UNFPAReproductive Health in Refugee Situations: An Interagency Field Manual
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REPRODUCTIVE HEALTH IN REFUGEE SITUATIONS: AN INTER-AGENCY FIELD MANUAL


Contents:


Special Note:

The reader must refer to the relevant chapters in the Manual to properly implement the MISP.


This Chapter describes a series of actions needed to respond to the reproductive health (RH) needs of populations in the early phase of a refugee situation (which may or may not be an emergency). The Minimum Initial Service Package (MISP) can be implemented without any new needs assessment since documented evidence already justifies its use. The MISP is not just kits of equipment and supplies; it is a set of activities that must be implemented in a coordinated manner by appropriately trained staff.


The major killers in refugee emergencies– diarrhoea, measles, acute respiratory infections (ARI), malnutrition and malaria, where prevalent -- are well documented. Resources should not be diverted from dealing with these problems. However, there are some aspects of reproductive health that also must be addressed in this initial phase to reduce mortality and morbidity, particularly among women.

Please remember that the components of MISP form a minimum requirement. The expectation is that the comprehensive services as outlined in the rest of this Field Manual will be provided as soon as the situation allows.
 

 
  • IDENTIFY an organisation( s) and individual( s) to facilitate the coordination and implementation of the MISP;

  • PREVENT and manage the consequences of sexual violence;

  • REDUCE HIV transmission by

    • enforcing respect for universal precautions against HIV/ AIDS and

    • guaranteeing the availability of free condoms;

  • PREVENT excess neonatal and maternal morbidity and mortality by

    • providing clean delivery kits for use by mothers or birth attendants to promote clean home deliveries,

    • providing midwife delivery kits (UNICEF or equivalent) to facilitate clean and safe deliveries at the health facility, and

    • initiate the establishment of a referral system to manage obstetric emergencies; and

  • PLAN for the provision of comprehensive RH services, integrated into Primary Health Care (PHC), as the situation permits
     

Reproductive health in refugee situations
Photos
An inter-agency field manual

Foreword

Preface

Acknowledgments
 

Chapters


1. Fundamental Principles

2. Minimum Initial Service Package (MISP)

3. Safe Motherhood

4. Sexual and Gender-based violence

5. Sexually Transmitted Diseases, including HIV/AIDS

6. Family Planning

7. Other Reproductive Health concerns

8. Young People

9. Surveillance and Monitoring
 

Appendices


a1. Information, Education, Communication

a2. Legal Considerations

a3. Glossary of Terms

a4. Reference Addresses


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©1999 United Nations High Commissioner for Refugees

This document is issued for general distribution. All rights are reserved. Reproductions and translations are authorised, except for commercial purposes, provided the source is acknowledged.


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Components of the MISP

Identify an Organisation(s) and Individual(s) to Facilitate the Coordination and Implementation of the MISP

A qualified and experienced person should be identified to coordinate RH activities at the start of the emergency response. The overall leading agency should be responsible for the designation of such a person, and the person appointed should work under the supervision of the overall Health Coordinator.

RH focal points should be designated within each camp, and within each implementing agency. These health professionals, experienced in reproductive health, should be in post for a minimum of six months, as it is likely to take this long to establish comprehensive RH services.

All relief organisations should, in accordance with their mandates, and within the framework of emergency preparedness and response, train and sensitise their staff on RH issues and gender awareness. (See Terms of Reference for the RH Coordinator at the end of this chapter.)


Prevent and Manage the Consequences of Sexual Violence

Sexual violence is strongly associated with situations of forced population movement. In this context, it is vital that all actors in the emergency response are aware of this issue and preventive measures are put in place. The UNHCR Guidelines for Prevention and Response to Sexual Violence against Refugees (1995) should be adhered to in the emergency response. Measures for assisting refugees who have experienced sexual violence, including rape, must also be established in the early phase of an emergency.

Women who have experienced sexual violence should be referred to the health services as soon as possible after the incident. Protection staff should also be involved in providing protection and legal support to survivors of sexual violence.

Key actions to be taken during the emergency to reduce the risk of sexual violence and respond to survivors are:

  • design and locate refugee camps, in consultation with refugees, to enhance physical security

  • ensure the presence of female protection and health staff and interpreters

  • include the issues of sexual violence in the health coordination meetings

  • ensure refugees are informed of the availability of services for survivors of sexual violence

  • provide a medical response to survivors of sexual violence, including emergency contraception, as appropriate

  • identify individual or groups who may be particularly at risk to sexual violence (single female heads-of-households, unaccompanied minors, etc.) and address their protection and assistance needs.

See Chapter Four for further information on elements of prevention and response to sexual violence.


Reduce HIV Transmission

Enforce Respect for Universal Precautions Against HIV/AIDS
Universal precautions against the spread of HIV/ AIDS within the health care setting must be emphasised during the first meeting of Health Coordinators. Under the pressure of an emergency situation, it is possible that field staff are tempted to take short cuts in procedures which can jeopardise the safety of patients and staff. It is essential that universal precautions be respected. (See Chapter Five for details on universal precautions.)

