Memorandum submitted by the Reproductive
Health Access, Information and Services in Emergencies (RAISE)
Initiative
1. The following contribution to the International
Development Committee Inquiry on Maternal Health has been provided
by the RAISE Initiative, a collaboration between Marie Stopes
International and Columbia University.[164]
The document seeks to highlight maternal health challenges in
emergency settings, with a particular focus on displaced populations.
2. OVERALL EMERGENCY
CONTEXT
2.1 The magnitude and gravity of the world's
emergencies today make them impossible to ignore. In 2006, 23
countries were identified as generating displacement and at least
52 countries affected by displacement, with Africa as the region
with the highest concentration of internally displaced people
(IDPs) worldwide [1].
2.2 According to OCHA, in 2003, 200 million
people were affected by natural disaster and 45 million people
were in need of life saving assistance due to complex emergencies
[2]. Every year, millions of people worldwide flee their homes
to escape persecution, conflict and violence. Globally, the estimated
number of conflict-induced (IDPs) is hovering around 25 million
and the number of refugees is estimated at around 12 million [2].
The majority of these people find themselves unable to access
national health services, meaning that donor efforts to support
health systems through SWAps and budget support rarely reaches
them. Instead they rely on humanitarian relief efforts.
2.3 The United Nations (UN) and humanitarian
non-governmental organisations (NGOs) are among the main providers
of humanitarian assistance worldwide. The environment in which
these agencies operate is complex and often challenges the effective
and adequate delivery of service to affected populations. Efforts
to address gaps and strengthen effectiveness of humanitarian response
have resulted in several reform processes. Most significant is
the UN humanitarian reform process, which led to the introduction
of a "cluster approach" aimed at enhancing co-ordination
and collaboration among different humanitarian actors, as well
as strengthening technical capacity and service delivery on the
ground. Under the approach, the Inter Agency Standing Committee
(IASC) designated "global cluster leads" in nine selected
areas of humanitarian activity (clusters). Among these, the World
Health Organization (WHO) is lead for the cluster on health [3,
4]. While the approach can be considered an improvement in many
respects, it continues to fail to ensure the integration of sexual
and reproductive health (SRH) service delivery as an integral
part of the humanitarian response; in the current IASC definition
of the health cluster SRH receives only scant attention.
3. MATERNAL HEALTH
CONTEXT
3.1 Every year, an estimated 210 million
women have life threatening complications of pregnancy, often
leading to serious disability, and a further half a million women
die in pregnancy, childbirth and the puerperium. More than 99%
of these deaths are in developing countries. Moreover, more than
120 million couples have an unmet need for contraception and 80
million women each year have unwanted or unintended pregnancies.
45 million of these pregnancies are terminated, and of these 45
million abortions, 19 million are unsafe [5].
3.2 The critical importance of SRH care
to reducing maternal death and morbidity is well documented and
recognised by the international community. Yet, lack of access
to comprehensive reproductive health services, in particular family
planning, skilled birth attendance and emergency obstetric care
(EmOC) continue to lead to many unnecessary deaths, in particular
in the developing world.
3.3 In its recent report on population issues
[6], the World Bank identified lack of access to contraceptives
and family planning as among the driving forces behind maternal
death and unsafe abortion. "Yet", the report observes,
"donor countries and development agencies have shifted toward
other issues, and global funds and initiatives have largely bypassed
funding for family planning, with less attention being focused
on the consequences of high fertility".
4. MATERNAL HEALTH
IN EMERGENCY
SETTINGS
4.1 Conflict and humanitarian crisis further
complicate access to SRH. SRH needs are particularly acute in
countries emerging from conflict or natural disaster. Health systems
in these countries are often characterised by damaged infrastructure,
limited human resources and lack of capacity to provide health
services, including SRH. In addition, stewardship of the health
system in these countries is often weak and service delivery fragmented
as a result of proliferation of NGOs. Moreover, general health
NGOs may not have the experience, knowledge or commitment to deliver
SRH according to internationally agreed standards. [7, 8, 12].
4.2 Other factors, such as security issues
and lack of priority given to SRH by national and international
humanitarian players, continue to put refugee and IDP women at
risk of death, disease or disability due to pregnancy related
causes.
4.3 In sum, major maternal health challenges
in emergency settings that require urgent attention from the international
community, including DFID, are:
— Ongoing lack of focus or priority
given to SRH service delivery within a humanitarian response by
key national and international actors, including; host governments,
the UN system, donor governments and health focused NGOs.
