items that still pose a threat, such as sharp objects, should be buried i a deep pit at least 10 metres from a water source. Medical waste should ot be disposed of i commual dumps. Cleaig, disifectig ad sterilisig. Pressure-steam sterilisers are recommeded for cleaig medical istrumets betwee use o differet patiets. If sterilisatio is ot available, or for istrumets that are heat sesitive, istrumets must be cleaed ad high-level disifected (HLD). HIV ca be iactivated by boilig for 20 miutes or by soakig i chemical solutios icludig a five per cet solutio of chlorie bleach for 20 miutes or i a two per cet glutaraldehyde solutio for 20 miutes. Proper hadlig of corpses. It is advisable for relief workers to wear gloves ad cover ay wouds o hads or arms whe hadlig corpses. The relief worker should wash thoroughly with soap ad water afterwards. Special cautio should be take with body fluids as they may be potetially ifectious. Treatig ijuries at work. I cases of ijury with a sharp istrumet, the woud should be washed thoroughly with soap ad water. Splashes of blood or other body fluid ito the mouth or eyes should be rised thoroughly with water or salie respectively. Further procedures to be followed after a accidetal exposure to blood have bee developed by Médecis Sas Frotières (MSF). Prophylactic treatmet agaist HIV trasmissio, kow as Post Exposure Therapy (PET), may be warrated. Guidelies cotaiig iformatio about potetial risks i the eviromet, how to protect agaist those risks, ad what to do i case of accidets such as eedle-stick ijuries, cuts or blood splatterig should be developed ad distributed to field workers. It is equally importat to provide clear iformatio about what does ot costitute a risk. The guidelies should idicate whe it is appropriate to use protective clothig ad why. Health workers should also be give guidace o how to avoid uecessary ijectios ad other procedures ivolvig sharp istrumets. Access to Codoms If cosistetly ad correctly used, codoms offer effective protectio agaist STDs, icludig the sexual trasmissio of HIV. Sice may refugees have already bee exposed to this message, there may be a demad for codoms i the early phases of a refugee situatio. Codoms are cotaied i the MISP (See Chapter Two) ad should be made freely available for those who seek them. Take every opportuity to raise awareess ad promote codoms as a method of protectio agaist STDs, icludig HIV ifectio. The female codom is ot yet widely kow; but, if available, it should be used as a additioal method of protectio. Procuremet of good-quality codoms: There are may brads of codoms o the market. If a agecy does ot have experiece i procurig codoms, it may be desirable to cotact UNAIDS, UNFPA, UNHCR or WHO to facilitate the purchase of bulk quatities of

58 Sexually Trasmitted Diseases, Icludig HIV/AIDS 51 good-quality codoms at low cost. Aex 3 shows how to calculate the umber of codoms required. Good-quality codoms are essetial for the protectio of the cosumer ad the credibility of the relief programme. Codom distributio: To esure ogoig access i refugee situatios, a system of distributio must be i place. The system should iclude the followig: Codoms ad istructios for their use should be available o request i health facilities (especially where STDs are treated) ad distributio cetres (such as food ad o-food item distributio areas). Staff should be traied i the promotio, distributio ad use of codoms. Promotioal campaigs should be lauched at football matches, mass rallies, dace parties, theatres, group discussios, etc., to promote the use of codoms ad iform the public o how ad where to obtai them. Cotacts betwee the refugee ad local populatios are likely to occur. Therefore, codoms must also be made available to the wider host commuity. This requires liaiso with groups ivolved i AIDS prevetio ad family-plaig activities i the area. Oce the situatio has stabilised, health workers must decide whether or ot to cotiue free distributio of codoms. The itroductio of some form of partial costrecovery (social marketig) may be cosidered i situatios where this is feasible ad appropriate. Whe possible, the codom-distributio etwork ca be exteded to commuity agets, shops, bars, youth ad wome s groups, etc. Social marketig strategies i the host coutry or i the coutry of origi could be exteded ito the refugee situatio. Safe Blood Trasfusio Blood trasfusios must ot be doe if the facilities for safe trasfusio, icludig screeig for HIV testig, do ot exist. Safe blood trasfusio ca be orgaised withi the refugee settlemet i major operatios or should be arraged with local health facilities followig appropriate discussios with the Miistry of Health. Should local health facilities be used, support to these structures must be assured by the refugee programme. The likehood of becomig ifected with HIV through trasfusio of ifected blood is well over 90 per cet. Measures to esure the safety of blood trasfusio i refugee situatios are extremely importat. The mai recommedatios for prevetig HIV ifectio ad other blood-bore diseases through blood trasfusio are to: Trasfuse oly previously tested blood ad oly whe cliically ecessary. Use blood substitutes, such as simple crystalloid (physiological salie solutio for itraveous admiistratio) ad colloids wheever possible. Collect blood from doors idetified as beig least likely to trasmit ifectious agets i their blood. Selectio of safe doors ca be promoted by givig clear iformatio to potetial doors o whe it is appropriate or iappropriate to give blood ad by usig a blood-door questioaire. Volutary, o-remuerated blood doors are safer sources tha paid doors. Persoal iformatio give by the door must be treated as strictly cofidetial. Provide reagets to perform HIV testig of doated blood. Screeig for HIV ad other ifectious agets should be carried out usig the most appropriate assays. Develop clear policies ad protocols/ guidelies cocerig the appropriate use of blood for trasfusio, the recruitmet ad care of doors ad the safe disposal of waste products, such as blood bags, eedles ad syriges. Appoit a experieced perso to be resposible for refugee-specific blood trasfusio services. CHAPTER FIVE

59 52 Access to STD Care Because the risk of HIV trasmissio is greatly icreased i the presece of other STDs, early establishmet ad itegratio of STD services withi geeral health care services is a priority. STDs ad their complicatios, such as ifertility ad cogeital syphilis, are a major cause of ill health ad are usually grossly uder-reported. The prevetio of STDs ivolves the promotio of safer sex as well as early ad effective case fidig, advise o otificatio of parters ad case maagemet. STD services should be user-friedly, private ad cofidetial. Special arragemets may be ecessary to esure that wome ad youg people feel comfortable usig these services. I may societies, wome will ot seek treatmet if the health professioals at the cliic are all male, particularly if a physical examiatio is required. I these situatios, female health workers should provide services for wome. Appropriate ad effective case maagemet ivolves the followig: traiig health care providers providig guidelies for case maagemet, icludig case defiitio ad maagemet protocol cosistet availability of appropriate drugs cosistet supply of codoms moitorig idetifyig secodary or iformal providers of STD care Traiig health care providers. Health care providers, icludig voluteer workers, should receive traiig i prevetio of STD/HIV/ AIDS, be provided with iformatio materials ad serve as chaels for the distributio of codoms. Professioal health workers should be traied i the sydromic approach to STD maagemet. Health worker traiig should iclude the followig topics: sydrome recogitio ad diagosis effective treatmet based o observed sydromes importace of cofidetiality educatio for prevetio/cousellig focused o specific populatio groups codom promotio ad provisio parter otificatio ad maagemet moitorig STD Case Maagemet. Treatmet of symptomatic cases should be stadardised o the basis of sydromes ad ot depedet o laboratory aalysis. A treatmet protocol (cosistet with atioal protocols) based o sydromic case maagemet should be prepared ad adopted. (See examples i Aexes 4 ad 5.) The most effective drugs should be used at the first ecouter. Iitial drug requiremets should be based o available data from the coutry of origi or estimated as idicated i Aex 8. Moitorig activities will the serve to review real eeds. If IEC efforts are effective, if services are userfriedly ad people from outside the camp are attedig the health facilities, the eed for drugs may icrease rapidly. Parters of patiets with a STD are likely to be ifected themselves ad should be treated. Each patiet should be provided with cotact slip(s) to be give to his/her sexual parter(s). O the basis of these slips, parters should have access to the same treatmet as the patiet who preseted first. The process should be cofidetial, volutary ad o-coercive ad iclude all sexual parters of each STD patiet. Applyig a sydromic approach to STD case maagemet allows effective care for symptomatic cases without the eed for laboratory support. The exceptio to this is systematic testig for syphilis i pregat wome. This type of testig is cost effective eve i sites where the prevalece of syphillis i the geeral populatio is as low as oe per cet.

60 Sexually Trasmitted Diseases, Icludig HIV/AIDS 53 Iformatio, Educatio ad Commuicatio (IEC) Iformatio, educatio ad commuicatio activities are cetral to a successful HIV/ AIDS ad STD strategy i all situatios. IEC icludes a variety of activities at differet levels, from itesive perso-to-perso educatio to mass dissemiatio of iformatio. (For further iformatio o IEC, refer to Appedix Oe.) Comprehesive Care for People with HIV/AIDS Comprehesive care for people with HIV-related illesses should be see as a compoet of basic care i ay refugee situatio. This is especially importat whe refugees come from a area where HIV-related illesses are a major cause of morbidity ad mortality. (The WHO flow chart for suspected symptomatic HIV ifectio for the purpose of cliical maagemet is provided i Aex 6.) The elemets of comprehesive care iclude: cliical maagemet, ivolvig early diagosis of HIV-related illesses, ratioal treatmet ad plaig for follow-up care; supportive care to promote ad maitai hygiee ad utritio; educatio of idividuals ad families o HIV prevetio ad care; cousellig to help idividuals make iformed decisios o HIV testig, reduce stress ad axiety ad promote safer sex; ad social support, icludig iformatio ad referral to support groups, welfare services ad legal advice. A home-based care system, to which people with advaced HIV ifectio/aidsrelated illesses ca be discharged from ipatiet care, should be established early i refugee situatios. The itroductio of comprehesive care for HIV/AIDS i refugee situatios ivolves: sesitisig health workers to HIV-related illesses ad AIDS; developig a policy o the role of volutary ad cofidetial HIV tests (with related pre- ad post-test cousellig) for cliical diagosis (see Aex 1). If host coutries offer volutary cousellig ad testig services to the local populatio, iitiate discussios to determie the possibility of extedig these services to refugee populatios; adaptig existig cliical ad ursig guidelies for case maagemet of HIVrelated illesses i primary ad secodary care i refugee settigs. This should iclude guidelies o discharge ad referral of people with HIV-related problems, either for more sophisticated care or to home-based care; drawig up a essetial drug list for care of HIV-related illesses ad establishig mechaisms to esure the procuremet ad supply of these drugs; traiig health care workers i the use of the cliical guidelies; itroducig cousellig traiig for health ad lay workers ad developig guidelies for cousellig. This ca be itegrated ito cousellig for other problems related to the refugee situatio. It will be helpful if staff ivolved i this activity are ot subject to frequet rotatio; icludig those people livig with HIV/ AIDS i traiig programmes; esurig that HIV-related care is fully itegrated ito basic curative services ad that prevetio compoets (such as supply of codoms) ad STD treatmet are provided; developig commuity support for AIDS care by: explorig commuity potetial for stigma ad discrimiatio; explorig commuity capacities ad commitmet; CHAPTER FIVE

61 54 ecouragig the developmet ad traiig of self-help ad other commuity-based support groups; ad startig commuity-based care ad support activities, usig the self-help groups that have bee established. Moitorig Data o the umber of STD ad HIV/AIDS cases presetig for treatmet or detected i health services are essetial for plaig services ad as idicators of treds i STD prevalece i the commuity. Always suspect uder-reportig of STDs ad HIV/AIDS. Maagers of health care programmes may wat to check for the presece of iformal etworks of treatmet for STDs, such as i local markets. The followig is a list of suggested idicators for moitorig ad evaluatig HIV/AIDS ad STD itervetios i refugee situatios: STD/HIV/AIDS Idicators a Idicators to be collected from the health-facility level percetage of blood screeed for HIV before trasfusio ad per cet foud positive for HIV icidece of STDs practice of uiversal precautios a Idicators collected at the commuity level outlets for codoms distributio kowledge of correct codom use codom use a Idicators cocerig traiig ad quality of care traiig of health workers i sydromic case maagemet quality of STD case maagemet (Refer to Chapter Nie Surveillace ad Moitorig.)

62 Sexually Trasmitted Diseases, Icludig HIV/AIDS 55 CHAPTER FIVE Checklist for STD/HIV/AIDS Programmes From MISP q Guaratee availability of free codoms q Eforce uiversal precautios ahiv/std/aids situatioal aalysis is udertake atraied people from refugee commuity are idetified aiformatio, educatio ad commuicatio programmes are i place auiversal precautios i health settigs are practiced afree good-quality codoms are regularly available ad accessible asystem of codom distributio is i place asafe blood trasfusio services are i place, guidelies dissemiated, HIV test kits available, staff traied amaagemet protocols for STDs are defied ad dissemiated adrugs for STD treatmet are o had astaff are traied/retraied o sydromic case maagemet asystem for parter otificatio ad treatmet are istituted avolutary cousellig ad testig (VCT) services are i place (as appropriate) ahome-based care for people with AIDS is i place acousellig ad support services for people with HIV/AIDS are i place

63 56 HIV Testig i Refugee Situatios ANNEX 1 HIV Testig i Refugee Situatios Available resources for HIV testig should be devoted, first ad foremost, to esurig a safe blood supply for trasfusios. A volutary HIV testig ad cousellig (VCT) programme is a lower priority i a refugee situatio but should ot be ruled out if resources are available ad if these services are available i the host coutry or were available i the coutry of origi. HIV testig to diagose HIV-related illess may be idicated, but oly if two coditios are met: coset, pre- ad post-test cousellig ad cofidetiality ca be assured; ad a cofirmatory testig procedure is udertake as outlied i UNAIDS Policy o HIV Testig ad Cousellig. People kow to be HIV ifected or to have AIDS should remai withi their commuities or withi the refugee settlemets, where they should have equal access to all available care ad support. UNAIDS/WHO Positio o Madatory HIV Testig i Refugee Situatios Madatory HIV testig i refugee circumstaces, with the sigle exceptio of testig blood for trasfusio, is ot justified. WHO ad UNAIDS have determied that such testig should ot be pursued as a matter of policy. a Idetifyig people with HIV/AIDS through madatory testig does othig to stop the spread of the virus. a Madatory testig is a violatio of huma rights, ad it leaves those who are idetified as HIV-positive ope to discrimiatio ad persecutio. a No egative HIV test ca be assumed to have excluded the possibility of HIV ifectio i the perso tested. There is a latet period of several weeks followig ifectio, durig which the HIV test ca come up egative, but the perso is still capable of trasmittig the ifectio through uprotected sexual cotact or blood. Occasioally, too, tests have show false egative results. a A egative HIV test offers o assurace that the perso tested will ot be exposed to HIV ad become ifected soo thereafter. a A egative HIV test is, therefore, o reaso to relax the uiversal precautios that health workers eed to observe at all times; or does a egative HIV test give ay reaso to feel that sterile procedures durig medical itervetios are ay less importat. I practice, every patiet should be regarded as a potetial carrier of HIV, Hepatitis B or other blood-bore ifectios, sice testig removes oe of the potetial for trasmittig these diseases. a UNHCR ad Iteratioal Orgaizatio o Migratio (IOM) issued a joit policy i 1990 which strictly opposes the use of madatory HIV screeig, ad ay restrictios based o a refugee s HIV status. Nevertheless, some States have adopted madatory HIV testig for refugees ad exclude those who test positive. Other States place restrictios o the admissio of persos whom they kow to be HIV positive or have AIDS. Although some coutries have established waiver procedures, resettlemet cases of refugees who are HIV positive or have AIDS are certai to be more complex tha most resettlemet cases. a Resettlemet cosideratios of refugees livig with HIV are difficult ad must be give special attetio to avoid placig these persos at greater risk for discrimiatio, refoulemet, ad istitutioalisatio.

64 Sexually Trasmitted Diseases, Icludig HIV/AIDS 57 Mother-to-Child Trasmissio ad HIV ad Ifat Feedig Primary prevetio of HIV i girls ad wome of reproductive age remais the most importat compoet of ay strategy or programme to prevet mother-to-child trasmissio (MTCT). For wome who are HIV egative or of ukow status, breastfeedig should be protected, promoted ad supported. (See Chapter Three-Safe Motherhood) CHAPTER FIVE ANNEX 2 Mother-to-Child Trasmissio ad HIV ad Ifat Feedig For HIV-ifected pregat wome, the oly itervetios prove to reduce sigificatly MTCT of HIV are the use of atiretroviral therapy (ARV) ad the avoidace of breastfeedig. Wome who are kow to be HIV positive should be couselled about the possibility of avoidig breastfeedig. They should cosider usig commercial ifat formula, homeprepared formula, or a modified form of breastfeedig, such as expressig ad heat treatig their ow breast milk. They could also breastfeed for a shorter time tha usual, or fid a HIV-egative wet urse. However, most of these optios are usually impractical. Studies are cotiuig o the effectiveess ad service delivery implicatios of providig short-course ARV treatmet which may represet a feasible itervetio i some settigs ad for some circumstaces. I some settigs, cosideratio could be give to providig HIV-positive mothers with breast milk substitutes ad supportig its safe use. The supply of the substitute should be guarateed for at least six moths. The acquisitio ad distributio of breast-milk substitutes should be i compliace with the Iteratioal Code of Marketig of Breast-milk Substitutes. Cosiderable resources are required to prepare formula, whether commercial or home made. The mother eeds water to clea equipmet ad prepare feeds; she eeds adequate fuel to boil water to sterilise equipmet ad make feeds safe. She must do this six times a day, or prepare six feeds at oe time ad keep them cool for up to 24 hours to prevet spoilage. This is ot ofte practical whe ormal life is disrupted. If feeds caot be mixed correctly, if equipmet caot be adequately cleaed ad sterilised, or if prepared feeds caot be stored to prevet spoilage, the risks of sickess ad death to the ifat may be greater tha the risk of trasmissio of HIV through breastfeedig. Bear i mid these cosideratios whe cousellig wome. Health care providers should support wome ad, whe possible, their families, i makig the best decisio o how to feed their ifat give their particular circumstaces. Breastfeedig may be the most appropriate ad safest optio. For more iformatio o HIV ad Ifat Feedig refer to the HIV ad Ifat Feedig Packet produced by UNAIDS, UNICEF ad WHO, Geeva, Also refer to Nutritio ad HIV/ AIDS, Sub-committee o Nutritio News, Number 17, WHO, Geeva, 1998.

65 58 ANNEX 3 Formula for Calculatig Codom Requiremets Formula for Calculatig Codom Requiremets Codom eeds ca be calculated if you ca estimate the followig: The size of the target populatio (i.e., refugee populatio ad adjoiig areas). Roughly 20 per cet of this umber represets the size of the sexually active male populatio. The percetage of males usig codoms. Results from previous kowledge, attitudes, behaviour ad practices (KAPB) studies ca be used whe they exist. If they do ot exist, pla from data provided by the most reliable source ad adapt accordig to eeds. Pla for about 12 codoms per sexually active male per moth. Add to the above figure 20 per cet for wastage ad loss. a Example: A baselie calculatio for procurig oe moth s supply of codoms for a estimated refugee ad adjoiig populatio of 10,000 people, with 20 per cet of sexually active males usig codoms, is as follows: 2,000 sexually active males 2,000 20/ per cet usig codoms x 0.2 = codoms per moth x 12.0 = 4,800 20% wastage/loss = 960 total codoms per moth 4,800 total wastage/loss Estimated total eeds for oe moth: 5,760 codoms Codoms usually come i boxes of 144, called a gross. Quatities of follow-o supplies should be modified accordig to the field situatio (demographic profiles i refugee camps may be very differet from the ormal demographic profile; use rates of codoms may also vary). To avoid shortages, make sure a three-moth reserve supply is available.

66 Sexually Trasmitted Diseases, Icludig HIV/AIDS 59 CHAPTER FIVE STD Treatmet Based o Sydromic Approach ANNEX 4 Sydrome Treat For STD Treatmet Based o Sydromic Approach Urethral discharge Goorrhoea ad chlamydia Geital ulcers Syphilis ad chacroid Vagial discharge 1 Goorrhoea, chlamydia ad trichomoas Lower abdomial pai Goorrhoea, chlamydia ad aaerobes Iguial bubo as for chlamydia Scrotal swellig Goorrhoea ad chlamydia Neoatal eye discharge Neoate goorrhoea ad chlamydia 1. If a woma complais of vagiitis (itchig) treat for cadidiasis.