Guarantee the Availability of Free Condoms
Availability of condoms should be ensured from the beginning so that they can be provided to anyone who requests them. Sufficient supplies should be ordered immediately. (See Annex 3, Chapter Five, Prevention and Care of Sexually Transmitted Diseases including HIV and AIDS for calculating condom supplies.)

As well as providing condoms on request, field staff should make sure that refugees are aware that condoms are available and where they can be obtained. Condoms should be made available in health facilities especially when treating cases of STDs. Other distribution points should be established so that those requesting condoms can obtain them in privacy.


Prevent Excess Neonatal and Maternal Morbidity and Mortality

Provide Clean Delivery Kits for Use by Mothers or Birth Attendants to Promote Clean Home Deliveries
A refugee population will include women who are in the later stages of pregnancy, and who will therefore deliver within the initial phase. Simple delivery kits for home use should be made available for women in the late stages of pregnancy. These are very simple kits that the women, themselves, or traditional birth attendants (TBAs) can use. They can be made up on site and include: one sheet of plastic, two pieces of string, one clean razor blade and one bar of soap. UNFPA also supplies this kit.

A formula, based upon the Crude Birth Rate (CBR), is used to calculate the supplies and services required. With a CBR of three to five per cent per year, there would be some 75-125 births in a three-month period in a population of 10,000. From this, a calculation can be made as to how many kits should be ordered.

Provide Midwife Delivery Kits (UNICEF or equivalent) to Facilitate Clean and Safe Deliveries at the Health Facility
In the early phase of an emergency, births will often take place outside the health facility without the assistance of trained health personnel. Approximately 15 per cent of births will involve some complications. Complicated births should be referred to the health centre. The supplementary unit of the New Emergency Health Kit 98 (NEHK-98) has all the materials needed to ensure safe and clean normal deliveries. Many obstetric emergencies can be managed with the equipment, supplies and drugs contained in the NEHK-98. Obstetric complications that cannot be managed at the health centre should be stabilised before transfer to the referral hospital.

Initiate the Establishment of a Referral System to Manage Obstetric Emergencies
Approximately three to seven per cent of deliveries will require Caesarean section. Additional obstetric emergencies may need to be referred to a hospital that is capable of performing comprehensive essential emergency obstetric care. (Refer to Chapters Three and Seven for information on pregnancy and delivery complications.)

As soon as the situation permits, a referral system that manages obstetric complications must be available for use by the refugee population 24 hours a day. Where feasible, a host-country referral facility should be used and supported to meet the needs of refugees. If this is not feasible because of distance or the inability of the host-country facility to meet the increased demand, then an appropriate refugee-specific referral facility should be provided. In either case, it will be necessary to coordinate with host-country authorities concerning the policies, procedures and practices to be followed within the referral facility. The protocols of the host country should be followed, although some variation may have to be negotiated. Be sure there is sufficient transport, qualified staff and materials to cope with the extra demands.


Plan for the Provision of Comprehensive RH Services, Integrated Into Primary Health Care, as Soon as Possible

It is essential to plan for the integration of RH activities into primary health care during the initial phase. If not, the provision of these services may be delayed unnecessarily. When planning, it is important to include the following activities:

  • The collection of background information on maternal, infant and child mortality, available HIV/ STD prevalence and contraceptive prevalence rates (CPR). This information can be obtained from the refugees' country of origin from such sources as WHO, UNFPA, the World Bank and Demographic and Health Survey (DHS). Gathering this information could be the responsibility of the Headquarters of implementing agencies who may have ready access to these data.

  • The identification of suitable sites for the future delivery of comprehensive RH services (as described in the remainder of this Field Manual). It is important to address the following factors when selecting suitable sites:

    • security both at the point of use and while moving between home and the service delivery point

    • accessibility for all potential users

    • privacy and confidentiality during consultations

    • easy access to water and sanitation facilities

    • appropriate space

    • aseptic conditions

  • An assessment of the capacity of staff to undertake comprehensive RH services should be made and plans put in place to train/ retrain staff. Equipment and supplies for comprehensive RH services should be ordered. This will allow comprehensive services to begin as soon as the situation stabilises.


Broad Terms of Reference for a RH Coordinator/ Focal Point

Under the auspices of the overall health coordination framework, the RH Coordinator/ Focal Point should

  • be the focal point for RH services and provide technical advice and assistance on reproductive health to refugees and all organisations working in health and other sectors as needed.

  • liaise with national and regional authorities of the host country when planning and implementing RH activities in refugee camps and among the surrounding population, where appropriate.

  • liaise with other sectors (protection, community services, camp management, education, etc.) to ensure a multi-sectoral approach to reproductive health.

  • create/adapt and introduce standardised strategies for reproductive health which are fully integrated within PHC.

  • initiate and coordinate various audience-specific training sessions on reproductive health (for audiences such as health workers, community services officers, the refugee population, security personnel, etc.).

