Best Practices: Preserving Health, Saving Lives: Priority Reproductive Health Services in Emergencies
HealthLink: Issue 143 | 1 March 2007
contributed by: Sarah Chynoweth, Program Manager, Reproductive Health Program, Women's Commission for Refugee Women and Children
region: Global
Preserving Health, Saving Lives:
Priority Reproductive Health Services in Emergencies
Reproductive health in emergencies emerged as an important component of emergency response in the mid-1990s when the conflicts in former Yugoslavia and Rwanda underscored the need for reproductive health services for conflict-affected women and girls.1 In an effort to systematize reproductive health into relief services in an effective and appropriate way, the Inter-agency Working Group (IAWG) on Reproductive Health in Refugee Situations, a group of approximately 40 United Nations, academic research, governmental and nongovernmental organizations that came together in 1995 to address reproductive health for refugees, developed the Minimum Initial Service Package (MISP) for reproductive health. The MISP is a set of priority activities to be implemented during the onset of an emergency (conflict or natural disaster). It was first articulated in 1996 in the field-test version of the IAWG's seminal publication, Reproductive Health in Refugee Situations: An Inter-agency Field Manual. The MISP was later included as a standard in the 2004 revision of the Sphere Humanitarian Charter and Minimum Standards in Disaster Response for humanitarian assistance providers.
The goal of the MISP is to reduce mortality, ill-health and disability among populations affected by crises, particularly women and girls. These populations may be refugees, internally displaced persons (IDPs) or populations hosting refugees or IDPs. When implemented in the early days of an emergency, the MISP saves lives and prevents illness, especially among women and girls. Neglecting reproductive health in emergencies has serious consequences: preventable maternal and infant deaths; sexual violence and subsequent unwanted pregnancies and unsafe abortions; and the spread of HIV. 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 trained staff. The MISP is comprised of five key activities including:
- Identifying an organization(s) and individual(s) to facilitate the coordination and implementation of the MISP;
- Preventing sexual violence and providing appropriate assistance to survivors;
- Reducing the transmission of HIV;
- Preventing excess maternal and neonatal mortality and morbidity;
- Planning for the provision of comprehensive reproductive health services, integrated into primary health care, as the situation permits.
The MISP is a standard for humanitarian actors, outlining which reproductive health components are most important in preventing death and disability, particularly among women and girls, in emergency settings. Although comprehensive reproductive health services should be available to the entire population once the situation stabilizes, reducing the transmission of HIV, preventing sexual violence, providing care for survivors of sexual violence, ensuring clean deliveries and access to emergency obstetric care in the first days of a crisis are a priority because these actions will save lives and prevent illness.
There are significant consequences if the MISP is ignored in a crisis. The lives of the displaced, particularly women and girls, are put at risk when the MISP is not implemented. For example, women and girls are often at risk of sexual violence when attempting to access food, firewood, water and latrines. Their shelter may not be adequate to protect them from intruders or they may be placed in a housing situation that deprives them of their privacy. Those in power may exploit vulnerable women and girls by withholding access to essential goods in exchange for sex. Not observing universal precautions in a health-care setting may allow the transmission of HIV to patients or health workers. Without a referral system in place to transfer patients in need of emergency obstetric care services (e.g., cesarean section) to an equipped health facility with competent staff, women may die or suffer long-term injuries (e.g., obstetric fistula). The MISP provides an outline of the basic steps to be taken in order to avoid these negative consequences.