67 60 ANNEX 5 Drugs for Treatmet of STDs Drugs for Treatmet of STDs (Choice of drugs should be based o atibiotic sesitivity studies i a specific area) Treat For Drugs Depedig o Adult Dose (for ucomplicated Sesitivity Studies or early ifectios) Goorrhoea Ciprofloxaci mg - sigle dose - oral Spectiomyci 2 g - sigle dose - IM Cefixime 400 mg - sigle dose - oral Ceftriaxoe 250 mg - sigle dose - IM Kaamyci 2 g - sigle dose - IM Sulfamethoxazole/Trimethoprim 400mg/80mg - 10 tabs oce daily for 3 days Chlamydia Doxycyclie mg - twice daily for 7 days - oral Tetracyclie mg - four times a day for 7 days - oral Erythromyci 500 mg - four times a day for 7 days - oral Sulfafurazole 500 mg - four times a say for 10 days - oral Syphilis Bezathie peicilli G 2.4 MUs - sigle dose - IM Procaie peicilli G 1.2 MUs - daily for 10 days - IM Tetracyclie (1,2) 500 mg - four times a day for 15 days - oral Doxycyclie (1,2) 100 mg - twice daily for 15 days - oral Erythromyci mg - four times a day for 15 days - oral Chacroid Erythromyci 500 mg - three times a day for 7 days - oral Ciprofloxaci mg - sigle dose - oral Ceftriaxoe 250 mg - sigle dose - IM Spectiomyci 2 gm - sigle dose - IM Sulfamethoxazole/Trimethoprim 800mg/160mg - twice daily for 7 days - oral Doovaosis Sulfamethoxazole/Trimethoprim 800mg/160mg - twice daily for 14 days - oral Doxycyclie mg - twice daily for 7 days Tetracyclie mg - four times a day for 7 days Chlorampheicol 500 mg - four times a day for 2 days Trichomooas Metroidazole 3 2 g - sigle dose - oral Cadidosis Nystati pessaries 100,000 IU - twice itravagially for 14 days Clotrimazole or micoazole pessaries 200 mg - oce itravagially for 3 days Micoazole 500 mg - itravagially - sigle dose Bacterial Metroidazole mg - twice a day for 7 days - oral vagiosis or 2 g - sigle dose - oral 1 Cotraidicated i pregacy 2 For persos allergic to peicilli, but may be less effective. Close follow up is ecessary to esure a cure. 3 Cotraidicated i first trimester of pregacy NOTE: Drugs for treatmet of STDs are cotiuously revised. Health care providers should rely o the most up-to-date recommedatios. Based o: Maagemet of STDs WHO/GPA/TEM/94.1 ad WHO Model Prescribig Iformatio: Drugs Used i STDs ad HIV Ifectios WHO 1997

68 Sexually Trasmitted Diseases, Icludig HIV/AIDS 61 ANNEX Suspected Symptomatic HIV Ifectio (a) Ay cardial fidigs (b) o Two or more characteristic fidigs? (c) o yes yes Suspected Symptomatic HIV Ifectios WHO Flow Chart CHAPTER FIVE Oe characteristic fidig? (c) yes Two or more associated fidigs? (d) yes o Three or more associated fidigs? (d) yes Ay epidemiological risk factors? (e) yes o o Two associated fidigs? (d) o yes o Symptomatic: ot HIV related Positive lab test for HIV? yes Symptomatic: HIV ifectios Aotatios: a) The purpose is to help the health care provider to recogize the patiet with symptomatic HIV ifectio, as a aid to cliical maagemet. HIV testig, whe available ad affordable, ca be used to substatiate the cliical diagosis. b) Cardial Fidigs: Kaposi sarcoma 1 Peumocystis cariii peumoia Toxoplasma ecephalitis Oesophageal cadidiasis Cytomegalovirus retiitis c) Characteristic Fidigs 2 : Oral thrush (i patiet ot takig atibiotics) Hairy leukoplakia Cryptococcal meigitis (may be a cardial fidig i Africa) Miliary, extrapulmoary or ocavitary pulmoary tuberculosis 3 Herpes zoster, preset or past, particularly multidermatomal, age 50 years Severe prurigo Kaposi sarcoma (other tha as cardial fidig) High-grade B-cell extraodal lymphoma d) Associated Fidigs²: Weight loss (recet uexplaied) of more tha 10% of baselie body weight, if assessable³ Fever (cotiuous or itermittet) for more tha 1 moth³ Diarrhoea (cotiuous or itermittet) for more tha 1 moth Ulcers (geital or periaal) for more tha 1 moth Cough for more tha 1 moth³ Neurological complaits or fidigs 4 Geeralised lymphadeopathy (extraiguial) Drug reactios (previously ot see), e.g. to thiacetazoe or sulfoamides Ski ifectios (severe or recurret), e.g. warts, dermatophytes, folliculitis e) Epidemiological Risk Factors: Preset or past high-risk behaviour: drug ijectig multiple sex parters sex parter(s) with kow AIDS or HIV ifectio sex parter(s) with kow epidemiological risk factor or from a area with a high prevalece of HIV ifectio males havig peetrative sexual itercourse with males Recet history of geital ulcer disease. History of trasfusio after 1975 of uscreeed blood, plasma or clottig factor; or (eve if screeed) from a area with a high prevalece of HIV ifectio. History of scarificatio, tattooig, ear piercig or circumcisio usig o-sterile istrumets. 1. Kaposi sarcoma is a cardial fidig oly whe: (i) itraoral lesios are preset; (ii) lesios are geeralised; or (iii) lesios are rapidly progressive or ivasive. 2. If o other obvious cause of immuosuppressio is evidet. 3. The combiatio of fever, weight loss ad cough is characteristic of both tuberculosis ad AIDS. 4. Neurological complaits or fidigs associated with HIV ifectio iclude seizures (especially focal), peripheral europathy (motor or sesory), focal cetral motor or sesory deficits, demetia ad progressively worseig headache. Adapted from WHO/GPA/IDS/ HCS/91.6 Guidelies for the Cliical Maagemet of HIV Ifectio i Adults, December 1991.

69 62 ANNEX 7 WHO Essetial Drugs HIV/AIDS Maagemet WHO Essetial Drugs for HIV/AIDS Maagemet Idicatios Drugs Dehydratio Oral Rehydratio Salts Diarrhoea Loperamide Bacterial Ifectios Cotrimoxazole Amoxicilli Ciprofloxaci Ceftriaxoe 1 Ketocoazole is expesive, therefore oly limited supplies should be cosidered ad oly if there are eforceable criteria for its use. 2 The appropriate use of atidepressat medicie should be cosidered i situatios where cliical depressio is diagosed. 3 Give the possibility of overdose, tricyclics should perhaps be prescribed oly i 5 or less at a time ad by a physicia. 4 The use of axiolytics (Diazepa - Bezodiazepie family) may also be cosidered for temporary maagemet of severe axiety reactios where respiratio is ot impaired (e.g., peumocystis cariii peumoia). Fugal Ifectios Parasitic Ifectios Palliative Care ad Pai Maagemet Tuberculosis Cliical Depressio 2 Micoazole Nystati (oral ad oitmet) Ketocoazole 1 Metroidazole (oral) Codeie Isoiazid Rifampici Pyraziamide Ethambutol Tricyclics 3 Bezodiazepie Family 4 Sources: WHO Model Prescribig Drugs used i HIV Ifectios, WHO/ EDM Stadard treatmets ad essetial drugs for HIV-related coditios WHO/DAP Dec UNAIDS Techical Update Access to drugs October 1998.

70 Sexually Trasmitted Diseases, Icludig HIV/AIDS 63 CHAPTER FIVE Sexually Trasmitted Diseases: Example for estimatig of drug requiremets ad costs for a populatio of 200,000 ANNEX 8 Sexually Trasmitted Diseases Treatmet Protocol Cost per treatmet i US$ Total cost iiiii US$ Populatio years 50% of total populatio Expected % of STD (1) 5% Expected % of geital ulcers 20% of (1) bezathie bezylpeicilli 2.4 MU 1 dose plus erythromyci, 500mg 3/day x 7 days 0.24 plus 1.68 = Expected % of urethal discharge 50% of (1) ciprofloxaci, 500mg x 1 plus doxycycli, 100mg 2/day x 7 days 1.72 plus 0.17 = Expected % of cervicitis 5% of (1) 250 ciprofloxaci, 500mg plus doxycycli, 100mg 2/day x 7 days Expected % of vagiitis 25% of (1) metroidazole, 2gr plus ystati 2p/day x 14 days 0.04 plus 0.50 = Codoms estimate durig STD maagemet x 12 = US$5.40 per 144 pieces TOTAL US$ 10,356

71 64 Further Readigs Essetial AIDS Iformatio Resources, WHO/ AHRTAG, Geeva/Lodo, Guidelies for HIV Itervetios i Emergecy Settigs, UNHCR/ WHO/UNAIDS, Geeva, Workig with Youg People: A Guide to Prevetig HIV/AIDS ad STDs, Commowealth Secretariat, WHO/UNICEF, Lodo, O uiversal precautios A Practical Guide to Ifectio Cotrol: How to Use Uiversal Precautios ad Pla for Essetial Supplies, WHO, Geeva, Guidelies o Disifectio ad Sterilisatio, Médecis sas Frotières (MSF), Brussels, Guidelies o Procedures to be Followed after a Accidetal Exposure to Blood, MSF, Brussels, O access to codoms Maagig Codom Supply Maual, WHO, Geeva, Specificatios ad Guidelies for Codom Procuremet, WHO, Geeva, The Female Codom: A iformatio pack, WHO/ UNAIDS, Geeva. The Female Codom ad AIDS UNAIDS Poit of View, Geeva, The Male Latex Codom WHO/UNAIDS, Geeva, O safe blood trasfusio Blood Needs i Disaster Situatios: Practical Advice for Emergecies, Trasfusio Iteratioal, No.59, March Blood Safety UNAIDS Poit of View, Geeva Blood Safety UNAIDS Techical Update, Geeva Guide for Plaig Operatios for Refugees, Displaced Persos ad Returees: from Emergecy Respose to Solutios, Iteratioal Federatio of Red Cross ad Red Crescet Societies, Geeva, Guidelies for the Appropriate Use of Blood, WHO, Geeva, Use of Blood Plasma Substitutes ad Plasma i Developig Coutries, WHO, Geeva, O HIV testig ad cousellig Cousellig ad HIV/AIDS UNAIDS Techical Update, Geeva, Guidelies for Blood Door Cousellig o Huma Immuodeficiecy Virus (HIV) Iteratioal Federatio of Red Cross ad Red Crescet Societies/WHO/ GPA Geeva 1994 (WHO/GPA/TCO/HCS/94.2) Policy of HIV Testig ad Cousellig UNAIDS, UNAIDS/97.1 Recommedatios for the Selectio ad Use of HIV Atibody Tests, WHO Weekly Epidemiological Record, No. 20:145-9, Geeva, Volutary Cousellig ad Testig UNAIDS Techical Update, Geeva,1999. O the maagemet of STDs Adler, M., ad S. Foster, J. Riches, ad H. Slavi. STD Ifectios: Guidelies for Prevetio ad Treatmet, ODA/DFID Occasioal Paper, Lodo Maagemet of Sexually Trasmitted Diseases, WHO, Geeva, Prescribig Iformatio: Drugs Used i Sexually Trasmitted Diseases ad HIV ifectio, WHO, Geeva, Sexually trasmitted diseases: policies ad priciples for prevetio ad care UNAIDS/WHO Geeva,1997. STD Case Maagemet Workbooks WHO/ GPTCO/PMT/95.18A, Geeva, The public health approach to STD cotrol UNIADS Techical Update, Geeva, O comprehesive care AIDS Home Care Hadbook, WHO, Geeva, Guidelies for the Cliical Maagemet of HIV Ifectio i Adults, WHO, Geeva Guidelies for the Cliical Maagemet of HIV Ifectio i Childre, WHO, Geeva HIV/AIDS Cousellig: A Key to Carig: Guidelies for Policy Makers ad Plaers, WHO, Geeva O stadard treatmet ad essetial drugs for HIV/AIDS maagemet Access to drugs, UNAIDS Techical Update, Geeva, Stadard treatmets ad essetial drugs for HIVrelated coditios, WHO/DAP, Geeva,1997. WHO Model Prescribig Drugs used i HIV Ifectios, WHO/EDM, Geeva,1999.

72 Family Plaig 65 6 Family plaig helps save wome s ad childre s lives ad preserves their health by prevetig utimely ad uwated pregacies, reducig wome s exposure to the health risks of childbirth ad abortio ad givig wome, who are ofte the sole caregivers, more time to care for their childre ad themselves. All couples ad idividuals have the right to decide freely ad resposibly the umber ad spacig of their childre ad to have access to the iformatio, educatio ad meas to do so. CHAPTER SIX Family Plaig Cotets: Prelimiary Cosideratios Assessmet of Needs Implemetatio of Family Plaig Services Examples of Cotraceptive Methods that May Be Provided i Refugee Settigs Male Ivolvemet i Family Plaig Programmes Moitorig

73 66 Family Plaig Refugee wome ad me should be ivolved i all aspects of family plaig programmes; ad the programmes should be coducted with full respect for the various religious ad ethical values ad cultural backgrouds withi the refugee commuity. From the earliest stages of a operatio, relief orgaisatios should be able to respod to refugees demad for cotraceptives. As the situatio stabilises, a rage of safe ad effective moder methods of family plaig, approved by WHO, should be available. The provisio of family plaig services requires appropriately traied staff ad a reliable supply of material ad fiacial resources. Protocols used to maage family plaig services i the coutry of origi may be differet tha those used i the host coutry. To the extet possible, host coutry protocols should be followed, although some egotiatio may be ecessary where differeces exist. Most family plaig methods are used by wome. Wome have the right to cofidetiality ad privacy about their choice of methods. But frequetly me are the decisio-makers withi the family uit. Where appropriate, me should be give appropriate iformatio ad ecouraged to take a active role i the family plaig decisio-makig process. This will help esure that joit resposibility is take for family plaig decisios ad will maximise acceptace of the programme withi the commuity. Prelimiary Cosideratios The situatio i the refugees coutry of origi will be a importat factor ifluecig expectatios, perceived eeds ad demad for family plaig. Laws, ifrastructure, religious ad ethical values ad cultural backgrouds ad the traiig of health-care providers from the host coutry also have a importat affect o the services that ca be offered. Some wome may wat to cotiue usig a cotraceptive method that they used before displacemet. These wome s demads for cotiued family plaig should be met as soo as possible. Give the risk of pregacy ad exposure to sexually trasmitted diseases (STDs), icludig HIV, that ofte prevails i refugee situatios, codoms should be available as early as possible. (See Chapter Two MISP.) Cousellig services should also be available. Providig a full rage of family plaig services will usually ot be feasible util the situatio has stabilised somewhat. A refugee situatio is cosidered stabilised whe the crude mortality rate falls below oe i 10,000 per day, whe there are o major epidemics, ad whe the settled refugee populatio is ot expected to repatriate or relocate withi six moths. Assessmet of Needs Backgroud iformatio o reproductive health (RH) i the coutry of origi should be available from pre-existig data. Sources for this iformatio iclude UNAIDS, UNFPA, WHO ad other govermetal ad o-govermetal agecies that work i reproductive health ad family plaig. Headquarters ad regioal offices should be able to provide this iformatio to field operatios. A review of the atioal or other (UNFPA, NGO, bilateral, etc.) family plaig programmes of the host coutry must be coducted to fid ways ad meas for collaboratio ad to idetify ay differeces i protocols which must be resolved. If services are made available to refugees, they should also be available to the surroudig local populatio o request. The followig activities will help assess the demad for family plaig withi a refugee populatio: Carry out a ivestigatio of attitudes held by the refugee populatio cocerig cotraceptio. Assess attitudes ad kowledge of providers from the refugee populatio,

74 Family Plaig 67 icludig those ivolvig traditioal methods. Gather iformatio o cotraceptive prevalece by method i the coutry of origi. Verify i-coutry availability of supplies ad cotiuity of supplies. Determie if refugees ca use existig facilities i the host coutry. The support of commuity, social ad religious leaders should be sought before settig up family plaig services. Without this support, oly those willig to risk commuity cesure may use the services. For example, i some traditioal cultures, talk of wome s reproductive rights may provoke oppositio. But support may be give for a iformatio, educatio ad commuicatio (IEC) campaig emphasisig child spacig, safe motherhood ad the health of wome. Discussios should be held with idividual wome (icludig leaders ad traditioal birth attedats [TBAs]) ad wome s orgaisatios to obtai their advice o the locatio of service poits, the timig of services at the health facilities ad the level of privacy ad cofidetiality that will esure maximum use. iformatio should be provided, allowig wome ad me to select freely a method that suits their eeds. High quality meas that: the eeds of cliets are assessed; a appropriate rage of methods is provided; complete ad accurate iformatio about all methods is offered, thus esurig iformed choice; a mix of methods matches the eeds of all potetial cliets; providers have the ecessary techical skills to offer the methods safely (i.e., providers scree wome for medical cotraidicatios, assess STD/HIV risks, ad ca medically maage side effects); providers are traied i techically accurate ad culturally appropriate cousellig techiques ad use them effectively; services are coveiet, accessible ad acceptable to cliets; follow-up care to esure cotiuity of services is provided; ad a adequate logistics system esures a cotiuity of supplies. CHAPTER SIX Implemetatio of Family Plaig Services To esure a appropriate ad effective family plaig programme, the followig compoets must be itegrated, accordig to the fidigs of the assessmet: High-Quality Family Plaig Services All RH services should be of the highest quality possible. High-quality cotraceptive care ivolves providig wome ad me with safe ad appropriate methods to meet idividuals ad couples eeds at every stage of their reproductive lives. Accurate ad complete Procuremet of Cotraceptives ad Logistics of Distributio It is ot possible to provide quality services uless a uiterrupted supply of cotraceptives is esured ad staff are appropriately traied. Local supply chaels should be ivestigated. If these are iadequate, supplies should be obtaied through reliable suppliers or with support from UNFPA, UNHCR or WHO. These agecies ca facilitate the purchase of bulk quatities of good-quality cotraceptives at low cost. The followig are the basic steps required to maage stocks of cotraceptives: Select cotraceptives. Selectio should be based o past use withi the refugee

75 68 commuity, the providers skills, ad cosideratio for the laws, procedures ad practices of the host coutry. Negotiatio maybe ecessary to resolve ay differeces. Estimate quatities to be procured. Estimates should iitially be based o data from the coutry of origi ad, later, o data geerated withi the refugee situatio. Set up a system for record keepig. See sectio below o moitorig. Set up procedures for efficietly maagig the procuremet, distributio ad ivetory of cotraceptives. Uderor over-supply may be avoided by careful orgaisatio, primarily by appoitig a idividual who will assume this specific resposibility. made of qualified or experieced refugees or local staff. If lay workers are used for commuity-based distributio, they must be traied i appropriate skills ad attitudes ad must be supervised. Those ivolved i providig family plaig services must show respect for the cliet s opiio ad for the eed for cofidetiality. To icrease use, the provider may eed to be of the same sex ad cultural backgroud as the user ad have strog commuicatio skills. To esure admiistrative, techical ad referral support, there must be coordiatio ad cooperatio with the host coutry s family plaig programme ad with NGOs or UN agecies, such as UNFPA. Such cooperatio will also icrease the chaces of sustaiability of the refugee family plaig programme. Plaig Outlets ad Opportuities for Family Plaig Services Family plaig delivery sites should be accessible ad coveiet. Ideally, family plaig services should be available at health cetres, outreach health posts ad through commuity-based distributio chaels, whe appropriate. Some groups, such as adolescets, umarried wome ad me, may eed special cosideratio so they feel comfortable usig the services ad so they ca avoid the risk of stigmatisatio by the commuity. Cotraceptives should be available at the cosultatio poit; the cliet should ot be referred to a cetral pharmacy to obtai the selected method. Cousellig ad family plaig methods should be systematically offered to refugees after providig services related to post-abortio care, STDs or after childbirth. Huma Resource Needs Family plaig programmes should be orgaised ad supervised by a experieced urse, midwife or doctor ad maximum use should be Preparatio of the iformatio, educatio ad commuicatio (IEC) compoet Cousellig should always be a itegral part of family plaig services. Appropriate, culturally acceptable IEC materials help idividuals ad couples make free cotraceptive choices. Iformatio must iclude the beefits ad costraits of differet methods, ad how to use them. (See Appedix Oe The Essetials of IEC Programmes.) Preparatio of a adequate traiig programme for service providers I may situatios, there will be traied providers amog the refugee populatio. These people should be employed to the fullest extet possible. All staff ivolved i providig family plaig services must have adequate traiig o cotraceptive methods ad cousellig, as idicated i the list below. This traiig should be supplemeted by periodic refresher courses. O-the-job traiig ad supervised practice are essetial to esure adequate performace ad must be itegral compoets of the supervisory programme.