— Lack of skilled staff, equipment,
supplies, means of communication and transportation.
— Lack of access to life-saving EmOC.
— Lack of or limited access to and
availability of family planning services.
— Lack of access to post abortion care
and safe abortion where legal.
5. CASE STUDY
5.1 For nearly 20 years, parts of northern
Uganda have been embroiled in an almost uninterrupted civil conflict
centred around the insurgency of a rebel group, the Lord's Resistance
Army (LRA), against central government authorities. The conflict
has resulted in the displacement of approximately 1.5 million
people [9].
5.2 Uganda has one of the fastest growing
populations in Eastern Africa and a high maternal death rate.
Although the Ministry of Health (MoH) has developed numerous policies
and guidelines promoting SRH, resources attributed to this issue
are limited, and so is their impact. Clear discrepancies exist
regarding the SRH status of urban, rural and conflict affected
populations in the north, with a majority of the available resources
(both financial and human) funnelled to urban hospitals that are
inaccessible to a large part portion of the population.
5.3 The conflict has clearly had a negative
impact on basic health services in northern Uganda. The infrastructure
has been damaged and many facilities were forced to shut down.
Ongoing insecurity has thwarted improvements to SRH services and
facilities in the camps. As a result, health care units in the
camps are often overwhelmed and largely managed by unqualified
staff. Access to better equipped district hospitals is severely
limited due to lack of transport, restricted freedom of movement
and curfews. Consequently, SRH in northern Uganda has fallen dramatically
below national averages [9, 10].
5.4 While antenatal services are fairly
well established, emergency obstetric care (EmOC) is nearly non-existent.
As a result, the percentage of women delivering in a health facility
in the northern districts is the lowest in the country at only
29.9% compared to a national average of 41.1%. Poor family planning
coverage (with only 19.1% of the demand for family planning satisfied
in northern Uganda compared to a national average of 36.9%) and
self-induced abortions compound the critical lack of EmOC and
cause additional mortality and morbidity. Although some training
in life-saving EmOC is being provided, critical gaps exist in
health worker competence, equipment, means of communication and
transportation to support women's access or referral to EmOC [9,
10].
5.5 Further challenging the maternal health
and well-being of IDP women in the northern districts is the poor
use of family planning. Limited availability of and knowledge
about contraceptives, combined with a widely held misconception
about family planning, particularly among men, has resulted in
the lowest contraceptive prevalence rates in the entire country.
The use of any modern method in the north is 8.1% compared to
a national average of 17.9%. IDP women however are reportedly
desperate for family planning support and this unmet need is clearly
reflected in the rates of abortion, which are reportedly the highest
in the country [9, 10, 11].
5.6 Major additional problems affecting
maternal health in northern Uganda include inadequate SRH co-ordination
under the cluster approach and the WHO-led health cluster. Although
groups are reportedly established for the health sector in general,
gender-based violence (GBV) and HIV, this is not the case for
SRH. As a result, SRH co-ordination meetings are not in place,
and when they are their output is limited. Moreover, SRH is reportedly
"buried" in the general health co-ordination meetings
that primarily address infectious disease control [9].
6. CONCLUSION
6.1 The case of Uganda shows the tremendous
SRH challenges faced in an emergency, as well as the consistent
need to push for the inclusion of SRH as part of the humanitarian
response. Some progress has been made over the years in this area
with some policies and guidelines in place. What is now required
is a concerted drive to translate policy into action. Ongoing
marginalisation of SRH services critical to ensure maternal health
within the humanitarian response will result in the unnecessary
death and disability of many women and infants. Moreover, not
addressing women's SRH will have far reaching implications for
the community as a whole, because of the critical role women play
in holding families and communities together and in the recovery
and rehabilitation of societies [13].
7. RECOMMENDATIONS
FOR DFID
7.1 As a global leader in women's health
and gender issues and a major humanitarian actor, DFID is well
placed to draw attention to the pressing SRH needs of affected
populations in emergencies, and to use its influence at both national
and international levels to ensure the incorporation of SRH as
an integral part of humanitarian policy and action. In this regard,
we welcome the inclusion of language on SRH in the new CHASE Humanitarian
Funding Guidelines for NGOs (to be released in October) as an
important step in encouraging agencies to include SRH in their
humanitarian programmes.