Humanitarian workers are responsible for ensuring that MISP priority activities are implemented. MISP activities are not limited to reproductive health staff or even the general health sector. The MISP cuts across all sectors, including food security, water and sanitation services and shelter. However, assessments undertaken by the Women's Commission for Refugee Women and Children (Women's Commission) during 2004 and 2005 demonstrated that many humanitarian actors working in emergencies did not know the priority reproductive health services of the MISP that should be implemented in every emergency setting. A 2004 assessment of Sudanese refugees in Chad revealed that most relief workers were not familiar with the MISP and consequently did not know it's overall goal, key objectives and priority activities. There was no overall reproductive health coordinator and only one agency had an identified reproductive health focal point. Moreover, many humanitarian staff did not understand the importance or necessity of implementing priority reproductive health services. For example, one relief worker interviewed said, "We need to concentrate on basic activities – not complicated ones like HIV."2 In 2005, the Women's Commission MISP assessment during the tsunami crisis in Indonesia showed that while half the humanitarian staff interviewed were aware of the MISP, only one of 25 relief workers could define its priority objectives and activities. Again, humanitarian actors in general failed to grasp that priority reproductive health services saves lives. One field staff member said, "During the first two months of an emergency, reproductive health does not apply."3
The MISP also builds the foundation for comprehensive reproductive health services as the situation stabilizes and all components of the MISP have been implemented. However, assessment findings in the post-crisis phase demonstrate that the MISP is not a priority in humanitarian settings, even once a situation reaches a relatively stable phase. For instance, an assessment of reproductive health-care services undertaken in 2003 among Afghan refugees in Pakistan found that only six of the 18 refugee camps surveyed had a reproductive health focal point.4 Although women and girls represent 55 percent of the 2 million people displaced in Colombia, reproductive health focal points were non-existent and agencies were not planning to implement the MISP.5 Based on these findings, the Women's Commission developed the MISP for Reproductive Health in Crisis Situations: A Distance Learning Module to raise awareness about and provide guidance on addressing reproductive health in crisis situations.
The MISP module is a self-instructional learning tool. It defines each component of the MISP; explains the rationale for implementing the MISP; provides instruction on how to achieve multisectoral implementation of the MISP, including how to plan for more comprehensive services once the situation stabilizes; details the role and functions of the reproductive health coordinator; and describes how to obtain essential supplies for MISP interventions. The MISP Module incorporates a multisectoral set of activities to be implemented by humanitarian workers operating in health, camp design and management, community services, protection and other sectors. It is particularly useful for members of emergency response teams, and other first humanitarian responders in crisis situations. It focuses on populations displaced by crises, such as armed conflict and natural disasters. Although the module is most relevant to those working in emergency settings, it can also be used as a minimum standard post-crisis to ensure that priority reproductive health activities are established. The MISP module is also beneficial for donors who would like to familiarize themselves with these priority reproductive health services in complex humanitarian emergencies and students interested in working in a crisis-setting.
The MISP module takes approximately two to three hours to complete and is made user-friendly with: frequently asked questions; case studies on field realities and good practices; text boxes on challenges and solutions; diagrams and photographs; direct links to additional key resources; chapter quizzes; a sample proposal and a post-test. It provides an opportunity for users that satisfactorily pass the MISP module post-test to receive a certification of completion and for U.S.-based nurses to receive 3.5 continuing education credits toward professional nursing licensure.
Although research shows that there is growing awareness and support for the MISP in standards, practice and funding,6 this has not translated to the availability of these critical services for displaced populations and others affected by the crises, especially in the early days, weeks and months of new emergencies. Consequently, millions of displaced people, especially women and girls, are put at unnecessary risk for sexual assault, ill health and death. Not only are humanitarian actors bound by international standards, but it is their ethical duty to protect women and girls from harm and disease. The MISP module – specifically designed to address the gap between existing guidelines/standards and humanitarian actors'/donors' knowledge and behavior in responding to the needs of populations affected by conflict or disaster – has the potential to create a sea change in humanitarian actors' knowledge about, and commitment to, ensuring implementation of the MISP in all new emergencies, which, in turn, will preserve the health and save the lives of the affected population, particularly women and girls.
References
1 Schreck, Laurel, "Turning Point: A Special Report on the Refugee Reproductive Health Field," International Family Planning Perspectives, 2000, 26 (4): 162-166.
2 Women's Commission for Refugee Women and Children and United Nations Population Fund, Lifesaving Reproductive Health Care: Ignored and Neglected, Assessment of the Minimum Initial Service Package (MISP) of Reproductive Health for Sudanese Refugees in Chad, August 2004, p.18.
3 Women's Commission for Refugee Women and Children, Reproductive Health Priorities in an Emergency: Assessment of the Minimum Initial Service Package in Tsunami-affected Areas in Indonesia, February/March 2005, p. 9.
4 Women's Commission for Refugee Women and Children, Still in Need: Reproductive Health Care for Afghan Refugees in Pakistan, October 2003.
5 Marie Stopes International and Women's Commission on behalf of the RHRC Consortium, Displaced and Desperate: Assessment of Reproductive Health for Colombia's Internally Displaced Person, February 2003.
6 Inter-agency Working Group for Reproductive Health in Refugee Situations, Reproductive Health Services for Refugees and Internally Displaced Persons: Report of an Inter-agency Global Evaluation, 2004.
For more information on the Women's Commission, visit http://www.womenscommission.org
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