76 Family Plaig 69 The elemets of a adequate traiig programme for service providers iclude: Techical Competece descriptio of methods (icludig advatages ad effectiveess) mode of actio, side-effects, complicatios, dager sigs appropriate groups of users ad istructios for use or admiistratio cotraidicatios ad drug iteractios techical skills relatig to the provisio of each method (e.g., isertio of IUD or hormoal implat) follow-up ad re-supply requiremets, icludig orderig supplies record keepig For methods that require specific techical skills such as implats, IUDs, volutary sterilisatio ad the diaphragm providers eed hads-o traiig i method provisio ad close supervisio. Iterpersoal Skills commuicatio ad cousellig skills appropriate attitudes towards users ad o-users ad respect for their choices appropriate resposes to rumours ad miscoceptios respect for digity, privacy, cofidetiality uderstadig of the eeds of specific groups, such as adolescets, sigle wome ad me Commuicatio Skills It is importat for providers to be traied i culturally sesitive, ubiased commuicatio techiques that ecourage ope, iteractive relatioships with cliets. Skills ecessary for this kid of commuicatio iclude listeig, clarifyig, ecouragig cliets to speak, ackowledgig cliet feeligs, ad summarisig what has bee said. I additio, providers should be taught strategies for effective cousellig of cliets about method choices i a limited time period. Providers should also be traied to use visual ad other support materials ad to idetify cliets with special eeds, such as those with a high risk of STDs, post-abortio cliets, breastfeedig wome, adolescets, etc. Admiistrative Skills May family plaig providers must also perform routie admiistrative ad maagerial tasks, such as record keepig, referrals ad ivetory cotrol, ad should therefore be traied i these activities. Traiig should emphasise ot oly the specific skills ecessary to carry out these fuctios, but also why they are importat. Pla protocols to be used durig the family plaig cosultatio First cotact ivolves: registratio ad takig a idividual RH history; physical, gyaecological ad pelvic examiatio whe idicated (for example, to ascertai whether a woma is pregat, to ivestigate uexplaied vagial bleedig, to determie the presece of a STD); cousellig regardig available methods ad the user s preferred choice accordig to her/his STD/HIV risk; provisio of the cotraceptive method supply, as idicated; cousellig o whe ad how to use the cotraceptives; cousellig o possible side effects ad reassurace that she/he ca retur to the health facility at ay time ad chage methods; schedulig a follow-up visit. See Aex 2 for a example of the decisiomakig process durig a first visit. Aex 3 CHAPTER SIX

77 70 shows a example of a checklist used at a first visit to scree female refugees for cotraidicatios agaist the use of various methods. Host-coutry checklists may exist for each method ad should be used where appropriate. For a ew user, frequet follow-up (at oe moth, three moths ad six moths) gives the cliet opportuities to ask questios about use ad ay side-effects which she/he may have experieced. As the user becomes familiar with a method, he/she o loger eeds frequet follow-up visits. With some methods, such as pills, codoms, ad ijectables, cliets must make regular visits to obtai the cotraceptives, so follow-up is more automatic. Whatever the frequecy of follow-up visits, the user should be assured of immediate access if she/he experieces ay difficulties. Whe arragig follow-up visits, providers must be sesitive to the literacy ad umeracy of the cliet. Examples of Methods That May Be Provided i Refugee Settigs Providers ad users must be aware of the particularities of each method, its effectiveess, safety, side effects. They should also kow its effect o the risk of STD trasmissio, its appropriateess for breastfeedig wome ad the usual legth of time betwee discotiuatio of the method ad retur to ormal fertility. Iformatio o the commo methods is preseted here. I o cases should abortio be promoted as a method of family plaig (ICPD para 8.25). Other barrier methods, such as spermicides ad female codoms, may be requested by refugees who are familiar with these methods from their coutry of origi. If requested, every effort should be made to supply these methods. Hormoal Cotraceptives Oral Cotraceptive Pills should iclude at least: oe combied oral cotraceptive (COC): ethiyl oestradiol < mg ad levoorgestrel 0.15 mg; oe progestoge-oly oral cotraceptive (POP): levoorgestrel 0.03 mg or orethisteroe 0.35 mg. Ijectable Cotraceptives could iclude depotmedroxyprogesteroe acetate (DMPA, Depoprovera), oe ijectio every three moths, orethisteroe eatharem (NET-EN) oe ijectio every 2 moths, or Cyclofem, oe ijectio per moth. Traied health professioals should admiister ijectables. It is recommeded that oly oe ijectable method should be used to avoid cofusio ad misuderstadig over the schedule for reijectio. Supportive cousellig ad cotiued reassurace durig follow-up visits will help cliets tolerate commo side effects, such as chaged patters of mestrual bleedig. See Chapter Four for details about the provisio of Emergecy Cotraceptive Pills (ECPs). Natioal policies ad the demads of welliformed users should guide the use of ECPs i refugee situatios. Barrier Methods I most refugee situatios, the most importat barrier method will be male latex codoms. Cosistet ad correct use of codoms ca play the dual role of protectio agaist STD ad HIV ifectio ad prevetio of coceptio. They ca be used aloe or i combiatio with aother method to icrease effectiveess. Oly waterbased lubricats should be used with codoms. Copper IUDs (Itra-Uterie Devices) IUD isertio, like sterilisatio ad implats, requires special traiig, facilities ad equipmet that must be i place before these methods are provided. Wome kow to be ifected or at high risk for a STD, icludig HIV, should ot have a IUD iserted. For ulliparous wome, a IUD is ot the method of first choice.

78 Family Plaig 71 Natural Family Plaig (NFP) Methods Natural Family Plaig methods iclude the basal body temperature method, the cervical mucus or ovulatio method, the caledar method ad the sympto-thermal method. NFP is particularly appropriate for people who do ot wish to use other methods for medical reasos or because of religious or persoal beliefs. Cousellig must be provided to both parters whe choosig these methods ad whe practisig them. The methods require iitial traiig ad regular follow-up util cofidece is achieved i detectig fertility sigs. Teachig these methods to potetial users is relatively time cosumig, ad requires separate sessios for those refugees who wish to use them. Breastfeedig Breastfeedig is effective as a cotraceptive method if a woma is exclusively breastfeedig o demad her ifat (o other food beig give to the baby), she is ot mestruatig ad her ifat is less tha six moths old. If ay oe this these three criteria are ot met, the a additioal method of cotraceptio is advised. Family plaig methods recommeded for breastfeedig mothers are: from delivery up to six weeks postpartum: barrier methods, postpartum IUD isertio ad sterilisatio; from six weeks to six moths postpartum: barrier methods, progesti-oly methods (pills, ijectables, implats), IUDs, ad sterilisatio; after six moths postpartum: COCs ad combied ijectables, ad atural family plaig methods. Hormoal Implats A implat is a log-lastig progestoge-oly cotraceptive. The most widely used types (Norplat ad Norplat 2) cosist, respectively, of six or two silastic capsules cotaiig the progestoge levoorgestrel. The capsules, iserted uder the ski of the arm, slowly release the progestoge. These implats are effective for five years. They should oly be iserted or removed by properly traied persoel. Before usig ay log-term cotraceptive withi a refugee situatio, service providers must be sure that the ecessary facilities ad skilled persoel exist i the coutry of origi to reverse or remove the method, sice refugees may retur home at ay time. If such facilities do ot exist i the coutry of origi, the method should ot be used. Volutary Surgical Cotraceptio Both male (vasectomy) ad female sterilisatio are desirable methods of cotraceptio for some cliets. As a surgical method, sterilisatio should oly be performed i safe coditios, with the formal coset of the user ad by traied persoel with the ecessary equipmet. Sterilisatio should ot be excluded especially if it is familiar to the refugees from their coutry of origi ad is allowed withi the host coutry. Male Ivolvemet i Family Plaig Programmes Me must be ivolved i family plaig programmes to icrease recogitio of other RH issues, such as the prevetio of STDs/HIV/ AIDS, ad to icrease acceptace withi the commuity. Activities might iclude couples cousellig, codom promotio, special health facility times for me, peer-group sessios ad social groups. Cosideratio of me s perspectives ad motivatio must be itegral to programme activities. Cotraceptive use by me eables them to share the resposibility of family plaig with their female parters. Some services may eed to be specifically tailored to meet the eeds of male users. CHAPTER SIX

79 72 Moitorig Providers should maitai a daily activity register ad idividual forms to help them record iformatio ad offer effective follow-up. The followig iformatio should be recorded: date user ame or, if required for cofidetiality, oly a umber user iformatio (age, parity, address) method selected (ad brad ame) side effects experieced type of user (ew, repeat, etc.) reaso for discotiuatio dropout or chaged to other method date of ext visit (for follow-up). Record-keepig forms should be simple ad appropriate to the iformatio gathered ad to staff literacy levels. All staff should receive traiig i how to maitai appropriate records ad be iformed of how the iformatio beig collected will be useful to users ad providers. Family Plaig Idicators a Idicators to be collected at the health-facility level Cotraceptive Prevalece Rate (CPR). CPR is the percetage of wome who are usig (or whose parter is usig) a method of cotraceptio at a give poit i time. a Idicators to be collected at the commuity level Commuity-based surveys could be carried out to assess the kowledge, attitudes ad practices of refugees cocerig family plaig services. a Idicators cocerig traiig ad quality of care Regular skills traiig ad assessmets. Health persoel implemetig family plaig programmes should be traied ad their skills assessed regularly. A idicator of this competecy should be moitored at least oce a year. A possible idicator to assess the skills of family plaig workers is the proportio of health workers appropriately implemetig family plaig services. (Refer to Chapter Nie Moitorig ad Surveillace.)

80 Family Plaig 73 Checklist for Establishig Family Plaig Services aassessmet of attitudes of differet groups udertake acotraceptive prevalece i coutry of origi kow afamily plaig services sites established with participatio of refugees acotraceptives procured ad logistics system i place ahealth ad commuity workers traied i family plaig service delivery afamily plaig record keepig system i place aivolvemet of male commuity udertake Further Readigs Pocket Guide for Family Plaig Service Providers, Blumethal, P. et al. JHPIEGO, Baltimore, MD, Cotraceptive Logistic Guidelies for Refugee Settigs, Family Plaig Logistics Maagemet Project, Joh Sow, Ic., Arligto, VA, Hatcher, R. ad W. Riehart, R. Blackbur, ad J. Geller. The Essetials of Cotraceptive Techology, a joit WHO/USAID publicatio, Populatio Iformatio Program, Cetre for Commuicatio Programs, The Johs Hopkis School of Public Health, Baltimore, MD, Improvig Access to Quality Care i Family Plaig: Medical Eligibility Criteria for Cotraceptive Use, WHO, Geeva, Medical ad Service Delivery Guidelies for Family Plaig, WHO, IPPF, AVSC, Secod Editio, Techical ad Maagerial Guidelies o Family Plaig, WHO, Geeva Barrier Methods ad Spermicides: Their Role i Family Plaig Care, Natural Family Plaig - A Guide for Provisio of Services, Norplat Cotraceptive Implats: Maagerial ad Techical Guidelies, Ijectable Cotraceptives: Their Role i Family Plaig Care, Guidelies for Commuity-based Distributio of Cotraceptives, Emergecy Cotraceptio: A Guide Service Delivery, Female Sterilisatio: A Guide to the Provisio of Services, Techical ad Maagerial Guidelies for Vasectomy Services, Itrauterie Devices: Techical ad Maagerial Guidelies for Services, WHO Brochures: What Health Workers Need to Kow Natural Family Plaig Providig a Appropriate Cotraceptive Method Choice Female Sterilisatio Vasectomy Breastfeedig ad Child Spacig IUDs Ijectable Cotraceptives CHAPTER SIX

81 74 ANNEX 1 Appropriate Family Plaig Methods at Differet Stages i a Woma s Reproductive Life Appropriate Family Plaig Methods at Differet Stages i a Woma s Reproductive Life Adolescets Combied oral cotraceptives Codoms a Vagial spermicides a Wome who wish to delay their first birth Implats Combied oral cotraceptives Ijectables b Codoms a Diaphragm/cap Vagial spermicides a Natural family plaig a a less tha 90% effective b retur to fertility may be delayed after use of ijectables c exclusive breastfeedig aloe has a sigificat cotraceptive effect if other criteria are also met: complete ameorrhea ad a period of less tha 6 moths sice delivery d icludig post-abortio cliets Breastfeedig wome who wish to space births c Nohormoal methods: - IUDs - codoms - diaphragm/cap - vagial spermicides Progesteroe-oly hormoal methods: - miipills - implats - DMPA/NET-EN Wome ot breastfeedig who wish to space births d Implats Combied oral cotraceptives Ijectables b IUDs Codoms a Diaphragm/cap Vagial spermicides a Natural family plaig a Couples who wish to termiate child-bearig Vasectomy Female sterilizatio Implats IUDs Perimeopausal wome IUDs Codoms a Diaphragm/cap Vagial spermicides a Source: Providig a appropriate cotraceptive method choice, WHO, Used by permissio.

82 Family Plaig 75 ANNEX 2 Cotraceptive Choice Decisio Tree for Refugees Who Desire More Childre CHAPTER SIX NO Is the cliet breastfeedig? YES Does the cliet desire a method that does ot require frequet use or resupply? Is the cliet mestruatig? Is the child give food supplemets i additio to breastfeedig? Has the cliet bee breastfeedig for more tha six moths? NO YES ONE OR MORE YES ALL NO Is the cliet at risk of circulatory disease? Discuss the suitability of: implats IUDs DMPA/NET-EN The cliet is ot adequately protected from pregacy ad requires a complemetary method. The cliet is adequately protected from pregacy NO Discuss the suitability of: mothly ijectables combied oral cotraceptives barrier methods atural family plaig YES Discuss the suitability of: barrier method atural family plaig YES Is the cliet more tha six weeks post partum? Discuss the suitability of: IUDs barrier methods implats miipills DMPA/NET-EN Discuss the suitability of barrier methods YES Does the cliet wish to adopt a cotraceptive method to complemet breastfeedig, or is she ulikely to retur for services? NO NO Advise the cliet that she may be adequately protected from pregacy but should retur for cotraceptio as soo as oe of the three criteria above is met. Source: WHO, used by permissio.

83 76 ANNEX 3 Family Plaig Cosultatio Card Camp: Number: Name: Age: Address: Educatio: *IUD (itra-uterie device) Pregacies: Births: Livig Childre: Desired: Age of yougest livig child: Wishes to SPACE: duratio: Wishes to LIMIT: Last mestrual period: Date / / Duratio: Affluece: Method(s) already used: Method desired: A. ANAMNESIS 1. Nullipara 2. Post partum < 6 weeks 3. Post abortum < 6 weeks 4. Caesarea sectio < 6 moths 5. Diabetes ot uder surveillace 6. Two of the followig: age > 35 years o heavy smoker o obesity o 7. Hypermeorrhea/dysmeorrhea 8. Metrorrhagia 9. Medicial treatmet which could iterfere with efficiecy of oral cotraceptives Available methods NO YES IUD COC POP INJ* o o ( ) + + o o ( ) o o ( ) o o ( ) o o ( ) o o o o ( ) o o o o + ( ) ( ) + B. HISTORY 1. Phlebitis, arterial thrombosis, embolism 2. Extra-uterie pregacy 3. Upper geital ifectio 4. Recet liver disease (< 6 moths) o o + + ( ) o o ( ) o o ( ) o o + C. GENERAL AND GYNAECOLOGICAL EXAMINATION 1. Yellow cojuctiva (liver malfuctio) 2. Cardiac valvular pathology 3. Blood pressure above 14/9 4. Mammary tumour 5. Phlebitis, importat varicose veis 6. Pregacy 7. Upper or lower geital ifectio o o + o o o o + + ( ) o o + o o o o o o Possible complemetary exams: CONCLUSION: RECOMMENDED METHOD(S) METHOD RETAINED Date: / / NAME QUALIFICATION Sigature COC (combied oral cotraceptive pill) POP (progesteroe-oly pill) INJ (ijectable)

84 Family Plaig 77 ANNEX 4 Whe orderig cotraceptives, always keep i mid the time it will take betwee the date of your order ad actual receipt of the cotraceptives (usually 2 to 3 moths). Calculatig Cotraceptive Requiremets Example of eeds for oe year i Two Camps: A ad B CHAPTER SIX Items CONDOMS Target group (males): 20% of populatio Users: 20% of the target group 12 codoms per user per moth CONTRACEPTIVES Target group (wome yrs): 20% of populatio Cotraceptive Prevalece Rate: 15% 65% of the users prefer depoprovera (4 per year) 30% of the users prefer pills (13 cycles per year) 5% of the users prefer IUD Populatio Camp A wome wome or doses 900 wome or cycles 150 wome or 150 IUDs Populatio Camp B wome 975 wome or doses 450 wome or cycles 75 wome or 75 IUDs Total (both camps) (+20% wastage) doses (+10% wastage) cycles (+10% wastage) 225 IUDs Uit costs ($) average $5.40 per 144 pieces $1.5 per vial $60 per 100 cycles $1.2 per IUD Total costs ($) per year $70 170

85 78

86 Other Reproductive Health Cocers 79 7 This Chapter does ot iclude a discussio of all remaiig reproductive health (RH) issues. It deals with two particularly serious aspects of reproductive health: maagig complicatios of spotaeous ad usafe abortio, ad elimiatig the practice of female geital mutilatio ad carig for wome who have udergoe this procedure. CHAPTER SEVEN Other Reproductive Health Cocers Cotets: Post-Abortio Care 1 4 Emergecy Maagemet of Post-Abortio Complicatios 4 Post-Abortio Family Plaig 4 Liks to Other RH Services 4 Moitorig ad Surveillace Female Geital Mutilatio 2 4 Scope ad Defiitio 4 WHO classificatio 4 Prevetio of Female Geital Mutilatio i Refugee Situatios 4 Care of Wome with Female Geital Mutilatio i Refugee Situatios 4 Strategies to Elimiate Harmful Traditioal Practices 1. This sectio draws heavily o WHO s Cliical Maagemet of Abortio Complicatios: A Practical Guide, WHO s Complicatios of Abortio, Techical ad Maagerial Guidelies for Prevetio ad Treatmet ad the Post-abortio Care: A Referece Maual for Improvig Quality of Care, Post-abortio Care Cosortium This sectio draws heavily upo Female Geital Mutilatio, WHO Iformatio Kit ad the WHO Maagemet of Pregacy, Childbirth ad the Postpartum Period i the Presece of Female Geital Mutilatio.

87 80 Other Reproductive Health Cocers Itroductio Complicatios of Spotaeous ad Usafe Abortio Health professioals should be able to recogise ad maage the complicatios of spotaeous ad usafe abortios, which are major public health cocers as recogised i both the Iteratioal Coferece o Populatio ad Developmet (ICPD) i Cairo (1994) ad The Fourth World Coferece o Wome i Beijig (1995). The followig statemet from the ICPD uderpis the guidace offered i this Chapter: I o cases should abortio be promoted as a method of family plaig. All Govermets ad relevat itergovermetal ad o-govermetal orgaisatios are urged to stregthe their commitmet to wome s health, to deal with the health impact of usafe abortio as a major public health cocer ad to reduce the recourse to abortio through expaded ad improved family plaig services. Prevetio of uwated pregacy must always be give the highest priority ad every attempt should be made to elimiate the eed for abortio. Wome who have uwated pregacies should have ready access to reliable iformatio ad compassioate cousellig...where abortio is ot agaist the law, such abortio should be safe. I all cases, wome should have access to quality services for the maagemet of complicatios arisig from abortio. Post-abortio cousellig, educatio ad family plaig services should be offered promptly, which will also help to avoid repeat abortios. Cairo, ICPD, 1994, paragraph 8.25 Usafe abortio cotributes sigificatly to the morbidity ad mortality of wome of reproductive age throughout the world. WHO defies usafe abortio as a procedure for termiatig uwated pregacy either by persos lackig the ecessary skills or i a eviromet lackig miimal medical stadards or both. Every day, a estimated 55,000 usafe abortios take place, resultig i the deaths of 200 wome daily. WHO reports that up to 13 per cet of pregacy-related deaths, world-wide, are due to usafe abortios. I some coutries, deaths due to usafe abortio may be resposible for up to 45 per cet of all materal deaths. Furthermore, it has bee estimated that for every death, hudreds more wome suffer chroic pai or disability. The most frequet complicatios are icomplete abortio, sepsis, haemorrhage, ad itra-abdomial ijury. Log-term health problems iclude chroic pelvic iflammatory disease, tubal blockage ad secodary ifertility. Spotaeous abortio or miscarriage ca result i complicatios that require life-savig emergecy care. Female Geital Mutilatio Female geital mutilatio comprises all procedures that ivolve partial or total removal of the female exteral geitalia ad/or ijury to the female geital orgas for cultural or ay other o-therapeutic reasos. Female geital mutilatio is widespread amog refugee wome who come from the cultures i which it is practised. While it is ot required by ay religio, it is a practice rooted i traditios related to geder ad power iequalities etreched i a society s political, social, cultural ad ecoomic structures. May wome ad me believe that geital mutilatio is ecessary for wome s health, to maitai virgiity ad to make them acceptable to their commuity. Care provided to wome who have bee subjected to female geital mutilatio will be improved if staff fully uderstad ad are able

88 Other Reproductive Health Cocers 81 to deal with its potetial cosequeces. Health care workers should make it a priority to elimiate harmful traditioal practices, such as female geital mutilatio. Post-Abortio Care for Maagig Complicatios of Spotaeous ad Usafe Abortio Post-abortio care (PAC) is the strategy to reduce death ad sufferig from the complicatios of usafe ad spotaeous abortio. The elemets of PAC are: emergecy maagemet of icomplete abortio ad potetially life-threateig complicatios post-abortio family plaig cousellig ad services makig liks betwee post-abortio emergecy services ad other RH care services. Sice icomplete ad/or septic abortios may threate a woma s life, health providers must be able to deal promptly with their cosequeces. As for obstetric emergecies, a appropriate referral system should be established ad available 24 hours a day. (See Chapter Three.) Whe plaig for PAC, commuity eeds ad perceptios, icludig wome s prefereces for type ad geder of PAC provider ad locatio of services, must be solicited ad cosidered. Each refugee situatio requires a protocol for maagig post-abortio complicatios. Refer to Table 1 for broad guidelies o the type of facility, the compositio of staff ad the types of emergecy post-abortio care that may be available. Factors to cosider i developig the protocol are: staff traiig, qualificatios ad supervisio to achieve miimum stadards, supplies ad equipmet, coditios (clealiess, space, privacy, etc.) at the health facilities, emergecy trasport system, ad capacity of referral facility. Where feasible, host-coutry health referral facilities should be used ad supported. Emergecy Maagemet of Post-Abortio Complicatios Wome of reproductive age experiecig at least two out of three of the followig symptoms should be cosidered as potetial patiets with a threateed or icomplete abortio: vagial bleedig crampig ad/or lower abdomial pai a possible history of ameorrhoea (o meses for over oe moth) The followig steps should be take to maage post-abortio complicatios: Talk to the woma about her coditio. Ay woma who presets with complicatios of usafe abortio or miscarriage eeds immediate high-quality care. Health care workers should be aware that wome seekig such care are uder severe emotioal stress i additio to physical discomfort. Privacy, cofidetiality ad coset for treatmet should be esured. Coduct iitial cliical assessmet. The iitial assessmet may reveal or suggest the presece of a immediate life-threateig complicatio such as shock. Shock should be addressed without delay i order to prevet death or keep the woma s coditio from worseig. Maagig shock: All health persoel should kow the uiversal measures to treat shock: do ot give fluids by mouth; keep airway ope; tur head ad body to CHAPTER SEVEN

89 82 oe side ad keep warm. Health cetres should be equipped with IV fluids (salie, plasma substitutes or safe blood), systemic atibiotics ad oxyge. Complete cliical assessmet. This cosists of takig a thorough RH history, performig careful physical ad pelvic examiatios ad, whe ecessary, obtaiig appropriate laboratory tests. A complete assessmet will idetify other possible complicatios (such as itra-abdomial ijury, vagial bleedig [light to severe], ifectio/sepsis ad pai) leadig to a appropriate treatmet pla. Maage complicatios. Complicatios should be treated immediately by qualified persoel. Prompt referral ad trasfer may be eeded if the woma requires treatmet beyod the capability of the facility where she is see. Her coditio will eed to be stabilised before she is trasferred to a higher-level referral service. The followig treatmets may be ecessary: Rest: i case of light to moderate bleedig. Replacemet of fluids: i case of shock or severe vagial bleedig, salie solutio, plasma substitutes or safe blood. Laparotomy/surgery: i case of suspicio of a itra-abdomial ijury. Itraabdomial ijury is commoly due to uterie perforatio, possibly as a result of a attempted abortio. Uterie evacuatio: for removal of retaied products of coceptio. First ad early secod-trimester icomplete abortios ca be treated by vacuum aspiratio or dilatatio ad curettage (D&C). Vacuum aspiratio, maual or electric, has bee foud to result i fewer complicatios tha D&C ad causes less trauma to the patiet. Health workers should refer icomplete abortios i the middle- or late-secod trimester to a facility with surgical ad full emergecy backup for treatmet. Atibiotics: for ifectio or septic shock. These are commo complicatios of icomplete abortio. Treatmet with broadspectrum atibiotics by IV or IM is idicated. Maagemet of pai: Appropriate pai maagemet esures that the woma experieces a miimum of axiety ad discomfort. Wome s eeds for pai maagemet will vary, depedig o their physical ad emotioal state. Prevetio of tetaus: A tetaus vacciatio should be give, as a woma may have bee exposed to tetaus ad her vacciatio history is likely to be ucertai. Laparotomy, surgery ad uterie evacuatio should be udertake by qualified ad supervised staff i appropriate ad safe coditios, preferably i a host-coutry health facility.