  • introduce standardised protocols for selected areas (such as syndromic case management of STDs, referral of obstetric emergencies, medical response to survivors of sexual violence, counselling and family planning services, etc.).

  • develop/ adapt and introduce simple forms for monitoring RH activities during the emergency phase that can become more comprehensive once the programme is consolidated.

  • report regularly to the health coordination team.


Material Resources

New Emergency Health Kit– 98
(NEHK-98)

The revised NEHK-98 (for 10,000 people for three months) contains the following supplies to implement the MISP:

  • What is in the NEHK-98 to implement the MISP

  • Materials for universal precautions for infection control

  • Equipment, supplies and drugs for deliveries at health centres Equipment, supplies and drugs for some obstetric emergencies

  • Equipment, supplies and drugs for post-rape management


Photo of bookletA booklet describing the NEHK-98 and how it can be ordered is available from WHO.


Reproductive Health Kit

A RH Kit for Emergency Situations has been developed by UNFPA, in cooperation with others, for use in refugee situations. It complements the NEHK-98 and should be ordered as needed to launch the MISP and support the referral system. The RH Kit is made up of 12 sub-kits, which can be ordered separately. Materials and supplies in Subkits 3 and 6 are already available in the NEHK-98. To order RH sub-kits from UNFPA, contact the UNFPA Country Director in the country of asylum, the UNFPA Emergency Relief Office in Geneva or the UNFPA Procurement Office in New York.

The RH Kit is targeted for use in the initial acute phase of the emergency. Once the situation stabilises, procurement of RH materials and supplies should be done along with other health programme supply and drug ordering.

Photo of bookletA booklet describing the RH Kit and how it can be ordered is available from UNFPA. (See Appendix Four for contact addresses.)


What is in the UNFPA RH Kit

  • For use at primary health care/ health centre level: 10,000 population for three months
    0 Training and Administration
    1 Condoms
    2 Clean delivery sets
    3 Post-rape management
    4 Oral and injectable contraceptives
    5 STD Drugs

  • For use at health centre or referral level: 30,000 population for three months
    6 Professional midwifery delivery kit
    7 IUD insertion
    8 Management of the complications 8 of unsafe abortion
    9 Suture of cervical and vaginal 8 tears
    10 Vacuum extraction

  • For use at the referral level: 150,000 population for three months
    11 A – Referral-Level Surgical 11 (reusable equipment)
    11 B – Referral-Level Surgical 11 (consumable items and drugs)
    12 Transfusion (HIV testing for blood 11 transfusion)


Monitoring and Surveillance

During the early phase of the emergency, a limited amount of data should be collected to assess the implementation of the MISP. Information on mortality and morbidity by age and sex should be routinely collected during the early phase of an emergency. Refer to Chapter Nine for more information on these indicators.

Consider selecting MISP indicators from the following list.

MISP Indicators

  • Incidence of sexual violence:
    Monitor the number of cases of sexual violence reported to health services, protection and security officers.

  • Supplies for universal precautions:
    Monitor the availability of supplies for universal precautions, such as gloves, protective clothing and disposal of sharp objects.

  • Estimate of condom coverage:
    Calculate the number of condoms available for distribution to the population.

  • Estimate of coverage of clean delivery kits:
    Calculate the number of clean delivery kits available to cover the estimated births in a given period of time.


Checklist for the RH MISP

  • Collect or estimate basic demographic information

    • Total population

    • Number of women of reproductive age

    • Number of men of reproductive age

    • Crude birth rate

    • Age-specific mortality rate

    • Sex-specific mortality rate

    • Number of pregnant women

    • Number of lactating women

  • Prevent and manage the consequences of sexual and gender-based violence

    • Systems to prevent sexual violence are in place

    • Health service able to manage cases of sexual violence

    • Staff trained (retrained) in prevention and response systems for cases of sexual violence

  • Prevent HIV transmission

    • Materials in place for adequate practice of universal precautions

    • Condoms procured and distributed

    • Health workers trained/ retrained in practice of universal precautions

  • Prevent excess neonatal and maternal morbidity and mortality

    • Clean delivery kits available and distributed

    • UNICEF midwife kits (or equivalent) available at the health centre

    • Staff competency assessed and retraining undertaken

    • Referral system for obstetric emergencies functioning

  • Plan for the provision of comprehensive RH services

    • Basic information collected (mortality, HIV prevalence, CPR)

    • Sites identified for future delivery of comprehensive RH services

  • Identify an organisation(s) and individual(s) to facilitate the MISP

    • Overall RH Coordinator in place and functioning under the health coordination team

    • RH focal points in camps and implementing agencies in place

    • Staff trained and sensitised on technical, cultural, ethical, religious and legal aspects of RH and gender awareness

    • Materials for the implementation of the MISP available and used


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REPRODUCTIVE HEALTH IN REFUGEE SITUATIONS: AN INTER-AGENCY FIELD MANUAL