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Implementing sexual and reproductive health care in humanitarian crises
... The disease caused by new coronavirus determined severe direct and indirect repercussions over women's reproductive health. 1,2 Some indirect consequences deserve to be mentioned: interruption in women's health care; expanded demand for safe abortion services, related to the lack of contraceptives or fear of unknown consequences of COVID-19; increase in maternal death due to cases not related to COVID-19, to readjustments in health services or lack of resource allocation; 3 difficulty in restructuring of women care services to return to the pre-pandemic levels; 4 consequences of the increase in domestic and gender based violence, due to the social distancing policy and/or quarantine; 5 negative psychological effect, including posttraumatic stress disorder symptoms, confusion and anger; 6 discrimination associated with COVID-19 and its effects in patients and healthcare providers; aspects related to women's mental health, once mental disorders may increase significantly. 7 In relation to direct pandemic repercussions, several doubts about specific issues persist. ...
... It is an enzyme from the renin-angiotensin-aldosterone system, responsible to inactivate the angiotensin II, a vasoconstrictor substance related to cardiovascular diseases, converting it to angiotensin. [1][2][3][4][5][6][7] Some studies suggested that the ACE2 receptor would be the "door knob" of the host cells for the SARS-CoV-2 entry, and the positive regulation increases susceptibility to the virus. In pregnant women, an increase in the ACE2 receptors is observed, which would augment susceptibility. ...
... 4 In face of benefits of breastfeeding, the main national and international institutions opt to ensure breastfeeding for suspect, probable or confirmed patients. 5,6,22,51 Breastfeeding the child can also provide passive protection of antibodies against SARS-CoV-2. Apparently, there is no transmission via breast milk, but there is concerning about the risk of infection, once an infected mother may transmit by intimate contact. ...
Objectives: reviewing the available literature on COVID-19 infection and the maternal and perinatal outcomes. Methods: this is a narrative review of the literature carried out from March to September 2020, usingthe MESH: coronavirus, Covid 19, SARS-CoV-2, pregnancy, gravidity, pregnancy complications and pregnancy complications infectius. All study designs, reviews, recommendations and technical notes were included, without distinction of language and that would bring the approach of the new coronavirus in the gestational and perinatal scenario. Results: the COVID-19 pandemic has had devastating effects, affecting millions of people and claiming almost a million lives worldwide. Initially, pregnant women were not seen as a risk group for the disease, however as the proportion of women affected during the pregnancy-puerperal cycle increased, several studies were published showing an increased risk of complications. Brazilian studies have also warned of a high number of maternal deaths, associated with the presence of comorbidities but, above all, with the social determinants of the disease and serious failures in care. Conclusion: the need for new studies with an adequate research design was observed, as many studies are only letters or small series of cases, in addition expert recommendations, without the necessary scientific rigor.
... Literature on evidenced-based humanitarian response has identified at least three factors that must be in place in order to achieve it: first, evidence must exist and be of sufficient quality [4]; second, it must be communicated to practitioners in understandable, useful and usable ways [6,7]; and third, it must be used, implemented or otherwise applied by practitioners [8]. As Chynoweth et al. have stressed, not only is a strong evidence-base needed to improve humanitarian response, but also "it is important that humanitarian actors apply existing evidence" [8]. ...
... Literature on evidenced-based humanitarian response has identified at least three factors that must be in place in order to achieve it: first, evidence must exist and be of sufficient quality [4]; second, it must be communicated to practitioners in understandable, useful and usable ways [6,7]; and third, it must be used, implemented or otherwise applied by practitioners [8]. As Chynoweth et al. have stressed, not only is a strong evidence-base needed to improve humanitarian response, but also "it is important that humanitarian actors apply existing evidence" [8]. Similarly, Knox Clarke and Darcy's review of the quality and use of evidence in humanitarian action made clear that the existence of quality evidence does not guarantee its use [9]. ...
Background
For humanitarian organisations to respond effectively to complex crises, they require access to up-to-date evidence-based guidance. The COVID-19 crisis has highlighted the importance of updating global guidance to context-specific and evolving needs in humanitarian settings. Our study aimed to understand the use of evidence-based guidance in humanitarian responses during COVID-19. Primary data collected during the rapidly evolving pandemic sheds new light on evidence-use processes in humanitarian response.
Methods
We collected and analysed COVID-19 guidance documents, and conducted semi-structured interviews remotely with a variety of humanitarian organisations responding and adapting to the COVID-19 pandemic. We used the COVID-19 Humanitarian platform, a website established by three universities in March 2020, to solicit, collate and document these experiences and knowledge.
Results
We analysed 131 guidance documents and conducted 80 interviews with humanitarian organisations, generating 61 published field experiences. Although COVID-19 guidance was quickly developed and disseminated in the initial phases of the crisis (from January to May 2020), updates or ongoing revision of the guidance has been limited. Interviews conducted between April and September 2020 showed that humanitarian organisations have responded to COVID-19 in innovative and context-specific ways, but have often had to adapt existing guidance to inform their operations in complex humanitarian settings.