90 Other Reproductive Health Cocers 83 Table 1 Miimum Stadard for the Provisio of Emergecy Maagemet of Post-abortio Complicatios By Level of Health Care Facility ad Staff CHAPTER SEVEN Level Miimum Staff Emergecy Care Health Post/ Commuity Health Recogitio of the sigs ad symptoms Cliic Workers, Traditioal of the complicatios of spotaeous Birth Attedats ad usafe abortio ad referral to (TBAs) facilities where stabilisatio ad/or treatmet is available Health Cetre 1 Health Workers All above activities plus: Nurses Diagosis based o medical history Midwives ad physical ad pelvic examiatio Geeral Practitioers Resuscitatio/preparatio for treatmet or trasfer Iitiatio of emergecy treatmets (atibiotic therapy, IV fluid replacemet ad oxytocics) Pai cotrol, simple aalgesia ad sedatio, ad local aaesthesia Haematocrit/Haemoglobi testig If traied staff, practisig miimum safe stadards, ad appropriate equipmet are available, above activities plus: Uterie evacuatio durig first trimester for ucomplicated case of icomplete abortio Referral-Level Nurses Above activities plus: District Hospital Midwives Emergecy uterie evacuatio through (usually a host- Geeral Practitioers secod trimester coutry facility) Ob/Gy Specialists Treatmet of most post-abortio Surgeos complicatios Local ad geeral aaesthesia Diagosis ad referral for severe complicatios (septicaemia, peritoitis, real failure) Laparotomy Blood crossmatch, HIV testig ad safe blood trasfusios Tertiary-level Nurses Above activities plus: Regioal or Midwives Uterie evacuatio as idicated for all Natioal Hospital Geeral Practitioers icomplete abortios Ob/Gy Specialists Treatmet of severe complicatios Surgeos (icludig bowel ijury, severe sepsis, real failure) Treatmet of bleedig/clottig disorders 1. A health cetre i a refugee situatio usually provides i-patiet ad outpatiet services, has a basic laboratory ad pharmacy, ad is supervised by oe or more medical doctors. Take from: Complicatios of Abortio, Techical ad Maagerial Guidelies for Prevetio ad Treatmet, WHO, 1995.

91 84 Post-Abortio Family Plaig Lack of access to adequate family plaig services is a major cotributor to the problem of usafe abortio. Coversely, uwated pregacy ad, i may cases, usafe abortio are prime idicators of the umet eed for safe ad effective family plaig services. I most health systems, wome treated for the complicatios of usafe abortios rarely receive ay cousellig services to prevet subsequet uwated pregacies. Clearly, whe a woma receives care for post-abortio complicatios she should also receive comprehesive family plaig cousellig ad services, if she so desires. At a miimum, all wome receivig PAC should uderstad: that the prompt retur of ovulatio ca result i pregacy eve before meses returs; ad that there are safe cotraceptive methods that ca prevet pregacy, ad where those methods ca be obtaied. I additio, all staff providig PAC should kow how to cousel ad provide family plaig services. (Refer to Chapter Six for further details o family plaig services.) Liks to Other Reproductive Health Services Likig emergecy PAC services with other RH services is essetial ad logical, yet i much of the world these services remai distictly separate. As a result, may wome have o access to RH care ad suffer poor overall health. It is importat to idetify the RH services that each woma may eed ad offer her as wide a rage of services as possible, such as: Treatmet for reproductive tract ifectios Cervical ad breast cacer screeig ad treatmet (if applicable) Advice o proper utritio Advice o family plaig methods Advice about ateatal care Liks to uder-five cliics for existig childre (if applicable) Referral for services followig sexual violece Referral for cousellig services followig diagosis as HIV-positive. Moitorig ad Surveillace PAC services should be cotiuously reviewed. Maagers of these services should assess the level of use of these services, review all cliets records, the availability ad proper use of equipmet ad supplies, regularly assess specific idicators of the quality of care, idetify chages or problems that occur, provide feedback to staff, ad itervee to correct ay problems idetified. Checklist for Post-abortio Care aprotocol for maagemet of complicatios of usafe ad spotaeous abortios is developed ad used astaff are traied to maage complicatios of usafe ad spotaeous abortios ahealth facilities are equipped with appropriate materials aprotocol for post-abortio family plaig ad liks with other RH services are developed ad used areportig ad moitorig system to esure quality of care are i place

92 Other Reproductive Health Cocers 85 Moitorig may iclude: direct observatio of staff at work; use of checklists (for example, to evaluate critical skills); examiatio of cliic records; ad discussios with patiets, staff ad the commuity. Idicators to moitor effectiveess of PAC services Icidece of usafe ad spotaeous abortios: The icidece will idicate the magitude of the problem ad poit to possible uderlyig causes. For istace, the icidece of usafe abortio might idicate iadequate family plaig coverage for wome who wat to avoid or delay pregacy. Quality of PAC services: The ability of staff to udertake all aspects of PAC should be reviewed periodically through direct observatio of staff ad/or review of medical records. WHO Classificatio a Type I: Excisio of the prepuce with or without excisio of part or all of the clitoris. a Type II: Excisio of the clitoris together with partial or total excisio of the labia miora. a Type III: Excisio of part or all of the exteral geitalia ad stitchig/arrowig of the vagial opeig (ifibulatio). atype IV: Uclassified prickig, piercig or icisio of the clitoris ad/or labia stretchig of the clitoris ad/or labia itrocisio scrapig (agurya cuts) or cuttig (gishiri cuts) of the vagia or surroudig tissue itroductio of corrosive substaces or herbs ito the vagia ay other procedure that falls uder the defiitio of female geital mutilatio CHAPTER SEVEN Female Geital Mutilatio Scope ad Defiitio Female geital mutilatio comprises all procedures that ivolve partial or total removal of the female exteral geitalia ad/or ijury to the female geital orgas for cultural or ay other otherapeutic reasos. It is estimated that female geital mutilatio has bee performed o approximately 130 millio wome ad girls. About two millio girls risk beig subjected to female geital mutilatio each year. Most of the girls ad wome who have udergoe female geital mutilatio live i 28 Africa coutries, although some live i Asia, ad i other regios. Approximately 15 per cet of wome ad girls subjected to female geital mutilatio udergo ifibulatio. Most others udergo a clitoridectomy or excisio. There is a high icidece of ifibulatio i Djibouti, Somalia ad orther Suda, ad a high rate of complicatios.

93 86 Ifibulatio is also reported i souther Egypt, Eritrea, Ethiopia, orther Keya, Mali ad Nigeria. Physical Cosequeces Female geital mutilatio causes grave damage to girls ad wome ad frequetly results i serious health cosequeces which may iclude a icreased idividual risk of bloodbore ifectios such as HIV. Some of the effects are immediate; others become apparet oly years later. Girls ad wome udergoig the more severe forms of mutilatio are particularly likely to suffer serious ad log-lastig complicatios. Documetatio ad studies are available o the ature of the physical short-term ad log-term complicatios described below, but there has bee little study of the sexual or psychological effects of the procedure or of the frequecy with which complicatios occur. The mortality rate of girls ad wome udergoig geital mutilatio is ukow as few records are kept ad deaths due to the practice are rarely reported. Usually the operatio is performed o girls betwee four ad te years of age or youger, or, i some areas, adolescet girls. Village wome, TBAs or male barbers geerally perform the operatio, usually without aaesthetics or atiseptics. The effects o health deped o the extet of the cuttig, the skill of the operator, the clealiess of the tools ad eviromet, ad the physical coditio of the girl. The effects of the procedure last a lifetime ad may threate ot oly the woma s reproductive health ad well beig, but also the health of her childre. Health workers i refugee situatios are seldom kowledgeable about the physical, psychological ad social cosequeces of female geital mutilatio, or are they always sesitive to the cultural beliefs that support the practice. Therefore, it is vital that field staff determie whether female geital mutilatio is practised withi a refugee populatio ad idetify who is resposible for udertakig the procedure. Prevetio of Female Geital Mutilatio i Refugee Situatios RH programmes should iclude strategies to discourage female geital mutilatio, emphasisig the lik betwee the practice ad poor reproductive, sexual ad geeral health i wome ad girls. It is vital to uderstad the reasos for the practice before embarkig o iformatio campaigs. Efforts to elimiate female geital mutilatio ca greatly be ehaced by elistig the support of resposible commuity members. The medicalisatio of female geital mutilatio (i.e., supportig health care professioals to perform female geital mutilatio i health facilities uder more hygieic coditios) is ot acceptable i the attempt to make this procedure safer. Medicalisatio does ot elimiate the harm caused by female geital mutilatio ad it legitimises the procedure. Health workers employed i refugee situatios must be iformed that their ivolvemet i medicalisig female geital mutilatio will ot be tolerated uder ay circumstaces. Severe discipliary measures, icludig possible termiatio of workers cotracts, should be take if they are foud to be performig female geital mutilatio. Care of Wome with Female Geital Mutilatio i Refugee Situatios Wome who have udergoe female geital mutilatio, particularly Type III, eed special care, especially durig pregacy, delivery ad the postpartum period. Whe a ifibulated woma gives birth, staff should be aware of the followig poits: the formatio of rigid scar tissue aroud the vagial opeig as a result of the mutilatio is likely to lead to delay i the secod stage of labour, which may edager both the woma ad the baby; ad extesive episiotomies may be eeded to allow for safe delivery. Wome who have udergoe ifibulatio eed special care whe usig some forms of cotraceptive methods, such as the IUD, ad i maagig the complicatios of usafe ad spota-

94 Other Reproductive Health Cocers 87 eous abortio. Sexually trasmitted diseases (STDs) are also more difficult to diagose ad wome may be at a greater idividual risk for bloodbore ifectios, icludig HIV. Strategies to Elimiate Harmful Traditioal Practices, icludig Female Geital Mutilatio The issue of harmful traditioal practices, icludig female geital mutilatio, should be approached with great sesitivity. While there are o hard ad fast rules whe workig to prevet ad elimiate these practices, the followig strategies ad examples may provide some guidace to field workers: Experiece has show that the iitial step i addressig harmful traditioal practices is providig educatio ad iformatio o such practices, focusig o their egative cosequeces. However, actio-orieted activities must follow iitial awareess buildig. Campaigs to elimiate these practices are more likely to succeed ad be accepted by the target populatio whe they iitially emphasise the harmful health cosequeces rather tha the legal or huma rights aspects. Laws should be see to be protective rather tha puitive ad desiged to prevet harm to childre. This aspect should be emphasised at the commuity level so that the law comes to be see as providig protectio ad support to the idividual. It is ecessary to have a thorough uderstadig of the ature ad extet of the particular practice, icludig its roots ad social cosequeces. Health workers ca acquire this kowledge through discussios with the refugees, themselves. Educate target populatios (both me ad wome), such as religious leaders, traditioal leaders (chiefs, tribal elders ad political leaders), teachers, TBAs ad other health workers, as well as the geeral refugee populatio (icludig wome, me ad childre) about the harmful health cosequeces of these practices. It is particularly importat to educate youg girls about these issues. Promote, provide techical support to, ad mobilise resources for atioal ad local groups that will iitiate commuitybased activities aimed at elimiatig harmful traditioal practices. Natioal committees to elimiate harmful traditioal practices exist i may coutries ad their expertise should be tapped. I Keya, local NGOs ruig campaigs aimed at elimiatig female geital mutilatio discovered that refugees were more ope to discussig the topic if it was icluded i workshops that covered other RH issues, such as STDs, HIV/AIDS ad safe motherhood, rather tha if it was preseted o its ow. However, the campaig i refugee situatios i Ethiopia bega as a stad-aloe model ad was very successful. Oly later was it icorporated ito a larger RH programme. Clearly the, each programme must be tailored to the commuity it serves. I some coutries, alterative icomegeeratig activities should be devised for those who ear moey through harmful practices. Traditioal practitioers must also be able to fid other ways to secure the respect of their commuity. Videos provide a excellet meas of demostratig the harmful effects of some traditioal practices. Videos depictig a female geital mutilatio operatio or a woma who has ot udergoe female geital mutilatio givig birth have proved to be very effective. The use of drama ad other cultural activities, such as plays or sogs, ca also be a effective method of dissemiatig iformatio o the egative effects of harmful traditioal practices. Radio, local papers, ad mosques may also be used to help dissemiate this iformatio. I the Suda, some health workers focus mostly o me i their campaig to save girls from female geital mutilatio. Me are ofte the primary decisio-makers i the family, though they are also geerally uaware of the exact ature ad severity of the procedure. CHAPTER SEVEN

95 88 Health workers i Ugada support a rite of passage ceremoy while tryig to elimiate the harmful practices of female geital mutilatio. Programmes ecourage the ceremoial aspects of the comig of age for youg wome, but elimiate the cuttig part of the process. I Sierra Leoe, female geital mutilatio is part of a iitiatio rite for wome s secret societies. These societies ca be very importat for wome s self-empowermet, ot oly because they provide a support etwork, but because they also provide cotacts for icome-geeratig activities. While it is importat to ecourage groups that empower wome, it is equally importat to ecourage iitiatio ceremoies that do ot require female geital mutilatio. The importace of educatig girls ad wome caot be overstated. The icidece of harmful traditioal practices, such as female geital mutilatio ad early childhood marriage, decreases as female literacy icreases. Therefore, promotig ad supportig female educatio, both the erolmet of girls i schools ad adult literacy, should be a priority. Growig immigrat populatios i idustrialised coutries have brought female geital mutilatio with them to coutries where it had ot bee practised. UNHCR discourages iformig refugees, before resettlemet, of the crimialisatio of the practice i resettlemet coutries. Experiece has show that if told prior to departure, mass female geital mutilatio operatios may be coducted i the coutry of asylum before resettlemet occurs. Whe refugees are resettled to coutries that have laws agaist female geital mutilatio, the authorities of the resettlemet coutry should be ecouraged to iform refugees of these laws upo their arrival. Field staff are advised to pla carefully their strategy for elimiatig harmful traditioal practices i cojuctio with the refugee commuity, implemetig parters ad ay other relevat UN orgaisatios. It is importat to work with the refugee commuity to esure measures take are as effective as possible. Local NGOs, host commuities, ad the govermet, which may already have active campaigs i the coutry, could also be ivolved. Moitorig ad Supervisio Moitorig the chage i female geital mutilatio practices i a commuity is very difficult. Programmes should moitor complicatios experieced by wome durig birth ad ivestigate ay deaths that may be related to female geital mutilatio. Health care providers, both i health facilities ad i the commuity, should be supervised ad moitored routiely to esure that they are ot practisig female geital mutilatio. Further Readigs Cliical Maagemet of Abortio Complicatios: A Practical Guide, WHO, Geeva, Complicatios of Abortio: Techical ad Maagerial Guidelies for Prevetio ad Treatmet, WHO, Geeva, Female Geital Mutilatio: Fidigs from the Demographic ad Health Surveys Program, Macro Iteratioal Ic., Washigto, DC, Female Geital Mutilatio Iformatio Kit (icludes Joit UNICEF, UNFPA ad WHO Statemet o female geital mutilatio), WHO, Geeva, How To Guide: From Awareess to Actio Eradicatig Female Geital Mutilatio i Refugee Camps i Easter Ethiopia, UNHCR, Geeva, Maagemet of Pregacy, Childbirth ad the Postpartum Period i the Presece of Female Geital Mutilatio: A Report of a WHO Techical Cosultatio, WHO, Geeva, Policy Paper o Eradicatio of Harmful Traditioal Practices, UNHCR, Geeva Post-abortio Care: A Referece Maual for Improvig Quality of Care, Post-abortio Care Cosortium, JHPIEGO Corporatio: Baltimore, MD, Post-abortio Family Plaig: A Practical Guide for Programmes Maagers, WHO, Geeva, 1997.

96 Reproductive Health of Youg People 89 8 Growig up is stressful ad challegig i the best of times. For those youg people livig as refugees, the stresses are much greater. Their trasitio to adulthood is ofte made more difficult by the absece of the usual role models ad the breakdow of the social ad cultural system i which they live. They may have goe through persoal trauma themselves, icludig armed coflict, violece, isecurity, sexual abuse, harm to or loss of family members, disruptio of schoolig or employmet, of friedships, ad of family ad commuity support. CHAPTER EIGHT Reproductive Health of Youg People Cotets: Youg People i Refugee Situatios Priciples i Workig with Youg People Assessig the RH Needs of Youg People Respodig to the RH Needs of Youg People Commuity-based Programmes Moitorig ad Supervisio Defiig Childre ad Youg People a Childre 0-18 years Covetio o the Rights of the Child The defiitios of childre, adolescets ad adults may chage from culture to culture. Health workers must adapt the defiitios they use to suit the specific refugee situatio i which they are workig. Whether a adolescet has assumed the roles ad resposibilities of a adult is also a reflectio of the culture ad the refugee situatio. Whe workig with youg people, the cultural, ethical ad religious values of the refugee commuity must be respected. a Adolescets years UNFPA, WHO, UNICEF a Youth years UNFPA, WHO, UNICEF a Youg People years UNFPA, WHO, UNICEF

97 90 Reproductive Health of Youg People Youg people have special eeds i all circumstaces; ad each age group withi this populatio has differet problems ad requiremets. I refugee situatios, where it is difficult eough to set up basic reproductive health (RH) services for the etire commuity, health providers will also have to cosider ad address the special eeds of youg people. But youg people are tremedously flexible, resourceful ad eergetic. They ca help each other through peer cousellig ad peer educatio, ad they ca provide care to others ad assist health providers as voluteers. Youg People i Refugee Situatios Youg people ofte have a easier time adaptig to a ew situatio tha their parets do. They lear how to work the system quickly. I tryig to uderstad their special circumstaces ad meet their eeds, it is helpful to remember the followig: Adolescece is a time for learig about close relatioships. I ormal situatios, much of this iformatio is gaied from peers ad from role models i the youg perso s family ad commuity. These people may ot be available i refugee settigs. As respected adults i the lives of youg people, male ad female service providers may become importat role models ad should be aware of their potetial ifluece. Youg people ofte lack a well-developed future orietatio. This ca be reiforced by refugee or displaced status. Projects that provide these youg people with a reaso to look to the future may also help them cosider the cosequeces of usafe sexual activity ad the eed to take resposibility for their actios. The behaviour of youg people i refugee or displaced situatios may ot be subjected to the same kid of scrutiy as it would be uder ormal circumstaces. The separatio from oe s homelad, oe s elders ad oe s traditioal culture may create a situatio i which risky behaviour is less socially cotrolled. Thus there is a greater risk of early tee pregacy, sexually trasmitted diseases (STDs), drug abuse, violece, etc. Youg people are ot a homogeeous group. Youg wome ad youg me face very differet problems ad opportuities. Youg wome are much more vulerable to commo RH problems ad they ivariably bear most of the cosequeces. Also, youg people aged 10 to 14 years have differet eeds tha those aged 16 to18 or 20 to 24. Ad differet cultures have differet expectatios for youth i these differet age groups. For example, i some cultures, marriage is acceptable/expected for a 14- year-old girl; i may other cultures, it is ot. I may coutries with high STD/HIV prevalece, the most vulerable group is youg wome. The AIDS epidemic is exacerbatig the health risks that youg wome face. Their lack of power over their sexual ad reproductive lives compouds the risks of uwated pregacy, usafe abortio ad STD/HIV ifectio, all of which are likely to occur more frequetly i refugee situatios. Reproductive Health Needs of Adolescets The backgroud characteristics of youg people, icludig their religio, cultural upbrigig, place of origi (rural or urba), ad level of educatio will, to some extet, defie their eeds. However, basic RH eeds iclude: iformatio o sexuality ad reproductive health access to family plaig services preatal ad post-abortio care safe delivery treatmet of usafe abortios diagosis ad treatmet of sexually trasmitted diseases