7.2 At UK level DFID should:
— Monitor its own performance in supporting
humanitarian SRH programmes by tracking CHASE grant money allocated
to programmes that include SRH service delivery.
— DFID should systematically include
SRH as part of its needs assessments in emergency settings, as
well as use its research budget to commission studies on SRH in
emergencies.
7.3 At global level DFID should:
— Use its influence within the IASC
to ensure that SRH becomes a core focus area of the Health Cluster.
— Work with the humanitarian co-ordination
system to ensure that SRH needs are adequately addressed from
the outset of an emergency with the appointment of an SRH co-ordinator
under the health cluster.
— Use its position to influence policy
decisions on humanitarian issues of the main bodies of the United
Nations and the European Union to ensure comprehensive delivery
of SRH services from the onset of an emergency.
— Encourage humanitarian health focused
agencies operational in emergency settings to develop the necessary
human resources to set up and run effective comprehensive RH programmes
in emergency settings from the outset of every emergency.
7.4 At host country level DFID should:
— Work with host governments, most
notably the Ministries of Health and Finance to prioritise SRH
as part of the humanitarian response and ensure its inclusion
within national policies, budgets and action plans.
— Work with key partners on the ground
(MoH, UN agencies and NGOs) to ensure the availability of skilled
SRH health staff, appropriate equipment, supplies, means of communication
and transportation, to enable access and quality SRH service delivery,
including EmOC and family planning.
REFERENCES
1. Internal Displacement, Global Overview of
Trends and Development in 2006, Norwegian Refugee Council, Internal
Displacement Monitoring Centre.
2. http://ochaonline.un.org/HumanitarianIssues/tabid/1081/Default.aspx
3. December 2006: the Inter Agency Standing Committee
(IASC) Principals endorsed the IASC Guidance Note on Using the
Cluster Approach to Strengthen Humanitarian Response, see:
http://ocha.unog.ch/humanitarianreform/Portals/1/cluster%20approach%20page/Introduction/IASCGUIDANCENOTECLUSTERAPPROACH.pdf
4. http://www.humanitarianreform.org
5. Glasier, A, et al, Sexual and Reproductive
Health 1. Sexual and Reproductive Health: a Matter of Life and
Death, Lancet, vol 368, 4 November 2006, p 1595-1605.
6. HPN Discussion Paper. Population Issues in
the 21st Century: The Role of the World Bank, April 2007.
7. IAWG, Interagency Global Evaluation of Reproductive
Health Services for Refugees and Internally Displaced Persons.
2004, IAWG: Geneva.
8. Kealy, L, Women Refugees Lack Access to Reproductive
Health Services. Population Today, 1999. 27 (1): p 1-2.
9. Women's Commission for Refugee Women and Children
and UNFPA, We want Birth Control: Reproductive Health Findings
in Northern Uganda. 2007, Women's Commission /UNFPA: New York
Washington.
10. Uganda's Bureau of Statistics, Uganda Demographic
and Health survey 2006: Preliminary Report. November 2006: Kampala.
11. Singh, S et al. Unintended Pregnancy
and Induced Abortion in Uganda: Causes and Consequences. New York:
Guttmacher Institute. 2006. http://www.alanguttmacher.org/pubs/2006/11/27/UgandaUPIA.pdf
12. UNFPA. Rapid Assessment of Sexual and Reproductive
Health in Northern Uganda, A study carried out in the districts
of Lira, Apac, Amolatar, Pader, Kitgum and Amuru. UNFPA, written
by Mulumba, D and Nkoyooyo, A. 16 October 2006. p 47.
13. The Independent Expert's Assessment by Elisabeth
Rehn & Ellen Johnsin Sirleaf; Progresss of the World's Women
2002—volume 1: Women War Peace.
164 The Reproductive Health Access, Information and
Services in Emergencies (RAISE) Initiative, is a new initiative
led by Marie Stopes International and Columbia University. Launched
in July 2006, the initiative seeks to catalyse change in the way
RH is addressed by all sectors at all levels. Its main objective
is to ensure, as a matter of course, the delivery of a full range
of reproductive health services in an emergency or conflict setting.
Through its partnerships with major players in the humanitarian
and development community, RAISE focuses both on strengthening
organisational capacity to deliver SRH services in the field and
enabling a supportive global policy and funding environment. Back
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