Conclusions
Experiences from the field indicate that humanitarian organisations consulted guidance to respond and adapt to COVID-19, but whether referring to available guidance indicates evidence use depends on its accessibility, coherence, contextual relevance and trustworthiness. Feedback loops through online platforms like the COVID-19 Humanitarian platform that relay details of these evidence-use processes to global guidance setters could improve future humanitarian response.
... According to the study, memes exhibit immense importance to act as vehicles of health communication; this phenomenon also makes them vulnerable to certain ambiguities. Many meme-sharers often propagate information on the internet without considering sensitive issues regarding race, gender, sexuality, or religion (Chynoweth, Amsalu, Casey, & McGinn, 2018). On a different note, Geyman (2005) explores myths in the US healthcare system and cites discrepancies towards memes used as barriers to potential healthcare reforms. ...
... Additionally, factors like systemic racism, discrimination and stigma likely pose potential barriers to accessing sexual and reproductive healthcare especially for women and marginalised groups (Hall et al., 2020). Quarantine may also increase the chances of domestic abuse and gender-based violence as in the case of previous pandemics (Chynoweth et al., 2018). This situation has left pregnant women physically and mentally vulnerable during the pandemic. ...
We investigate the gendered use of Instagram memes on COVID-19 using a mixed-analysis approach. We find that memes referencing women are mostly related to community support and healthcare, which often express gratitude for frontline workers, while the majority of memes on men refer to news and promotion as well as suffering due to the high death rates and other financial hardships. As for sexual and gender minorities, memes mostly mention community support similar to the case of the memes referencing women. We argue that internet memes offer insight into ongoing trends in the public's perceptions of pandemics, and they should be further examined because they often communicate vital information on gender groups and public health.
... Previous research has indicated that refugee women may face what has been described as a "triple disadvantage," where the intersection of gender, migration status, and forced migration exacerbates challenges, amplifying their impact through mutual reinforcement [26]. In addition to this "triple disadvantage", it's noteworthy that in humanitarian settings, there has been scant attention given by policy, practice, and research to sexual and reproductive health (SRH) [27]. Neglecting SRH needs within humanitarian settings has significant repercussions. ...
Background
The Russian military invasion of Ukraine has sparked Europe's largest forced displacement since World War II, bringing about significant health vulnerabilities for migrants and refugees. European health information systems lack comprehensive data coverage, especially in underrepresented migration stages like transit. This study aims to address this gap by analyzing data from INTERSOS clinics at the Moldovan and Polish borders with Ukraine to identify the common health conditions prompting people to seek healthcare services during transit.
Methods
From 6th March to 31st May 2022, this cross-sectional study observed migrants and refugees receiving INTERSOS services at two mobile clinics in Moldova, and a facility in Poland. We analyzed data by age, sex, nationality, and reported disease frequencies and care provided.
Results
This study used routinely collected data from 1756 patients. The majority of the adult population seeking healthcare were females (76.5 %), 26.1 % were children and 18.7 % were older individuals. Noncommunicable diseases (NCDs) were the primary reason for seeking healthcare at these clinics, with 23.3 % of the study population being diagnosed with at least one chronic disease, and 3.4 % of people having multimorbidity. Mental and behavioural disorders were diagnosed in 12.6 % of the population, and somatoform disorders and related stress (F40-F48) in 10.8 %.
Discussion
Our study indicates the diversity of forcibly displaced populations and the corresponding diversity of their healthcare needs. In the shadow of a forced displacement crises triggered by the conflict in Ukraine, there is an urgent need to give more attention to subgroups of the population that are often neglected in humanitarian crises. These include older adults, females, and ethnic minorities. Additional attention should also be given to NCDs and sexual and reproductive health (SRH) care needs, especially given the high numbers of older adults and females in this population. Early medical support, psychological first aid and interventions in transit centers that promote survivor resilience and recovery are required.
Conclusion
Our findings shed light on the healthcare needs of forcibly displaced populations during transit, a stage often overlooked in migration health research. They underscore the diverse healthcare needs of forcibly displaced populations, emphasizing the necessity for humanitarian aid programs to acknowledge and address this diversity. Accessing data on displaced populations' healthcare needs in transit can help the preparing and planning of healthcare services for these populations in host or destination countries. Ensuring objective anonymization and preventing patient re-identification are essential, particularly in safeguarding refugee privacy and data protection to avoid the misuse of their data.
... It is stated that mandatory quarantine practices cause negative psychological effects such as stress and anger (Brooks et al., 2020). For this reason, quarantine practices increase the risk of gender-based violence and domestic abuse, as in previous epidemics (Chynoweth et al., 2018). In a study conducted with adults regarding sexual health, it was reported that 22% of the participants had a decrease in sexual desire during the pandemic period, 41% of the participants had a decrease in the frequency of sexual intercourse, and about one third of the participants (31%) had impaired partner relations during the pandemic. ...