98 Reproductive Health of Youg People 91 protectio from sexual abuse culturally appropriate psychosocial cousellig ad/or metal health services egotiatig skills Priciples i Workig with Youg People The primary priciple i workig effectively with youg people is to promote their participatio. Although this priciple applies to the provisio of RH services i adult populatios, it is particularly importat for youg people. As a group, youg people ofte have a culture of their ow, with particular orms ad values. They may ot respod to services desiged for adults. They are at a stage i life where they eed to develop a sese of cotrol over their bodies ad their health. At the same time, sice they are youg ad relatively iexperieced, they eed guidace that is both sesitive ad reassurig. The best way to ecourage youg people to participate is to develop a partership betwee them ad the providers with proper regard for paretal guidace ad resposibilities. Services will be more accepted if they are tailored to the eeds as idetified by youg people, themselves. Other priciples to remember: Service providers must uderstad the cultural sesitivities surroudig the provisio of iformatio ad services to youg people. To the extet possible, commuity leaders ad parets should be ivolved i developig programmes targeted at youg people. Service providers with deep cultural kowledge (especially if the provider is part of that culture) are more likely to provide services acceptable to the commuity tha those cosidered outsiders. Programmes should idetify ad ecourage peer leadership ad commuicatio. Peers are usually perceived as safe ad trustworthy sources of iformatio. It is essetial to have liks betwee health ad commuity services. Liks betwee health ad commuity services are ecessary to esure that youg people get the appropriate treatmet for problems which might be revealed through oe service but require additioal assistace from aother service (e.g., sexual violece or usafe abortio). Youg people eed privacy. The problems that brig them to a service provider ofte make them feel ashamed, embarrassed or cofused. Though space may be at a premium i a refugee camp, it is importat for providers to try to create the most private space possible i which to talk to youg people. Cofidetiality must be guarateed. Service providers eed to maitai cofidetiality i their dealigs with youg people ad be hoest with them about their health problems. I most cultures, the geder of the service provider is importat. A youg perso should be referred to a provider of the same sex. RH Services for Youg People Should: a be user-friedly a have competet staff who are friedly, welcomig, ad o-judgmetal a promote trust ad cofidetiality a be free or low cost a be easily accessible a have flexible hours a be located i attractive facilities a offer same-geder providers CHAPTER EIGHT

99 92 Assessig the RH Needs of Youg People I the absece of iformatio specific to the youg people, providers must assume that may of the commo problems cited above may be worse i the refugee situatio. The disruptio of health ad educatio services ad geeral state of disorder imply a lack of protectio ad supervisio, icreased sexual violece, ad a greater eed to exchage sex for food, shelter, safe passage ad protectio. It is importat to obtai iformatio about a youg perso s history of STDs ad pregacy status, usafe abortio, rape ad other forms of sexual abuse. Health care providers should also be aware of a youg perso s kowledge about ad access to ay form of cotraceptio, ad his/her beliefs, attitudes, perceptios ad values. More specifically, it is importat to gather iformatio about: cultural orms related to sexual relatioships ad rites of passage ito adulthood (icludig harmful traditioal practices, such as female geital mutilatio) curret orms/practices/perceptios/attitudes related to sex typical patters of adult authority over adolescet behaviour withi the camp services available to youg people (ad applicable restrictios) ad the degree to which the refugee commuity uderstads this availability perceptios of camp staff/service providers related to providig RH services to youg people youg people s perceptios of their RH eeds This iformatio ca be gathered through camp records, iterviews ad focus group discussios ad possibly through simple survey techiques. (Some further guidace is foud i Appedix Oe o IEC.) Respodig to the RH Needs of Youg People Youg people eed basic iformatio about sexuality ad reproductio. They also eed to lear how to protect their reproductive health. I may refugee settlemets, formal educatio eds after primary school. Therefore, iformatio about reproductive health must be commuicated i creative ways. Ay orgaised activity for youth sports, video showigs, hadicraft clubs may provide a opportuity for dissemiatig importat health iformatio to participats. It has bee prove that sex educatio leads to safe behaviour ad does ot ecourage earlier or icreased sexual activity. (See UNAIDS documet i Further Readig.) Therefore, youg people should be iformed about STD/HIV/ AIDS ad early pregacy, ad appropriate advice ad supplies should be made available to them. Youg people eed to develop certai skills to be able to make iformed, resposible decisios about their sexual behaviour. They eed to be able to resist pressure, be assertive, egotiate, ad resolve coflicts. They also eed to kow about cotraceptives, such as codoms, ad feel cofidet eough to use them. Peer cousellig ad peer educatio ca be very effective i stregtheig these skills ad attitudes. Youg girls who do ot atted school ad who are destied to marry immediately after the start of mestruatio may be particularly difficult to reach. However, their society may allow a commuity worker to visit the girls at home ad discuss health matters relatig to preparatios for parethood. Rape may be the reaso a adolescet first approaches health services. May victims of rape ad sexual abuse are girls, but boys are also vulerable to sexual violece. Youg people who have bee sexually abused eed immediate health services ad access to a safe eviromet. I refugee situatios, adolescet girls ad boys may be forced ito sellig sex simply to sur-

100 Reproductive Health of Youg People 93 vive. Refugee-commuity members should be ivolved i idetifyig ways to protect girls ad wome from sexual violece ad coercio. Oe possible protective measure is to esure that wome admiister the distributio of food ad shelter. (See Chapter Four Sexual Violece.) If a adolescet is pregat, it is vital to provide her with good ateatal care, sice youg wome, especially those uder 15 years of age, are proe to complicatios of pregacy ad delivery. May youg pregat wome will resort to usafe abortio. They will eed special care if complicatios from a usafe abortio develop. Iformatio about family plaig must be readily displayed ad available to help keep uwated pregacies to a miimum. (See Chapter Six - Family Plaig). Adolescet boys egagig i homosexual itercourse should be taught how to prevet STD/ HIV. However, IEC messages related to STDs should ot label this behaviour i a way that may stigmatise the boys (e.g., as homosexual), but should refer to the behaviour as me havig sex with me or same-geder sex. Psychological trauma resultig from refugee experieces may make youg people reluctat to seek services related to their sexual health. But they do eed to kow that these services are available to them, that they will receive care ad support if they wat it, ad that they will ot be judged or puished i ay way. Iformatio about the services could be displayed i places where youg people gather or provided through other activities or social services. Psychosocial support ad cousellig should be provided by traied cousellors wheever eeded, but particularly i cases of sexual abuse ad uwated pregacy. Commuity-Based Programmes Ideally, a perso with experiece i RH services for youg people should participate i the eeds assessmet ad plaig of the programmes. Youg people from all age groups should be idetified, as quickly as possible, to help desig the programmes ad evetually to take a leadership role. Whe a assessmet of curret eeds ad available resources has bee made, the group of service providers ad youg people who are assembled to develop the programme ca cosider the project objectives ad develop the correspodig activities. Plaers should defie simple mechaisms for collectig iformatio that ca later be used to measure the project s impact. That iformatio will also guide ay modificatios made to the programme. Youg people should be ivolved i evaluatig ad modifyig the programme. RH services for youg people are more effective ad acceptable whe they are liked to other activities or settigs, for example recreatio or work. Youth cetres, developed i some refugee settlemets, offer a place for youg people to lear, play ad receive health services. I other refugee settigs, youg people have access to health services durig special hours, usually after school or after work. Youg people eed their ow physical spaces for social iteractio. These may be the best veues for providig health services. Moitorig ad Supervisio RH programmes should be moitored to esure youg people have access to health services ad health care providers are carig for youg people without stigmatisig them. To be sure youg people are attedig health services ad beig targetted with health iformatio, may RH idicators should be measured by age ad sex break dow. See Chapter Nie for select idicators for youg people. CHAPTER EIGHT

101 94 Further Readigs A Picture of Health: A Review ad Aotated Bibliography of the Health of Youg People i Developig Coutries, WHO, Geeva, Actio for Adolescet Health: Towards a Commo Ageda, recommedatios from WHO, UNFPA, ad UNICEF, Comig of Age: From Facts to Actio for Adolescet Sexual ad Reproductive Health, WHO/FRH/ADH/97.18, Geeva, Cousellig Skills Traiig i Adolescet Sexuality ad Reproductive Health: A Facilitator s Guide, WHO, Geeva, Refugee Childre: Guidelies for Protectio ad Care, UNHCR, Geeva, Techical Report of the WHO/UNFPA/UNICEF Study Group o Programmig for Adolescet Health, WHO, Geeva, The Impact of HIV ad Sexual Health Educatio o the Sexual Behaviour of Youg People: A Review Update, UNAIDS, Geeva, Workig with Youg People i Sexual Health ad HIV/AIDS: A Resource Pack, AHRTAG, Lodo, 1996.

102 Surveillace ad Moitorig 95 9 Surveillace ad moitorig are basic elemets of programmes for both comprehesive reproductive health (RH) ad geeral health care. The perso who coordiates RH activities should esure timely ad appropriate iclusio of RH data ad idicators i the geeral health-reportig system. CHAPTER NINE Surveillace ad Moitorig Cotets: A System Framework A Eight-Step Approach to Surveillace ad Moitorig Overview of Data Sources RH Idicators Referece Rates ad Ratios for RH Idicators Sample Worksheet for Mothly RH Reportig The Five Essetial Compoets of a Moitorig System: 1 defiitio of essetial data to collect, icludig case defiitios 1 ; 2 systematic collectio of data; 3 orgaisatio ad aalysis of data; 4 implemetatio of health itervetios based o the data; ad 1. A case defiitio is a set of stadard criteria for decidig whether a perso has a particular disease or health related coditio. Criteria ca be cliical, laboratory or epidemiologic. 5 re-evaluatio of itervetios.

103 96 Surveillace ad Moitorig The aims of moitorig are to: idetify high-risk groups; idetify the most serious ad/or the most prevalet coditios; ad moitor the treds of these coditios ad the implemetatio ad impact of itervetios. System Framework This Chapter explais how to develop a system to collect ad use essetial RH data. The system starts whe a refugee situatio occurs ad o existig services are preset. It is described i chroological order ad i order of priority. The scheme ca be adapted ad altered to respod to differet situatios. Most RH surveillace should be itegrated ito the overall health-iformatio system (HIS). Durig a refugee emergecy, keep the HIS simple ad limited to the most importat causes of morbidity ad mortality. Step 1 (of the eight-step approach described below) suggests the essetial data relevat to reproductive health which staff should try to collect i the early phase. Whe more comprehesive services are available, other data ca be icorporated (as described i subsequet steps). Surveillace ad moitorig of both health status ad service delivery ivolve defiig measurable programme objectives (what the programme will strive to achieve) ad usig idicators to measure progress toward achievig those objectives. A idicator is a measuremet that, whe compared to either a stadard or desired level of achievemet, provides iformatio regardig a health outcome or a maagemet process. Idicators are measuremets that ca be repeated over time to track progress toward achievemet of objectives. I this Maual, we use a simple framework for objectives ad idicators. Impact objectives target chages i mortality ad morbidity expected to result from programme activities. Outcome objectives target chages i kowledge, attitudes, behaviours, or i availability of eeded services or commodities that result from programme activities. They relate directly to the priority itervetio (e.g., HIV/ STD prevetio, child spacig), the target populatio (e.g., wome of reproductive age), or those charged with carig for the target populatio (such as health care workers ad family members). Process objectives specify the actios eeded for programme implemetatio, ad correspod to various activities (such as traiig, supply of drugs ad equipmet, ad health educatio) ecessary to achieve the iteded outcomes ad impact. Note that this Chapter presets maily core impact ad outcome objectives. Maagers ca develop additioal items (especially process objectives) accordig to the populatios, available resources, ad workig eviromets. A selectio of idicators is preseted at the ed of each chapter ad the complete list of suggested idicators is preseted at the ed of this chapter. The RH Coordiator should select oe or more idicators based o programme objectives. Before the idicator ca be calculated, data will have to be collected for the umerator ad deomiator. Stadard measures should be used whe possible for compariso purposes, such as expressig some rates per 1,000 populatio. I some refugee settigs, prelimiary objectives may have to focus o settig up a system to collect iformatio o births ad eoatal deaths, for example, before the idicator eoatal mortality rate ca be calculated. Oce the eoatal mortality rate is calculated, this idicator ca be followed mothly or for some specified time period, i order to moitor outcomes from the safe motherhood programme.

104 Surveillace ad Moitorig 97 The followig is a example of the evaluatio framework: CHAPTER NINE PROCESS OUTCOME IMPACT Objectives 100% of commuity health workers traied to recogise ad refer obstetric complicatios 100% of wome with obstetric emergecies are referred i a timely maer ad their complicatios maaged appropriately Materal ad eoatal mortality ad morbidity reduced by %, i year Idicators % of health workers able to recogise ad refer obstetric complicatios % of wome with obstetric emergecies who received appropriate maagemet Reductio of eoatal mortality by %, i year A Eight-Step Approach to Surveillace ad Moitorig 1. Collect Basic Demographic Data Collect the followig RH-related data as soo as possible. Total populatio (by age ad sex) Number of births Crude birth rate Age ad sex specific mortality rates Number of wome/me of reproductive age Number of pregat wome Number of lactatig wome I additio to usig iformatio provided by refugee workers, estimates might be made usig registratios, or through commuity-based surveys (mortality, utritioal or household). Iformatio from the coutry of origi of the refugees should also be obtaied ad used as estimates (for example, the Crude Birth Rate i the coutry of origi). 2. Defie a System of Simple ad Essetial Data Collectio Durig programme desig ad implemetatio, programme plaers should have established measurable objectives. Based o these objectives, determie which idicators will be used ad what iformatio is eeded to calculate the idicators, ad establish case defiitios (such as those for live births ad stillbirths) so that idicator measuremets are clear. Next, determie the logical data flow, icludig time periods ad reportig schedule. Idetify people resposible for data collectio, icludig refugees (see Step 3 below). Fially, icorporate ito the routie programme/camp health-iformatio forms, the data eeded to calculate the RH idicators. (See Sample worksheet for RH reportig Aex 6.) Possible sources of data are: Daily birth or delivery reports. At miimum, the reports must iclude age of the mother, place of delivery, mode of delivery (vagial, caesarea sectio), sex, birth outcome (live, stillbirth), ad birth weight. If over- or uder-reportig is suspected, cross check the iformatio with the esti-

105 98 mated umber of pregat wome or with the agecy resposible for distributig ratios. Cliic-based log books or registries for ateatal care, referrals, family plaig, ad STD sydromic case maagemet as part of the out-patiet log book. Wome seekig care for the complicatios of usafe or spotaeous abortios should also be tracked through cliic ad hospital-based registratio/ log books. Health facility records, commuity reportig, cemetery records ad referral facilities records outside the refugee situatio. These should be used to track materal ad eoatal deaths. Other sources of data iclude commuity surveys, case ivestigatios, laboratory reports ad commuity outreach-worker reportig. 3. Idetify, Orgaise ad Trai Workers from the Refugee Commuity for Data Collectio Begi by idetifyig those refugees with midwifery skills ad/or traied traditioal birth attedats (TBAs), icludig those already providig services, who ca be traied to collect data. Otherwise, commuity members will have to be recruited. Orgaise these workers (by geographical sector, for example) ad have them report to a key perso ad place. Orgaisig them this way will help gai access to ad kowledge about the pregat ad lactatig wome i the populatio ad provide a commuicatio system to help refer wome with serious complicatios related to pregacy, delivery, the postpartum period or spotaeous or usafe abortio. Coduct traiig o the objectives ad flow of data collectio, case defiitios, completio ad timely submissio of collectio forms, ad o the use of the data to improve programmes. 4. Implemet Specific Reportig Procedures Experiece has show that several specific areas of RH moitorig ad surveillace have ot bee routiely coducted i refugee situatios. These iclude ivestigatios of each materal death ad reportig o cases of sexual violece. Ivestigatig Materal Mortality Ivestigatig the causes of materal deaths ca help idetify gaps i services ad the eed to improve referral procedures for obstetric complicatios. By reviewig cases, health care providers ca stregthe their skills i idetifyig the early warig sigs of obstetric emergecies. Camp staff should ivestigate deaths due to pregacy (direct materal mortality) ad deaths of pregat wome caused by the effects of pregacy o pre-existig coditios (idirect materal mortality). Both types of iformatio are essetial, sice direct mortality is ofte uderestimated. The goal is to determie which deaths were caused by pregacy or childbirth, or by complicatios or the maagemet thereof, ad how deaths ca be preveted i the future. Poits to be ivestigated iclude: time of oset of life-threateig illess; time of recogitio of the problem ad time of death; timeliess of actios; access to care, or logistics of referral; ad quality of medical care util death. The iformatio may come from grave watchers, hospital/health-post staff or from commuity reports. Verbal autopsy, which has bee used i certai refugee situatios, has proved relatively successful whe medical records are uavailable. Reportig Rape/Sexual Violece The perso resposible for addressig sexual violece ca devise a appropriate trackig

106 Surveillace ad Moitorig 99 system, i collaboratio with camp authorities ad health care workers. Survivors of sexual violece may be see i health facilities or reported by TBAs, commuity workers or other key iformats. Sice sexual violece is sesitive ad usually uder-reported, ote all reported cases or suspected cases. Cofidetiality of survivors must be esured. Prepare ad distribute summary reports to all iterested persos, agecies ad hostcoutry authorities, as idicated. Reassess programme objectives, idicators ad itervetios. Idicators ca be evaluated i terms of their accuracy, completeess, relevace ad timeliess. CHAPTER NINE 5. Aalyse the Data Aalyse the data to address the problems raised by the programme objectives. Calculate rates, ratios ad proportios, ad prepare tables, graphs ad charts. Compare these rates with expected values or referece rates. Treds are more importat tha poit estimates. Prioritise the most importat health problems as judged by cause-specific morbidity ad mortality. Idetify the subgroups at highest risk for health problems by perso, place ad time (such as by age ad sex). Idetify the factors potetially resposible for morbidity ad mortality. For example, a high umber of reported cases of geital ulcer disease amog adolescet wome could idicate a eed to target them for syphilis prevetio ad treatmet. Share data aalysis with service providers ad the commuity. 8. Improve Assessmet Capability ad Surveillace Systems Accordig to Need As disease icideces chage, the situatio stabilises ad service provisio becomes more comprehesive, the surveillace system may eed to be adapted. The system may eed to be expaded to iclude more coditios i the list of reportable illesses. Programmes ca add or chage idicators, or they ca add sources ad methods of data collectio. Aex 1 Aex 2 List of Aexes RH Idicators for Early Phase RH Idicators i Stabilised Phase 6. Implemet Programmes Based o the Aalysis Use the data to develop feasible, effective ad efficiet strategies for achievig the programme objectives. Implemet the selected strategies ad a system to moitor their progress. 7. Assess Programme Progress Assess programme progress by cofirmig whether programme objectives have bee met. Aex 3 Aex 4 Aex 5 Aex 6 Aex 7 RH Referece Rates ad Ratios Referece Rates ad Ratios for RH Idicators Estimatig Number of Pregat Wome i a Populatio Worksheet for Mothly RH Reportig Summary of RH Idicators

107 100 ANNEX 1 RH Idicators for Early Phase Programme/Compoet Objectives Idicator Type Defiitio Data use, Remarks, Importat (umerator/deomiator) Assumptios MINIMUM INITIAL SERVICE PACKAGE (MISP) THESE INDICATORS ARE APPLICABLE TO BOTH THE EARLY AND STABLISED PHASES 1) SV prevetio: Reduce the Icidece of Impact Number of icidets of SV reported i Cosider providig age ad sex-specific icidece of reported SV from % sexual violece the specified time period icidece rates. to % A case defiitio of Sexual Violece Total populatio eeds to be developed. 2) Uiversal precautios: 100% of Supplies for Outcome Number of health facilities with adequate Measures the effectiveess of distributio health facilities will have adequate uiversal supplies to carry out uiversal precautios system for supplies related to uiversal supplies to carry out uiversal precautios precautios. precautios agaist HIV/AIDS Number of camp service delivery poits Each service must defie adequate trasmissio. supply based o the umber of potetial exposures. 3) Codom distributio: Distribute Estimate of Outcome Number of codoms distributed i Measures whether codom supplies are supplies of codoms adequate for codom specified time period adequate. at least % of the total populatio. coverage Total populatio 4) Itra-partum care: Distribute Estimate of Outcome Number of clea delivery kits distributed Measures whether wome i late sufficiet clea delivery kits coverage of pregacy have access to clea for % of pregat wome. clea delivery Estimated umber of pregat wome delivery kits. kits May have to estimate umber of pregat wome (see Chapter 9, Aex 5)

108 Surveillace ad Moitorig 101 Programme/Compoet Objectives Idicator Type Defiitio Data use, Remarks, Importat Assumptios (umerator/deomiator) SAFE MOTHERHOOD 1) Materal ad child health status: Neoatal Impact Number of live bor ifats who die Measures the overall health status of ew-bors. Reduce the eoatal mortality rate mortality < 28 days of age i the specified time by %. rate period 1,000 Number of live births i the specified time period 2) Materal ad child health status: Low birth Impact Number of live bor ifats weighig Measures the health status of pregat wome Reduce the rate of live bor ifats weight <2,500 gms i the specified time period ad the adequacy of ateatal care. Birth weights weighig <2,500 gms., from % percetage 100 also idetify ifats at higher risk who may eed to %. Total umber of live births (with birth special care. weight recorded) i the specified time period 3) Materal ad child health status: Very low Impact Number of live bor ifats weighig Measures the health ad utritioal status of pregat Reduce the rate of live bor ifats birth weight <1,500 gms i the specified time period wome, ad ca help detect disease outbreaks i weighig <1,500 gms., from % percetage 100 a camp. to %. Total umber of live births (with birth weight recorded) i the specified time period 4) Materal ad child health status: Stillbirth Impact Number of ifats of 22 gestatio weeks A geeral measure of pregacy outcome. Reduce the umber of ifats bor dead ratio or greater or greater tha 500g who are from % to %. bor dead i the specified time period May be elevated durig outbreaks of diseases such 100 as malaria or syphilis. Total umber of live births ad stillbirths Verify defiitio of stillbirth based o atioal i the specified time period policies. 5) Materal ad child health status: Ivesti- Process Number of reported materal deaths Measures the programme s capacity to idetify all 100% of reported materal deaths gatio which are ivestigated accordig to materal deaths ad to determie the risk factors are ivestigated accordig to of materal established guidelies, ad the results that cotribute to those deaths. established guidelies, ad the results deaths of which are dissemiated to health staff are dissemiated to health staff. 100 Assumes that: a) both idirect ad direct materal Total umber of reported deaths of mortality evets are ivestigated, to reduce materal deaths. uder- reportig; b) a protocol for ivestigatios is i place. CHAPTER NINE ANNEX 2/1 RH Idicators for Stabilised Phase The list of idicators provided i Aex 2 has bee developed as a master list. It is the resposibility of the RH Coordiator to select from this list idicators that should be assessed i a give situatio. The idicators selected should be based o the objectives of the RH programme i each situatio. Targets set for each objective should be based o kowledge of the actual situatio or iformatio from coutry of origi where possible.

109 102 ANNEX 2/2 RH Idicators for Stabilised Phase Programme/Compoet Objectives Idicator Type Defiitio Data use, Remarks, Importat Assumptios (umerator/deomiator) 6) Ateatal care: Coverage Outcome Number of wome deliverig i the Measures whether pregat wome are Traied persoel will atted to all of ate- specified time period who had atteded receivig miimal ateatal visits. pregat wome at least oce. atal care ateatal services (at least oce). 100 * This idicator is measured at the time of birth. Number of live births i the specified time period 7) Ateatal care: 100% of Coverage Outcome Number of wome deliverig i the Measures whether pregat wome are beig pregat wome will be screeed for of syphilis specified time period who had bee screeed for syphilis. syphilis before delivery. screeig tested for syphilis durig the pregacy 100 * This idicator is measured at the time of birth. Number of live births i the specified time period 8) Ateatal care/std prevetio: Syphilis Impact Number of pregat wome screeed Measures how commo syphilis ifectio is amog Reduce the percetage of pregat ifectio for syphilis i the specified time period pregat wome, ad the potetial for cogeital wome who test positive for syphilis amog who tested positive for syphilis syphilis. from % to %. pregat 100 wome Number of pregat wome who were There is a possible bias if syphilis testig is ot tested for syphilis i the specified systematic. Is oly valid if all pregat wome are time period tested. 9) Ateatal care: The icidece Icidece Impact Number of usafe ad spotaeous Measures effectiveess of ateatal care i of usafe ad spotaeous abortios of usafe abortios before 22 weeks of gestatio prevetig early pregacy loss. Also is measure of should be less tha % ad spo- or below 500g i the specified time wome s geeral health. taeous period. abortios 1000 Number of live births i the specified time period 10) Ateatal care: Tetaus Outcome Number of wome deliverig i the Measures whether wome of reproductive age are At least % of wome deliverig vacciatio specified time period who had bee beig vacciated with tetaus toxoid. is adequately vacciated with tetaus coverage adequately vacciated with tetaus * This idicator is measured at the time of birth. toxoid. toxoid Neoatal tetaus cases should also be reported. 100 Number of live births i the specified time

110 Surveillace ad Moitorig 103 Programme/Compoet Objectives Idicator Type Defiitio Data use, Remarks, Importat Assumptios (umerator/deomiator) 11) Itra-partum care: Reduce the Icidece Impact Number of obstetric complicatios i the Measures the coverage ad outcome of ateatal icidece of obstetric complicatios of obstetric specified time period ad obstetric care. from % to %. complica tios Number of live births i a specified Cause-specific rates ca be calculated for various time period obstetric emergecies such as ruptured uterus, eclampsia, or haemorrhage. 12) Itra-partum care: 100% of Maage- Outcome Number of wome with obstetric Measures the quality of obstetric care. wome with obstetric emergecies met of emergecies who are treated i a will be treated i a timely ad obstetric timely ad appropriate maer i the Case defiitios for various obstetric emergecies appropriate maer. emerge- specified time period eed to be developed. cies 100 Total umber of wome with obstetric emergecies i the specified time period 13) Itra-partum care: A traied Coverage Outcome Number of wome who deliver i the Measures whether traied health workers atted health worker will atted at least of traied specified time period who are atteded deliveries. % of deliveries. delivery by a traied health worker services 100 Traied health workers could iclude staff i facilities Number of live births i the specified ad hospitals, etc. (TBAs are ot icluded i this time period category, per WHO guidelies.) 14) Itra-partum care: At least Kowledge Outcome Number of wome of reproductive Measures whether wome ca idetify dager sigs % of wome of reproductive age of dager age who ca ame at least two dager of obstetric complicatios, which ca facilitate referral ca ame at least two dager sigs sigs of sigs of obstetric complicatios for proper care. of obstetric complicatios. obstetric 100 complica- Number of wome of reproductive age tios 15) Itra-partum care: % of deliveries Caesarea Outcome Number of wome delivered by Measures access to emergecy surgical obstetric performed by Caesarea sectio will sectio Caesarea sectio i the specified services. be at acceptable stadards (depedig perce- time period o the physical characteristics of tage 100 Caesarea sectio rates will deped o the physical refugee wome). Number of wome deliverig i characteristics of refugee wome (e.g., pelvic size the specified time period is hereditary ad will affect these rates). CHAPTER NINE ANNEX 2/3 RH Idicators for Stabilised Phase

111 104 ANNEX 2/4 RH Idicators for Stabilised Phase Programme/Compoet Objectives Idicator Type Defiitio Data use, Remarks, Importat Assumptios (umerator/deomiator) 16) Itra-partum care: 100% of Maage- Outcome Number of wome with complicatios Measures the quality of care for complicatios due wome with complicatios due to met of due to abortios who are treated i a to usafe ad spotaeous abortio. usafe ad spotaeous abortios will complica- timely ad appropriate maer, i the be treated i a timely ad appropriate tios due specified time period maer. to abortios 100 Total umber of wome with complicatios due to abortios, i the specified time period 17) Post partum care: At least % Coverage Outcome Number of wome who have delivered Measures whether wome receive postpartum visits. of wome will receive at least oe post of postpar- i the specified time period who have partum visit withi days. tum care received at least oe postpartum visit Time period ca be up to 42 days followig delivery. withi days Factors determiig the timig of the visit iclude: 100 icidece ad type of obstetric complicatios, the Number of live births i the specified percet of low birth weight births, the proportio of time period home deliveries, ad the eoatal mortality rate, amog others. 18) Post partum care: At least % Vacciatio Outcome Number of ew-bors who receive BCG Measures the extet to which ew-bors receive first of ew-bors will receive BCG ad coverage ad Polio by first moth birthday vacciatios early. It is also used as idicator of Polio vacciatios withi first moth for BCG 100 quality of postpartum care. of life. ad Polio Number of live births durig specified i ew- period bors

112 Surveillace ad Moitorig 105 Programme/Compoet Objectives Idicator Type Defiitio Data use, Remarks, Importat Assumptios (umerator/deomiator) SEXUAL VIOLENCE 1) SV respose: Coverage Outcome Number of reported SV survivors who Measures whether SV survivors receives critical Provide basic psychosocial ad of services receive basic set of psychosocial & services. medical services to 100% of reported for SV medical services i the specified time SV survivors. survivors period Assumes protocols for psychosocial ad medical 100 services are defied ad dissemiated. Number of reported SV survivors i specified time period 2) SV respose: Timely Outcome Number of SV survivors who preset for Measures the ability of patiets to access services % of SV survivors will preset for care for care withi 3 days of a evet i the quickly, icludig emergecy cotraceptio. care withi 3 days of a evet. SV specified time period survivors 100 Number of reported SV survivors i a specified time period 3) SV respose: Prosecute at least Prosecu- Outcome Number of idetified SV offeders who Measures whether security forces ca effectively % of idetified offeders i reported tio of SV are prosecuted i the specified time apprehed ad prosecute offeders. SV cases. offeders period Assumes that survivors have made the choice to take 100 legal actios. Number of reported cases of SV i a Assumes guidelies ad procedures are defied for specified time period prosecutig offeders. 4) SV respose: Coverage Process Number of desigated health workers Measures the umber of health workers who ca All desigated health workers are of health traied (or retraied) withi the past potetially service SV survivors. traied to respod to SV survivors. worker 2 years to provide services to traiig i SV survivors servig SV 100 survivors Number of desigated health workers Desigated health worker is defied as those workers who will be providig a particular service. CHAPTER NINE ANNEX 2/5 RH Idicators for Stabilised Phase

113 106 ANNEX 2/6 RH Idicators for Stabilised Phase Programme/Compoet Objectives Idicator Type Defiitio Data use, Remarks, Importat Assumptios (umerator/deomiator) STDs icludig HIV/AIDS 1) Safe blood provisio: 100% of Blood Outcome Number of blood samples draw for Measures blood safety for trasfusio. blood draw for trasfusio will be screeig trasfusio that are screeed for HIV Assumes HIV test kits are available ad used correctly. screeed for HIV. for HIV i the specified time period % of blood which tested positive could also be reported 100 Number of blood samples draw for trasfusio i the specified time period 2) STD cotrol: Reduce the icidece Icidece Impact Number of cases of STDs reported i Measures a programme s potetial impact o the of STDs from % to %. of STDs a specified time period icidece of STDs Optimally, age, sex ad sydrome rates could be Total populatio calculated. 3) STD cotrol: Quality of Outcome Number of patiets with STDs assessed Measures the quality of STD case maagemet. % of patiets with STDs will be STD case ad treated accordig to protocol Assumes STD case maagemet protocols ad assessed, treated ad couselled maage- 100 appropriate drugs i place. accordig to protocol. met Number of patiets with STDs Requires observatio of skills as part of supervisio. 4) STD cotrol: Traiig i Process Number of desigated health workers Measures the extet of STD case maagemet All desigated health workers will be STD case traied to maage STD cases accordig traiig for health workers. traied (or retraied) to maage STD maage- to protocol cases appropriately. met 100 Assumes STD case maagemet protocols ad Number of desigated health workers appropriate drugs i place. 5) Uiversal precautios: % of Practice of Outcome Number of health workers who Measures whether health workers comply with health workers will carry out uiversal uiversal demostrate use of uiversal uiversal precautios. precautios. precautios precautios 100 Requires observatio of skills as part of supervisio. Number of health workers 6) Codom use: Codoms will be Outlets for Outcome Number of potetial outlets with codoms Measures the effectiveess of codom distributio available for distributio i 100% of codoms available for distributio systems. potetial outlets. distributio 100 List of potetial outlets eeds to be developed, but Number of potetial outlets could iclude health facilities, bars, ad outreach workers.

114 Surveillace ad Moitorig 107 CHAPTER NINE Programme/Compoet Objectives Idicator Type Defiitio Data use, Remarks, Importat Assumptios (umerator/deomiator) 7) Codom use: Kowledge Outcome Number of persos i target populatio Measures the impact of a commuity-educatio % of persos i target populatio of fuctio who recogise a codom, kow its programme about codom use o kowledge. will recogise a codom, kow its ad correct prevetive effecs, ad ca prevetive effects, ad will be able codom describe how to use it correctly to describe how to use it correctly. use 100 Number of persos i target populatio 8) Codom use: Codom Outcome Number of persos i target populatio Measures the impact of a commuity-educatio % of persos i target populatio use with reportig codom use at last itercourse programme about codom use o behaviour will report codom use at last o-regular with a o-regular parter, withi a itercourse with a o-regular parter. parters specified time period 100 Number of persos i target populatio who report havig had itercourse with a o-regular parter, withi a specified time period ANNEX 2/7 RH Idicators for Stabilised Phase

115 108 ANNEX 2/8 RH Idicators for Stabilised Phase Programme/Compoet Objectives Idicator Type Defiitio Data use, Remarks, Importat Assumptios (umerator/deomiator) FAMILY PLANNING 1) Family plaig: At least % Cotracep- Outcome Number of wome of reproductive age Measures what per cet of wome is usig of wome of reproductive age will use tive preva- usig ay method of cotraceptio cotraceptio. a method of cotraceptio. lece rate 100 (CPR) Number of wome of reproductive age Kowledge of the CPR i coutry of origi will assist i settig this target. 2) Family plaig: All health workers Coverage Outcome Number of health workers who provide Measures extet of family plaig traiig provided who provide family plaig services of family family plaig services ad who were to health workers. will be traied (or retraied) to provide plaig traied (or retraied) i the past 2 years appropriate family plaig services. traiig to provide family plaig services 100 Number of health workers who provide family plaig services 3) Family plaig: At least % Commuity Outcome Number of sexually active refugees able Measures kowledge of family plaig i the of sexually active refugees will kowledge to site major messages about family populatio ad is based o the major messages demostrate appropriate kowledge cocerig plaig give durig awareess activities. about family plaig. family 100 plaig Number of sexually active refugees targeted for family plaig messages 4) Family plaig: All cotraceptive Cotra- Outcome Number of service delivery poits which Measures effectiveess of cotraceptive supply service delivery poits will maitai ceptive maitai a miimum of 3 moths supply distributio system. a miimum of 3 moths supply of supply of each of combied oral cotraceptive each of combied oral cotraceptive pills, progesti-oly pills, ad ijectables pills, progesti-oly pills, ad ijectables. 100 Number of service delivery poits

116 Surveillace ad Moitorig 109 Programme/Compoet Objectives Idicator Type Defiitio Data use, Remarks, Importat Assumptios (umerator/deomiator) REPRODUCTIVE HEALTH OF YOUNG PEOPLE 1) Youg people ad STDs: Reduce Icidece Impact Number of reported cases of STDs Measures a programme s potetial impact o the the icidece of STDs amog youg of STDs amog youg people i the specified icidece of STDs amog youg people. people from to. i youg time period people 1,000 Need to defie age group for youg people relevat Total umber of youg people to local situatio. 2) Youg people ad safe Youg Impact Number of live births to youg wome Measures how commo births are amog youg motherhood: Reduce the percetage wome i the specified time period wome. of all births that occur to youg wome birth 100 from % to %. percetage Number of live births i the specified Need to defie age group for youg wome relevat time period to local situatio. 3) Youg people ad family plaig: Cotracep- Outcome Number of sexually active youg people Measures what per cet of sexually active youg At least % of sexually active youg tive preva- who use a method of cotraceptio people are usig cotraceptio. people will use a method of lece rate 100 cotraceptio amog Number of sexually active youg people youg surveyed people 4) Youg people ad STDs/HIV: Codom Outcome Number of sexually active youg people Measures the impact of a commuity-educatio At least % of sexually active youg use amog reportig codom use at last itercourse programme about codom use o youg people s people will report codom use at last youg 100 behaviour. itercourse. people Number of sexually active youg people surveyed 5) Quality of care: % of youg Quality of Outcome Number of youg people who are Measures the quality of reproductive health services people receivig adequate care reproduc- assessed, treated ad couselled for youg people. accordig to protocol. tive health accordig to protocol durig specified services time period Requires observatio of skills performace as part for youg 100 of supervisio. people. Number of youg people seekig services at health facility durig specific time period. CHAPTER NINE ANNEX 2/9 RH Idicators for Stabilised Phase

117 110 ANNEX 3 RH Referece Rates ad Ratios RH Referece Rates ad Ratios The figures show here have bee collected from various sources ad cover differet periods. They are iteded to give estimates of what may be expected i some populatios. These figures are ot to be used as defiitive baselie rates or as rates to be achieved. They merely idicate the possible rage ad may assist with resource plaig ad with targetig specific programmes. Abortios 10-15% of all pregacies may spotaeously abort before 20 weeks gestatio 90% of these will occur durig the first three moths 15-20% of all spotaeous abortios that occur require medical itervetios Hypertesive 5-20% of all pregacies will develop HDP Disorder of Pregacy 5-25% of all primigravida pregacies will develop HDP (HDP) or Pre-eclampsia Data Sources WHO Collaboratig Cetre i Periatal Care ad Health Services Research i Materal ad Child Health, Pregacy ad Ifat Health Braches, Divisio of Reproductive Health, NCCDPHP, Ceters for Diseases Cotrol ad Prevetio, Atlata, GA., USA Sig, S. ad Wulf, P., Estimated Levels of Iduced Abortio i Six Lati America Coutries, Iteratioal Family Plaig Perspectives, 1994, 20 (1): Labour ad 15% of all pregacies will require some type of Delivery itervetio at delivery Complicatios 3-7% of all pregacies will require a Caesarea sectio 10-15% of all wome will have some degree of cephalopelvic disproportio (higher i poorer socioecoomic populatios) 10% of deliveries will ivolve a primary postpartum haemorrhage (withi 24 hours of delivery) % of deliveries will ivolve a secodary postpartum haemorrhage (occurrig 24 hours or more after delivery) % deliveries will result i uterie rupture % of all deliveries will result i some type of birth trauma to the baby 1.5% of all births will have a cogeital malformatio (does ot iclude cardiac malformatios diagosed later i eoatal period). 31% of these malformatios will result i death.

118 Surveillace ad Moitorig 111 Safe Motherhood Referece Rates ad Ratios for RH Idicators Regioal Idicators Idicator Sub-Sahara South East Idustrial (1) Africa Asia ad Coutries Pacific CHAPTER NINE ANNEX 4 Referece Rates ad Ratios for RH Idicators Crude birth rate (per 1000 populatio) Neoatal Mortality Rate (per 1000 live births) Periatal Mortality Rate (per 1000 live births) Materal mortality ratio (per 100,000 live births) Ifat mortality rate (per 1000 live births) Coverage of Ateatal Care (%) Low birth weight percetage (per 100 live births) Births atteded by traied health persoel (%) Istitutioal Deliveries (% of live births) Usafe Abortio (1000 wome 15-49) Aaemia i Pregat Wome (%) Coverage of Tetaus vacciatio (Preg. Wome) STDs, icludig HIV/AIDS STD Icidece Rate (per 1,000 populatio) AIDS cases (per 100,000) Family plaig Cotraceptive prevalece rate Others Referece UNDP Huma Developmet Report ad World Health Report 1996 (1) Complete this table with coutry-specific iformatio either from host or coutry of origi.

119 112 ANNEX 5 Estimatig Number of Pregat Wome i a Populatio Estimatig Number of Pregat Wome i the Populatio If Total Populatio is If CBR is (per 1,000 populatio) a) Estimated umber of live births i the year b) Estimated live births expected per moths (a/12) c) Estimated umber of pregacies that ed i stillbirths or miscarriages (estimated at 15 per cet of live births = a 0.15) d) Estimated pregacies expected i the year (a + c) e) Estimated umber of wome pregat i a give moth (70 % of d)* f) Estimated % of total populatio who are pregat at a give period * this is a weighted estimate of full-term pregacies plus those pregacies that termiate early

120 Surveillace ad Moitorig 113 Sample Worksheet for Mothly Reproductive Health Reportig CHAPTER NINE ANNEX 6/1 Camp Name: Agecy: Moth: Total Pop: Pop of Wome 15-49: Sample Worksheet for Mothly Reproductive Health Reportig 1 Safe Motherhood Ate-atal Care <19 years >19 years Total 1a: Number of ateatal visits - First Time 1b: Number of ateatal visits - Repeat 1c: Total ateatal visits 1d: Number of wome treated for complicatios of abortios 1e: Number of pregat wome screeed for syphilis 1f: Number of pregat wome screeed for syphilis testig positive Idicators Ateatal coverage: estimated (1a/2e ) [This is a estimate see 2j below] Icidece of complicatios of usafe ad spotaeous abortio (1d/2e) Coverage of syphilis screeig (1e/2e) [This is a estimate see 2l below] Prevalece of syphilis ifectio i pregat wome (1f/1e) rates 2 Safe Motherhood Delivery hospital h.cetre home total 2a: Number of births atteded by traied staff 2b: Number of births NOT assisted by traied staff 2c: Number of births 2d: Number of stillbirths 2e: Number of livebirths 2f: Number of low birth weight (<2500 gms) 2g: Number of livebirths who die <28 days (eoatal deaths) 2h: Number of obstetric emergecies maaged 2i: Number of materal deaths Number of wome givig birth this period who received 2j: Ateatal care services (1-3 Visits) 2k: Adequate Tetaus Toxoid Vacciatio 2l: Screeed for Syphilis

121 114 Idicators Rates ANNEX 6/2 Worksheet for Mothly Reproductive Health Reportig Crude Birth Rate (2e/total populatio 1000) Neoatal Mortality Rate (2g/2e 1000) Low Birth Weight Rate (2f/2e 100) Stillbirth Rate (2d/2e 1000) Births atteded by traied persoel (2a/2e 100) Coverage of ateatal care (2j/2e 100) Coverage of syphilis screeig (2l/2e 100) Icidece of obstetric complicatios (2h/2e 1000) 3 Safe Motherhood Post-atal Care No. 3a: Number of wome visitig post-atal care services (withi 6 wks of birth) Idicator Post-Natal Care Coverage Rate (3a/2e 100) 4 Sexual Violece No. 4a: Number of cases of sexual violece reported 4b: Number of cases receivig medical care with 3 days Idicators Icidece of sexual violece (4a/total populatio ) Timely care for survivors of sexual violece (4b/4a 100) 5 STDs icludig HIV/AIDS No. 5a: Number of uits of blood trasfused 5b: Number of uits of blood for trasfusio tested for HIV 5c: Number codoms distributed 5d: Number of cases treated for STDs (total by age, sex ad sydrome) Sydromic Case Maagemet Male Female Total urethral discharge geital ulcers vagial discharge Total

122 Surveillace ad Moitorig 115 STD/HIV Idicators Rate CHAPTER NINE Blood screeig for HIV (5b/5a 100) Codom coverage (estimate 5c/ total populatio 1000) Icidece of STDs (total 5d/ total populatio 1000) (STD icidet rates could also be calculated by sex, age ad sydrome) ANNEX 6/3 Worksheet for Mothly Reproductive Health Reportig 6 Family Plaig No. 6a: Number of users of moder methods of family plaig By Method Registered begiig New acceptors Total ed of moth of moth this moth COCs Ijectible POPs IUDs TOTAL Idicator - Cotraceptive Prevalece Rate (6a/WRA 100) 7 Traiig Type of Traiig i RH Type of Health Worker Number a. b. c.

123 116 Summary of Reproductive Health Idicators ANNEX 7 Summary of Reproductive Health Idicators Name of Refugee Situatio Populatio Total Idicators -Safe Motherhood Ateatal coverage: estimated Number of Camps Reportig Icid.of complic.of usafe/spot.abort. per 1000 livebirths Coverage of syphilis screeig: estimated Prevalece of syphilis ifectio i pregat wome Crude Birth Rate Neoatal Mortality Rate per 1000 live births Low Birth Weight Rate Stillbirth Rate Births atteded by traied persoel Coverage of ateatal care Coverage of syphilis screeig Icidece of obstetric complicatios Post-Natal Care Coverage Rate Year: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC ALL Idicators Sexual Violece Icidece of sexual violece Timely care for survivors of sexual violece Idicators HIV/AIDS/STDs Blood screeig for HIV Codom coverage; estimated (per 1000 pop) Icidece of STDs (total per 1000 pop) Idicators Family Plaig Cotraceptive Prevalece Rate

124 Surveillace ad Moitorig 117 Further Readigs Berg, C., I. Daiel, ad D. Mora. Guidelies for Materal Mortality Epidemiological Surveillace, Pa America Health Orgaizatio, Washigto, DC, Bryce, J. ad J.B. Rougou, P. Nguye-Dih, J.F. Naimoli, ad J.G. Brema. Evaluatio of Natioal Malaria Cotrol Programmes i Africa, Bulleti of the World Health Orgaizatio, Vol. 72, Geeva, Goslig, Louisa ad Mike Edwards. A Practical Guide to Assessmet, Moitorig, Review ad Evaluatio, Developmet Maual 5, Save the Childre Fud, Lodo. Guidelies for Evaluatig Surveillace Systems, Morbidity ad Mortality Weekly Report, Vol. 37, Ceters for Disease Cotrol ad Prevetio, Atlata, GA, Guidelies for Moitorig Availability ad Use of Obstetric Services, UNICEF/UNFPA/ WHO. Hakewill, P.A. ad A. More. Moitorig ad Evaluatio of Relief Programmes, Tropical Doctor, Hausma, Beso ad Koert Ritmeijer. Surveillace i Emergecy Situatios, MSF Medical Departmet, Amsterdam, Last, J.M. A Dictioary of Epidemiology, Oxford Uiversity Press, New York, Mother-baby Package, WHO, Geeva, Primary Health Care Maagemet Advacemet Programme (modules iclude Assessig Iformatio Needs, Assessig Health Worker Activities, Morbidity ad Mortality Surveillace, Moitorig ad Evaluatig, Assessig Service Quality, Maagemet Quality, Cost Aalysis ad Other Relevat Topics; icludes maagers guides ad computer programmes), Aga Kha Foudatio, USA, Safe Motherhood Needs Assessmet Part VI: Materal Death Review Guidelies, WHO, Field-test Draft, Geeva, Teutsch, Steve M. ad R. Elliott Churchill. Priciples ad Practice of Public Health Surveillace, Oxford Uiversity Press, New York. Toole, M.J. ad R.M. Malikki. Famie Affected, Refugee ad Displaced Populatios: Recommedatios for Public Health Issues, Morbidity ad Mortality Weekly Report, Vol. 41, Toole, M.J. ad R.J. Waldma. Prevetio of Excess Mortality i Refugee ad Displaced Populatios i Developed Coutries, Joural of the America Medical Associatio, CHAPTER NINE

125 118

126 Iformatio, Educatio ad Commuicatio (IEC) Programmes 119 Iformatio, Educatio ad Commuicatio (IEC) Programmes a1 APPENDIX Oe Iformatio, Educatio ad Commuicatio (IEC) Programmes The essetials of IEC Iformatio, educatio ad commuicatio (IEC) combies strategies, approaches ad methods that eable idividuals, families, groups, orgaisatios ad commuities to play active roles i achievig, protectig ad sustaiig their ow health. Embodied i IEC is the process of learig that empowers people to make decisios, modify behaviours ad chage social coditios. Activities are developed based upo eeds assessmets, soud educatioal priciples, ad periodic evaluatio usig a clear set of goals ad objectives. IEC activities should ever be developed or implemeted idepedetly from a broader reproductive health programme that is beig desiged ad executed i the coutry. IEC activities ot oly eed to have a appropriate cotext i which they are shaped, but it is crucial that health services providers be prepared to respod to ay demad that may be created as a result of effective IEC activities. The ifluece of uderlyig social, cultural, ecoomic ad evirometal coditios o health are also take ito cosideratio i the IEC processes. Idetifyig ad promotig specific behaviours that are desirable are usually the objectives of IEC efforts. Behaviours are usually affected by may factors icludig the most urget eeds of the target populatio ad the risks people perceive i cotiuig their curret behaviours or i chagig to differet behaviours. Health iformatio ca be commuicated through may chaels to icrease awareess ad assess the kowledge of differet populatios about various issues, products ad behaviours. Chaels might iclude iterpersoal commuicatio (such as idividual discussios, cousellig sessios or group discussios ad commuity meetigs ad evets) or mass media commuicatio (such as radio, televisio ad other forms of oe-way commuicatio, such as brochures, leaflets ad posters, visual ad audio visual presetatios ad some forms of electroic commuicatio). Good commuicatio betwee users ad providers of ay service is essetial; but it is especially importat whe providig RH services, give the sesitive ature of some of the issues that are addressed (such as sexual violece, female geital mutilatio, ad providig cotraceptives to adolescets). Accordigly, IEC approaches must be carefully ad appropriately desiged ad selected. Although good oe-to-oe commuicatio at the poit of service provisio is essetial for trasmittig iformatio ad buildig trust with the cliet, commuicatio with other idividuals ad groups withi the commuity is also vital. It is through such commuicatio etworks that service providers ca obtai iformatio about users eeds, priorities ad cocers. Such iformal iformatio gatherig is the first step i assessig eeds (which ca be supplemeted by other more formal meas see sectio below). It also helps providers better uderstad the specific settig ad cotext i which they are workig, which will be useful i the later developmet of IEC approaches, messages ad materials. Cotets: Essetials of IEC Cousellig ad the Role of the Cousellor Steps i Developig Materials for a IEC Activity Udertakig a Reproductive Health (RH) Needs Assessmet Field tools for Coductig RH Needs Assessmets Liks to Providig Services, Support ad Follow-up

127 120 These types of coversatios, or passig o iformatio by word-of-mouth, has bee show to be oe of the most effective commuicatio chaels for acquirig kowledge ad promotig desired chages i behaviour. Evidece of this is the speed with which rumours spread ad the force of their impact. Field staff should ot igore these iformal opportuities to educate the public through casual coversatio with people i the commuity. Oce a refugee situatio stabilises, it becomes appropriate to cosider the developmet of more elaborate ad formal IEC strategies. This requires serious thought ad sigificat allocatio of time ad resources. The steps ivolved i the developmet of IEC are outlied here, but this is ot iteded to be a exhaustive guide. More i-depth iformatio ad details ca be foud i the items listed i Further Readig. Whatever materials ad formal programmes are developed, it is importat to esure that the differet aspects are coordiated, ad that the cotet of ay messages ad the media used to covey those messages are complemetary. It is also vital to esure that people are provided with the ecessary support ad resources to act i the maer advised. Commuicatio Commuicatio ca be both verbal ad overbal. I verbal commuicatio, the toe of voice ca commuicate feeligs ad emotios that are as sigificat as the words beig spoke. Accordigly, it is importat to choose words that do ot offed i ay way ad that are easily uderstood. Oe should avoid usig trigger words, jargo, medical or other sophisticated terms. The use of particular laguages may be importat i reachig all sectios of a commuity (wome may speak fewer laguages tha me, for example). I o-verbal commuicatio, body positio, gestures ad facial expressio, ofte referred to as body laguage, ca commuicate as much as words. It is ofte through such body laguage that we express our attitudes towards a issue, a perso or a perso s behaviour. Service providers must become skilled i iterpretig the body laguage of users as this may assist them i uderstadig users eeds ad cocers more fully. Service providers must also be aware of their ow body laguage ad the sigals they may be ukowigly sedig to users (e.g., movemets or expressios that idicate fatigue, boredom, fear, frustratio, idecisio). It is importat that the attitude coveyed by the service provider be compassioate ad ojudgmetal. Service Users Good commuicatio skills are ecessary to esure that good-quality services are provided ad that service users are satisfied. It is Good commuicatio skills could iclude the followig: a effective, active listeig i which the provider gives small verbal or o-verbal feedback that idicates to the cliet that (s)he is beig heard ad uderstood; a rephrasig what the cliet has said to make sure it is correctly uderstood; a askig ope-eded questios, askig the cliet to aswer questios with more tha oe word aswers; a makig eye cotact; a providig complete attetio; a ot beig curt or showig a codescedig attitude toward the cliet.

128 Iformatio, Educatio ad Commuicatio (IEC) Programmes 121 through commuicatio that trust ad rapport are established betwee the provider ad user of a service. Emotioal support ad the commuicatio of cocer ad uderstadig by health staff are ofte as crucial i providig quality services as is cliical care. If there is a strog provider-user relatioship established i this way, it becomes easier to move towards ope dialogue o more sesitive aspects of reproductive health. Other Idividuals ad Commuity Groups Beyod commuicatio with service users, it is ecessary to ope a dialogue with ifluetial idividuals ad groups withi the commuity. Such idividuals ad groups will eed to be idetified as early as possible. The ature ad itetio of services should be explaied to them ad their cocers ad priorities discovered ad uderstood. This will ot oly help make the services more appropriate to the clietele beig served, but it will help garer family ad commuity support for the cliet i the reproductive health behaviour beig promoted. The followig are some poiters for idetifyig such idividuals ad groups: Familiarise yourself with the commuity with the help of someoe who lives i the eviromet of the refugees ad who provides them with some service, advice or protectio. Idetify idividuals who are most importat i the social structure of the commuity with which you are workig. They ca be existig formal leaders (elected or appoited), but, more ofte tha ot, they are iformal leaders. This ca be doe by askig may people i the commuity. As certai idividuals are amed repeatedly, it will become clear that they are the true leaders. Idetify idividuals who have some ifluece withi the commuity, people whose opiios are respected. They will make suggestios about how to approach people ad work with them effectively. They ca also serve as role models for desired behaviours ad actios. Provide these idividuals with very clear iformatio about what your itetios are, what you pla to do, ad how they ca cotribute as parters. Be specific about what they will gai from workig with you ad allowig you access to the commuity. Provide them with iput about your plas before you proceed, ad secure their willigess to participate ad to support your efforts. Cousellig Cousellig is a key compoet of a IEC programme. I the best of circumstaces, a good cousellor is compassioate ad o-judgmetal, is aware of verbal ad o-verbal commuicatio skills, is kowledgeable cocerig RH issues, ad is respectful of the eeds ad rights of the users. I a refugee situatio, there is ofte a poor cousellor-to-cliet ratio, emergecies are commo ad the local eviromet is ot coducive to cousellig. However, at a miimum, cousellors should strive to esure that every service user has the right to the followig: Iformatio: to lear about the beefits ad availability of the services. Access: to obtai services regardless of geder, creed, colour, marital status or locatio. Choice: to uderstad ad be able to apply all pertiet iformatio to be able to make a iformed choice, ask questios freely, ad be aswered i a hoest, clear ad comprehesive maer. Safety: a safe ad effective service. Privacy: to have a private eviromet durig cousellig or services. Cofidetiality: to be assured that ay persoal iformatio will remai cofidetial. Digity: to be treated with courtesy, cosideratio ad attetiveess. APPENDIX Oe

129 122 Comfort: to feel comfortable whe receivig services. Cotiuity: to receive services ad supplies for as log as eeded. Opiio: to express views o the services offered. Although the GATHER method of cousellig may appear simplistic, it is complete ad thorough: G reet users A sk users about themselves T ell users about the service(s) available H elp users choose the service(s) they wish to use E xplai how to use the service(s) R etur for follow-up The Role of the Cousellor The cousellor s role is to provide accurate ad complete iformatio to help the user make her/his ow decisio about which, if ay, part of the services (s)he will use. The role of the cousellor is ot to offer advice or decide o the service to be used. For example, the cousellor will explai the available family plaig methods, their side effects ad for whom they are cosidered most suitable. The user the makes a decisio, based o the iformatio give, about which method she/he wishes to use. Effective cousellig requires uderstadig oe s ow values ad ot uduly ifluecig the user s by imposig, promotig or displayig them, particularly i cases where the provider s ad the user s values are differet. Udertakig a Needs Assessmet Be careful ever to assume that you kow what refugees eed or wat i their lives or from your projects. To pla effective itervetios, you must fid out what refugees thik ad kow about various issues, icludig their ideas about: what causes sickess ad disease ad what maitais health, health care, traditioal medicie, ad reproductive health. It is importat to build a relatioship of trust ad mutual respect i order to get accurate ad complete iformatio about sesitive issues such as sexual ad reproductive matters. It is usually ecessary to use multiple methods i udertakig a thorough eeds assessmet. Focus groups, idividual iterviews or Kowledge, Attitude, Behaviour ad Practice (KABP) surveys ca be valuable ways to gather iformatio ad help develop systems, activities, materials or messages to support RH itervetios. Oly after there is a accurate picture of the refugee commuity s kowledge, attitudes, behaviours, expectatios ad aspiratios surroudig reproductive health ca you determie what programme ad messages might be best suited to its eeds. RH itervetios ad IEC activities ad materials should be based o relevat research coducted through the use of quatitative (how may) ad qualitative (what, why ad how) methods. Research ad discussios should be see as a itegral ad ogoig part of plaig ad implemetatio. Quatitative: Use available icidece or prevalece rates of targeted problems. Kowledge, Attitude, Behaviour ad Practice (KABP) Surveys use a series of closed- ad ope-eded questios to determie what people i a commuity kow, thik, believe or do i relatio to their reproductive health. Fidigs are

130 Iformatio, Educatio ad Commuicatio (IEC) Programmes 123 preseted i the form of percetages of people who thik or do a certai thig. These surveys require may respodets that are radomly selected from the commuity. Iterviewers are eeded to implemet the survey ad they must be traied. This is geerally cosidered a expesive ad time-cosumig method. Also, this kid of survey does ot usually gather iformatio about what ihibits or promotes certai behaviours, sice those factors may arise from the cotext i which people live ad ot from their kowledge ad attitudes. Qualitative: Idividual iterviews allow the researcher to get deeper isights ito a perso s thoughts ad feeligs. Usig a iterview guide, iterviewer ad respodet talk at legth about the respodet s feeligs about a specific service or issue. If trust is established ad cofidetiality esured, the iterviewer ca ofte get very valuable iformatio about the iterviewee ad the commuity, iformatio that might ot otherwise be revealed. Focus Groups are i-depth discussios, usually of oe to two hours i legth, with a small group of people. Members of the Focus Group should have somethig i commo with each other (age, sex, ad experiece) i the expectatio that this will make it easier for them to talk together. They are represetatives of the target group i that they are deliberately chose. The itetio is to make sure differet groups withi the commuity are represeted withi the Focus Group, or that several Focus Groups are held with members draw from various sectors withi the commuity. Discussios are lead by a facilitator who follows a prepared guide that allows for probig ito the thoughts ad feeligs of group members. This method is ofte cosidered cost-effective, as may people are gathered together at oe time to express their opiios. Fidigs are preseted i the form of commets or extracts from iterviews, which illustrate what people are thikig about certai topics, or why they egage i a particular activity. Field Tools for Coductig RH Needs Assessmets The Reproductive Health for Refugees Cosortium 1 has field-tested ad fialised five RH eeds assessmet tools. These are Refugee Leader Questios Group Discussio Questios Survey for Aalysis by Computer Survey for Aalysis by Had Health Facility Questioaire ad Checklist The purpose of these tools is to assist relief workers i refugee/displaced perso settigs i gatherig iformatio to assess attitudes toward RH practices ad local medical practices/policies, the extet of eeded services ad the degree to which curret services provide what is eeded. It is importat to ote that ot all tools will be appropriate for all refugee situatios. The order i which the tools are used may also vary. I geeral, refugee leaders are cosulted before ay iformatio is gathered from the larger populatio. This is ofte followed by group discussios, key iformat iterviews ad facilities review. I some situatios, a survey may be coducted but this is ofte depedet upo resources, time, skills of available staff ad whether or ot the level of effort required by a quatitative survey is warrated. A clear eeds assessmet objective will help field workers decide which tools are appropriate for their particular situatio. The iformatio provided by the tools must be reviewed i the cotext of the broader objective of the eeds assessmet. Ay tool used should be adapted to the local situatio ad resources available. Judgemet is required by those applyig the tools. I may cases, other resources may exist to support the eeds assessmet ad these should be used. Exam- APPENDIX Oe The RHR Cosortium comprises America Refugee Committee, CARE, Ceter for Populatio ad Family Health, Columbia Uiversity s Mailma School of Public Health, The Iteratioal Rescue Committee, JSI Research ad Traiig Istitute, Marie Stopes Iteratioal ad the Wome s Commissio for Refugee Wome ad Childre.

131 124 ples of additioal strategies for collectig iformatio iclude: camp registratio records (iformatio o wome s ages, marital status, ad sometimes pregacy); cliic, health cetre ad/or traditioal birth attedat records; i-depth iterviews with represetatives from UNHCR, UNFPA, Miistry of Health ad NGO staff; camp health coordiatig committees ad NGO logistics officers; ad structured observatio at differet times of the day ad ight i the refugee commuity. Steps i Developig IEC Activities The iformatio gathered through the eeds assessmet provides the framework for the developmet of suitable IEC activities. Ay activities ad materials must always be culturally sesitive ad appropriate. These are the major steps you should follow whe desigig a IEC activity: Coduct a eeds assessmet. Set the goal. This is a broad statemet of what you would like to see accomplished with the target audiece i the ed. Establish behavioural objectives that will cotribute to achievig the goal. A objective must be SMART: S pecific (what ad who) M easurable (somethig you ca see, hear or touch usually expressed with a actio verb) A rea specific (where) R ealistic (achievable) T ime-boud (whe) Develop the IEC activities ad ivolve as may other parters as possible. After their successful implemetatio, you should be able to have a sigificat impact o achievig the behavioural objectives. Idetify potetial barriers ad ways of overcomig them. Idetify potetial parters, resources, ad other forms of support for your activities ad gai their sustaied commitmet. Establish a evaluatio pla. The idicators should determie the level of achievemet of the behavioural objectives. Havig such specific idicators makes evaluatig ad moitorig the progress ad impact of the activities much easier. Additioally, process idicators could be established to track to what extet ad how well the plaed activities have bee carried out. IEC Messages Develop IEC messages. A good message is short, accurate ad relevat. It will make, at the most, 3 poits. It should be dissemiated i the laguage of the target audiece ad should use vocabulary appropriate for that audiece. The message toe may be humorous, didactic, authoritative, ratioal or emotioally appealig. It may be iteded as a oe-time appeal or as repetitive reiforcemet. It is ofte ecessary to develop several versios of a message depedig o the audiece to whom it is directed. For example, differig iformatio about cotraceptive services will be relevat to wome who already have three or four childre already, from that which would be appropriate for adolescets who are just begiig to be sexually active. Their eeds ad priorities are differet, so the IEC materials used with each group must also differ. Fid out if materials already exist i the host coutry or coutry of origi, ad if appropriate, use these istead of developig ew oes.

132 Iformatio, Educatio ad Commuicatio (IEC) Programmes 125 Pre-testig, by tryig out the materials with small groups from your larger target audiece, is a essetial part of developig messages ad educatioal materials. It is through pre-testig that you will esure that people uderstad the message as iteded. Pre-testig may eed to be repeated frequetly util you are sure your iformatio is beig coveyed as desired. Determie suitable methods ad chaels of actio ad commuicatio. Oce the target audiece is idetified ad researched ad the key messages have bee chose, it is time to decide which media ad combiatios of iformatio chaels will reach the target group. Both formal ad iformal groups ca be targeted. Differet chaels do differet jobs. Each has its ow stregths ad weakesses, depedig the role it will take i the commuicatio programme. The choice of messages ad media will be iflueced by may factors: cost; literacy levels; artistic style withi the commuity; familiarity with, ad extet of peetratio of a particular medium for both service providers ad users; ad availability of the medium i the target populatio s commuity. The developmet ad refiemet of messages ad the choice of the commuicatio chael or medium are iseparable. Very differet messages will be developed for differet media, for example radio, stories, poems, sogs, posters or flip charts, for the ature of the medium affects what messages ca be successfully used. The skills of those usig the materials must also be cosidered. It may be ecessary to provide traiig to those staff expected to use the materials. For example, it is importat to recogise that placig a picture or poster o a cliic wall at which people may or may ot look is quite differet from usig a series of pictures i the form of a flip chart as a educatioal tool i a group settig. The followig are some suggestios for key messages o techical topics that may be shared. These are preseted as examples oly ad are show out of cotext. The choice of ay message will, i reality, be cotext-specific; ofte a group of messages will be decided upo, rather tha just oe. Sexual Violece: The importace for wome to seek medical care as soo as possible Where to go for cousellig if it is available How to prevet it, particularly i collaboratio with others i the commuity Safe Motherhood: The reasos why it is importat for wome to seek preatal care The eed to ad how to idetify obstetric complicatios ad refer immediately The reasos it is importat to breastfeed exclusively ad the importace of materal utritio Sexually Trasmitted Diseases (STDs)/HIV/AIDS: How to use codoms ad how to dispose of them safely How HIV is ad is ot trasmitted Meas of prevetio Commo sigs ad symptoms Where to receive cousellig Where to receive treatmet Where to go for support services Why it is importat to iform ad ivolve all sexual parters Family Plaig: How ad where to obtai reproductive health services, icludig cotraceptive supplies Where to get iformatio or cousellig How adequate birth spacig cotributes to healthy families APPENDIX Oe

133 126 Reproductive Health of Youg People: How youg people ca protect themselves through safe sex Delay ad patiece is a positive value ad that there are other ways to have fu Youg people eed to take resposibility for their ow health High-risk behaviours may result i log term, uwated cosequeces Liks to Providig Services, Support ad Follow-up For IEC of ay kid to be effective it must be liked with the availability of support ad resources so target audieces ca act i the maer which is beig recommeded. It is therefore essetial that the cotet of ay IEC programme accurately reflect the ature ad quality of the services provided. Logistical support must be adequate to esure the ecessary supplies (material ad huma) are cosistetly available ad adequate traiig should be provided to health workers to support iter-persoal commuicatio ad commuity follow-up. People must be able to act o the advice cotaied i the IEC messages ad materials. Further Readigs A Tool Box for Buildig Health Commuicatio Capacity, Healthcom, Academy for Educatioal Developmet, Washigto, DC, Debus M. Methodological Review: A Hadbook for Excellece i Focus Group Research, Washigto, DC, Academy for Educatioal Developmet, Developig Health ad Family Plaig Prit Materials for Low-Literate Audieces: A Guide, Program for Appropriate Techology i Health, Seattle, PATH, Developig Health Promotio ad Educatio Iitiatives i Reproductive Health: A Framework for Actio Plaig, WHO, RHR, Geeva, Facts for Life, UNESCO/UNICEF/WHO. Guide to Plaig Health Promotio for AIDS Prevetio ad Cotrol, WHO AIDS Series 5, Geeva, WHO, Refugee Reproductive Health Needs Assessmet Field Tools, RHR Cosortium, Tools for Project Evaluatio: A Guide for Evaluatig AIDS Prevetio Itervetios, Family Health Iteratioal, AIDSTECH/Family Health Iteratioal, Durham, NC, 1992.

134 Legal Cosideratios 127 Legal Cosideratios: Refugee Rights Related to Reproductive Health Reproductive Health Rights Based o Iteratioal ad Huma Rights Istrumets cotaied i iteratioal huma rights declaratios ad treaties. These priciples apply to all persos, icludig refugees, without discrimiatio. a2 APPENDIX Two Legal Cosideratios: Refugee Rights Related to Reproductive Health Refugees are etitled to the protectios outlied i the 1951 Covetio relatig to the Status of Refugees, ad its 1967 Protocol, as well as i other relevat iteratioal huma rights declaratios ad treaties, icludig: the Uiversal Declaratio of Huma Rights, the Coveat o Civil ad Political Rights, the Coveat o Ecoomic, Social ad Cultural Rights, ad the Covetio o the Elimiatio of All Forms of Discrimiatio Agaist Wome. Reproductive rights embrace may of the huma rights recogised i these documets. Other, more recet, documets, particularly the 1994 Cairo Programme of Actio of the Uited Natios Iteratioal Coferece o Populatio ad Developmet (ICPD) ad the Beijig Platform for Actio of the 1995 World Coferece o Wome, reflect broad iteratioal cosesus o the issue of reproductive rights. Reproductive health (RH) care may also be safeguarded by atioal laws, which exted govermet resposibility for such care beyod iteratioal obligatios. The policies of the host coutry should guide the implemetatio of RH care i refugee situatios ad humaitaria actors should familiarise themselves with these policies. The followig is a brief overview of basic priciples related to reproductive health that are The right to the highest attaiable stadard of physical ad metal health Sexual ad reproductive health are essetial elemets of the right to health, as they caot be separated from me ad wome s overall well-beig ad their right to the ejoymet of the highest attaiable stadard of physical ad metal health. Iteratioal huma rights law recogises that health represets a importat factor i the realisatio of the right to a adequate stadard of livig, icludig adequate food, clothig, housig, water ad saitatio. States parties to the Covetios i which this right is described are obliged to take measures that esure the reductio of the stillbirthrate ad of ifat mortality ad the healthy developmet of the child, ad the creatio of coditios which would assure to all medical service ad medical attetio i the evet of sickess. The right to the survival ad developmet of the child States parties to the Covetios are obliged to esure, to the maximum extet possible, the survival ad developmet of the child. I this cotext, the threat to wome s lives posed by the lack of RH care affects the health ad developmet of childre.

135 128 Obligatio o States to take measures to abolish traditioal practices prejudicial to the health of childre States shall take all effective ad appropriate measures with a view to abolishig traditioal practices prejudicial to the health of childre. These iclude the practices of female geital mutilatio ad early childhood marriage, which ot oly harm girls, but may also adversely affect their future offsprig. The right of equal access to health care States parties to the Covetios shall take all appropriate measures to elimiate discrimiatio agaist wome i the field of health care to esure, o a basis of equality of me ad wome, access to health care services, icludig those relatig to family plaig. The equal right to reproductive choice Me ad wome have the same rights to decide freely ad resposibly o the umber ad spacig of their childre ad to have access to the iformatio, educatio ad meas to eable them to exercise these rights. The right to educatio Everyoe has the right to educatio. I particular, wome have equal rights with me to specific educatioal iformatio to help esure the health ad well-beig of their families, icludig iformatio ad advice o family plaig. The best iterest of the child shall be the guidig priciple of those resposible for his/her educatio ad guidace; that resposibility lies i the first place with the parets. Adequate iformatio ad cousellig are critical to eablig refugees to make iformed choices about their reproductive health. The right of me ad wome of marriageable age to marry ad foud a family The World Health Orgaizatio recommeds that the miimum age for girls to marry should be 18 years. The betrothal ad the marriage of a child, as defied by atioal legislatio, is specifically prohibited Early materity is ofte a immediate result of early childhood marriage ad ca have adverse effects o the physical developmet of the mother ad her child. The rights of the family special protectio The family, as the atural ad fudametal group uit of society, is etitled to the widest possible protectio ad assistace, particularly for its establishmet ad while it is resposible for the care ad educatio of depedet childre. Special rights i relatio to motherhood ad childhood These are special provisios for pre- ad postatal health care for wome ad childre. The right to ejoy the beefits of scietific progress Everyoe has the right to ejoy the beefits of scietific progress ad its applicatios, which should also be iterpreted to ecompass reproductive health. Pregacy There are special rights pertaiig to pregat ad lactatig wome articulated i iteratioal documets (see above). The issue of termiatio of pregacy, however, is highly cotroversial. I most coutries, atioal laws

136 Legal Cosideratios 129 ad policies regulate the termiatio of pregacies. Where the matter is regulated, due regard must be paid to the laws ad policies of the host coutry. I may coutries where abortio is ormally highly restricted, it is oetheless permitted uder certai coditios whe a pregacy results from rape, icest, or threates the life of the woma. (Refer to UNHCR Guidelies o Prevetig ad Respodig to Sexual Violece agaist Refugees, specifically Chapter 4, Legal Aspects of Sexual Violece. These guidelies provide a clear ad comprehesive aalysis of the legal framework goverig the prevetio of sexual violece i the refugee cotext.) APPENDIX Two Sexual Violece Sexual violece agaist refugees is a global problem ad costitutes a violatio of huma rights as eshried i iteratioal declaratios ad treaties: The right to life, liberty ad security of perso The right to freedom from torture ad cruel, ihuma or degradig treatmet ad puishmet Childre s right to freedom from all forms of physical or metal violece The Geeva Covetios ad their Protocols, which are amog the foudatios of iteratioal humaitaria law, also apply to refugees, returees ad iterally displaced persos i times of armed coflict. These laws offer protectio to all civilias, particularly wome ad childre, agaist various forms of sexual violece, icludig mutilatio, forced prostitutio, sexual abuse ad rape. Regioal huma rights laws applicable i Europe, the Americas ad Africa similarly protect the rights to persoal digity ad itegrity ad prohibit degradig treatmet or puishmet ad violece agaist wome. Natioal laws also usually protect agaist sexual violece. The govermet o whose territory the sexual attack occurred is resposible for takig diliget remedial measures, icludig coductig a thorough ivestigatio ito the crime, idetifyig ad prosecutig those resposible, ad protectig victims from reprisals. Cairo Programme of Actio of the 1994 Uited Natios Iteratioal Coferece o Populatio ad Developmet (ICPD) Although ot legally bidig, the Cairo ICPD Programme of Actio is a importat step i recogisig reproductive rights iteratioally. It represets the political cosesus of 184 atios. The ICPD Programme provides for idividuals to decide freely ad resposibly the umber, spacig ad timig of their childre ad to have the iformatio ad meas to do so. It also icludes the right of all to make decisios cocerig reproductio free of discrimiatio, coercio ad violece. Furthermore, it expresses the right of me ad wome to be iformed ad to have access to safe, effective, affordable ad acceptable methods of family plaig of their choice, as well as other methods of their choice for regulatio of fertility which are ot agaist the law. The Beijig Platform for Actio of the 1995 World Coferece o Wome Also ot legally bidig, it oetheless represets iteratioal cosesus i edorsig may of the commitmets made i the ICPD Programme of Actio ad specifies actio to be take by States, iteratioal bodies, doors, o-govermetal orgaisatios ad others.

137 130 Further Readigs Cook, Rebecca J. Huma Rights ad Reproductive Self-Determiatio, 44 AM U. L. Rev., 975, Guidelies o Refugee Wome ad Guidelies o Refugee Childre, UNHCR, Geeva. Promotig Reproductive Rights: A Global Madate, Ceter for Reproductive Health Law ad Policy (CRLP), New York. Rights Awareess Traiig Programme, UNHCR, Geeva, Sexual Violece agaist Refugees: Guidelies o Prevetio ad Respose, UNHCR, Geeva, Wome of the World: Laws ad Policies Affectig Their Reproductive Lives: Aglophoe Africa, CRLP ad Iteratioal Federatio of Wome Lawyers (Keya Chapter), New York, 1997.

138 Glossary of Terms 131 Glossary of Terms a3 APPENDIX Three Glossary of Terms ateatal care coverage Percetage of wome atteded at least oce durig pregacy by skilled health persoel because of their pregacy. birth weight The first weight of the fetus or ewbor obtaied after birth. This weight is best measured withi the first hour of life before sigificat postatal weight loss occurs. case A perso i the populatio or study group idetified as havig a specific health problem or disease of iterest. case defiitio A set of stadard criteria for decidig whether a perso has a particular disease or health-related problem. Criteria ca be cliical, laboratory or epidemiologic. case-fatality rate (CFR) The probability of death amog diagosed cases of a specific health problem or disease. The CFR is defied as umber of deaths due to the disease i a specified time period divided by the umber of cases of the disease durig the same period. cause-specific death rate The umber of deaths attributable to a specific disease i a give populatio i a give time period (usually expressed per 100,000 persos per year). cotraceptive prevalece rate (CPR) Percetage of wome of reproductive age who are usig (or whose parter is usig) a cotraceptive method at a give poit i time. I practice the CPR is geerally reported o wome who are curretly married or i uio, which should be stated accordigly. crude birth rate (CBR) The umber of live births i a give period per 1,000 people i the same period. Usually expressed per year. crude death rate (CDR) The umber of deaths per 1,000 people i a give year. deliveries atteded by skilled health persoel Percetage of deliveries atteded by skilled health persoel irrespective of outcome (live birth or fetal death). skilled health persoel or skilled attedat Doctors (specialist or ospecialist), ad/or persos with midwifery skills who ca diagose ad maage obstetrical complicatios as well as ormal deliveries. (Traditioal birth attedats, traied or utraied, are ot icluded.) perso with midwifery skills A perso who has successfully completed the prescribed course i midwifery ad is able to give the ecessary supervisio, care ad advice to wome durig pregacy, labour ad the postpartum period. This perso is also able to coduct deliveries aloe, to provide lifesavig obstetric care, ad to care for the ewbor ad the ifat. epidemiology The study of the patters of huma disease, health ad behaviours.

139 132 fetal death (deadbor fetus) Death prior to the complete expulsio or extractio from its mother of a product of coceptio, irrespective of the duratio of pregacy. The death is idicated by the fact that after such separatio, the fetus does ot breathe or show ay other evidece of life, such as beatig of the heart, pulsatio of the umbilical cord, or defiite movemet of volutary muscles. icidece rate (IR) The umber of ew cases of a health problem or disease i a specified time that occurs i a populatio at risk of the disease i the same time period. The rate is expressed per 100, 1,000, 10,000 or 100,000. live birth The complete expulsio or extractio from its mother of a product of coceptio, irrespective of the duratio of the pregacy, which after such separatio, breathes or shows other evidece of life, such as beatig of the heart, pulsatio of the umbilical cord, or defiite movemet of volutary muscles, whether or ot the umbilical cord has bee cut or the placeta is attached. Each product of such a birth is cosidered livebor. low birth weight Less tha 2,500 g (up to ad icludig 2,499 g). materal death The death of a wome while pregat or withi 42 days of termiatio of pregacy, irrespective of the duratio ad the site of the pregacy, from ay cause related to or aggravated by the pregacy or its maagemet, but ot from accidetal or icidetal causes. Materal death is subdivided ito two groups: direct obstetric death Those deaths resultig from obstetric complicatios of the pregat state (pregacy, labour ad puerperium), from itervetios, omissios, icorrect treatmet, or from a chai of evets resultig from ay of the above. idirect obstetric death Those deaths resultig from previously existig disease or disease that developed durig pregacy ad which was ot directly the result of obstetric coditios, but which was aggravated by the physiologic effects of pregacy. materal mortality rate The umber of materal deaths per 100,000 wome of reproductive age (15-49). materal mortality ratio The umber of materal deaths per 100,000 live births durig the same time period. eoatal mortality rate Number of deaths i the eoatal period durig a give time period per 1,000 live births durig the same time period. eoatal period Commeces at birth ad eds 28 completed days after birth. Neoatal deaths (deaths amog live births durig the first 28 completed days of life) may be subdivided ito early eoatal deaths, occurrig durig the first seve days of life, ad late eoatal deaths, occurrig after the seveth day but before 28 completed days of life. periatal period Commeces at 22 completed weeks (154 days) of gestatio (whe birth weight is ormally 500 g) ad eds seve completed days after birth. periatal mortality rate Number of deaths i the periatal period durig a specified period of time per 1,000 total births (live births plus fetal deaths) durig the same period of time. post-eoatal mortality rate Number of deaths after 28 days up to, but ot icludig, oe year of age durig a give time period per 1,000 live births durig the same period.

140 Glossary of Terms 133 pre-term Less tha 37 completed weeks (less tha 259 days) of gestatio. Pre-term births are also referred to as premature births. prevalece rate The proportio of the populatio that has the health problem or disease uder study. The prevalece rate is expressed as the umber of existig cases of the disease at a specified poit i time i the total populatio. The ratio is expressed per 100, 1,000, 10,000 or 100,000. proportio A fractio where the umerator is a subset of the deomiator. radom samplig A method of selectig a sample whereby each elemet i the populatio has a equal chace (probability) of beig selected for the sample. rate A measure of the frequecy of some evet i a defied populatio at a specified time. I a rate, the umerator is a subset of the deomiator. The rate is expressed per 100, 1,000, 10,000 or 100,000. ratio A measure of the frequecy of oe group of evets relative to the frequecy of a differet group of evets (e.g., materal mortality ratio is the umber of materal deaths per 100,000 live births). The ratio is expressed per 100, 1,000, 10,000 or 100,000. relative risk A measure of the icidece of a coditio i those exposed to a particular factor i relatio to the icidece of that coditio i those ot so exposed. spotaeous abortio or miscarriage A fetal death i early pregacy. At what gestatioal age (poit i pregacy) a miscarriage becomes a stillbirth for reportig purposes depeds o the coutry s policy. stillbirth A fetal death i late pregacy. At what gestatioal age (poit i pregacy) a miscarriage becomes a stillbirth for reportig purposes depeds o the coutry s policy. surveillace A dyamic process i which data o the occurrece ad distributio of health or disease i a populatio is collected, orgaised, aalysed ad dissemiated. total fertility rate The umber of childre who would be bor per woma, if the woma was to live to the ed of her child-bearig years ad bear childre at each age i accordace with prevailig age-specific fertility rates. usafe abortio A procedure for termiatig uwated pregacy either by persos lackig the ecessary skills or i a eviromet lackig miimal medical stadards or both (WHO). vital statistics Data collected from cotiuous or periodic recordig or registratio of all vital evets, such as births, deaths, marriages ad divorces. wome of reproductive age (or wome of childbearig age) Refers to all wome aged 15 to 49 years (WHO). APPENDIX Three

141 134 a4 Referece Addresses Referece Addresses Cotact addresses from which you ca obtai cited referece documets ad other iformatio AEDES 34, rue Joseph II B-1040 Brussels, Belgium Fax: Appropriate Health Resources & Techologies Actio Group - AHRTAG Farrigto Poit Farrigto Road Lodo, EC1M 3JB UK Fax: ahrtag@g.apc.org Ceters for Disease Cotrol ad Prevetio Iteratioal Emergecy ad Refugee Health Brach Mailstop F-48, 4770 Buford Highway Atlata, Georgia USA Fax: baw4@cdc.giv Website: Iteratioal Federatio of the Red Cross ad Red Crescet Societies 17, chemi des Crets, Case postale Geeva, Switzerlad Fax: Website: Iteratioal Plaed Parethood Federatio Reget s College Ier Circle Lodo NW1 4NS UK Fax: Website: IPAS Box 999 Carrboro, NC USA Fax: ipas@ipas.org JSI Research ad Traiig Istitute 1616 North Fort Myers Drive Arligto, VA USA Fax: Macmillia Houdmills, Basigstoke Hampshire RG21 6XS UK Fax: Médecis sas Frotières Iteratioal (MSF) 39, rue de la Tourelle B-1040 Brussels, Belgium Fax: Website: Oxford Uiversity Press Walto Street, Oxford OX2 6DP UK Fax: Populatio Iformatio Program The Johs Hopkis School of Public Health 111 Market Street, Suite 310 Baltimore, Marylad USA Fax: poprepts@welchlik.welch.jhu.edu Reproductive Health for Refugees Cosortium (RHR Cosortium) Cotact: The Wome s Commissio for Refugee Wome ad Childre 122 East 42d Street - 12th Floor New York, NY USA Fax: wcrwc@itrescom.org

142 Referece Addresses 135 Save the Childre Fud UK 17 Grove Lae Lodo SE5 8RD UK Fax: Teachig Aids at Low Cost - TALC PO Box 49 St Albas Herts AL1 5TX UK Fax: UNAIDS, Iformatio Cetre 1211 Geeva 27, Switzerlad Fax: uaids@uaids.org UNFPA - Cotact local coutry offices or 220 East 42d Street New York, NY USA Fax: or UNFPA Emergecy Relief Office 9 Chemi des Aemoes 1219 Geeva, Switzerlad Fax: ufpaero@udp.org Website: UNHCR - Cetre for Documetatio for Refugees Case postale Geeva 2 Switzerlad Fax: cdr@uhcr.org Website: UNICEF Three Uited Natios Plaza New York, NY USA Fax: Website: World Health Orgaizatio Distributio ad Sales 1211 Geeva 27 Switzerlad publicatios@who.ch World Health Orgaizatio Departmet of Reproductive Health ad Research 1211 Geeva 27 Switzerlad Fax: lamberts@who.ch Website: World Bak 1818 H Street N.W. Washigto, DC USA Fax: Website: APPENDIX Four

143 Actio Cotre la Faim Africa Medical ad Research Foudatio America Refugee Committee CARE Cetre for Research o the Epidemiology of Disasters Cetro de Capacitació e Ecología y Salud para Campesios Ceter for Populatio ad Family Health Columbia Uiversity Mailma School of Public Health Family Health Iteratioal Iteratioal Cetre for Migratio ad Health Iteratioal Federatio of the Red Cross ad Red Crescet Societies Ipas Iteratioal Plaed Parethood Federatio Iteratioal Rescue Committee Iteratioal Orgaizatio for Migratio JSI Research ad Traiig Istitute Lodo School of Hygiee ad Tropical Medicie Marie Stopes Iteratioal Médecis du Mode Médecis sas Frotières MERLIN (Medical Emergecy Relief Iteratioal) Populatio Coucil Save the Childre Fud UK Uited Natios Childre s Fud Uited Natios High Commissioer for Refugees Uited Natios Joit Programme o AIDS Uited Natios Fud for Populatio Activities U.S. Agecy for Iteratioal Developmet U.S. Ceters for Disease Cotrol ad Prevetio U.S. Departmet of Health ad Huma Services U.S. Departmet of State Wome s Commissio for Refugee Wome ad Childre World Associatio of Girl Guides ad Girl Scouts World Health Orgaizatio

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