Objective: This study examine the health status of women in the flexible production process during the pandemic period. Material and Method: In this study, the qualitative research method was preferred. Maximum variation, sampling method, was used to determine the study group. The data were collected using a semi-structured interview form with the in-depth interview technique and the interviews lasted for 15-20 minutes. Content analysis was used in the research. The study was carried out with 15 people until data repetition occurred. Results: In the research, the category was determined and the categories are as follows: Changes in women's working life before and after the pandemic, economic problems during remote working, housework during the pandemic, being affected by the care of the elderly and children, the barriers of being a woman in business life during the pandemic and gender equality in business life before and after the pandemic. Conclusion and Recommendations: It has been determined that women pay attention to protection measures during the pandemic period. It was found that women were tired and stressed due to housework and childcare, lost income due to full closure during the pandemic period, exposed to double standards in their workplaces. It is recommended that future research, including men, compare perceptions during the pandemic.
... É uma enzima do sistema reninaangiotensina-aldosterona, responsável por inativar a angiotensina II, substância vasoconstrictora e relacionada a doenças cardiovasculares, convertendo-a em angiotensina. [1][2][3][4][5][6][7] Estudos sugerem que o receptor da ECA2 seja a "maçaneta da porta" das células hospedeiras para entrada do SARS-CoV-2 e que a regulação positiva aumenta a suscetibilidade ao vírus. Em mulheres gestantes existe aumento dos receptores da ECA2, o que aumentaria a suscetibilidade. ...
Objetivos: revisar a literatura disponível sobre a COVID-19 e seus aspectos maternos e perinatais. Métodos: uma revisão narrativa de literatura foi realizada nos meses de março a setembro de 2020, utilizando os descritores, coronavirus, Covid 19, SARS-CoV-2, pregnancy, gravidity, pregnancy complications e pregnancy complications infectius. Foram incluídos todos os desenhos de estudo, revisões, recomendações e notas técnicas, sem distinção de idioma e que trouxessem a abordagem do novo coronavírus no cenário gestacional e perinatal. Resultados: a pandemia de COVID-19 vem apresentando efeitos devastadores, acome-tendo milhões de pessoas e ceifando quase um milhão de vidas em todo o mundo. Inicialmente as gestantes não eram vistas como grupo de risco para a doença, porém na medida em que aumentou a proporção de mulheres acometidas durante o ciclo gravídico-puerperal diversos estudos foram publicados demostrando risco aumentado de complicações. Estudos brasileiros também alertaram para um número elevado de mortes maternas, associados à presença de comorbidades, mas, sobretudo, aos determinantes sociais da doença e a falhas graves da assistência. Conclusão: observou-se a necessidade de novos estudos com adequado delineamento de pesquisa, pois muitos estudos são apenas cartas ou pequenas séries de casos, além de recomendações de especialistas, sem o rigor científico necessário.
... A review of reproductive and sexual health interventions to increase utilization of services in crisis situations found that only half of interventions had high quality evidence to support their use (Singh et al., 2018). While intervention research is lacking, even interventions that are known to improve sexual and reproductive health outcomes, such as providing longacting reversible contraceptives in humanitarian settings, are rarely fully implemented (Chynoweth, Amsalu, Casey, & McGinn, 2018). However, this lack of data is due in part to the unique challenges of data collection in the humanitarian setting (Dickinson, Pyone, & van den Broek, 2016). ...
Background: High rates of unintended and unplanned pregnancies in the United States result in challenges to quality of life, negative maternal and neonatal outcomes, and increased federal spending. While several socioeconomic and environmental factors have been associated with increased risks of unintended pregnancy, limited research has been conducted to evaluate the relationship between life stressors and reproductive outcomes such as unintended and unplanned pregnancies. Additionally, fertility intentions and reproductive decision-making are understudied in relation to stressors experienced by vulnerable populations in the United States. Specifically, the stressors associated with uprooting and flight experienced by Syrian refugees who have resettled in the United States, and the impact of these stressors on reproductive decision-making, has yet to be studied. Purpose: The purpose of this dissertation is to deepen the scientific understanding of the dynamic process of pregnancy intention and planning in women experiencing major life stressors, both in the United States and in the context of forced migration. Paper One: A secondary analysis of longitudinal data from 1,730 women following their first birth was conducted. A total of 1,552 pregnancies were experienced in the 36-month follow-up period. An Andersen-Gill survival analysis was used to assess how changes in stress over time relate to risk of pregnancies that are unintended, unplanned, or both unintended and unplanned. Minor (HR 1.66 and HR 1.68) and major (HR 2.34 and HR 1.90) decreases in stress, as well as minor increases (HR 1.60 and HR 1.40) in stress, were associated with an increased risk of unintended and unplanned pregnancies respectively. Increases in risk were not seen in major increases in stress over time. Major increases in stress may be associated with improved vigilance in contraceptive use, or stress-related decreases in intercourse. Clinical and policy interventions to reduce unintended pregnancy should take into consideration the impact that changes in stress may have on reproductive outcomes. Paper Two: A mixed-methods evaluation of reproductive decision-making with 36 women from Syria who resettled in southeast Michigan was conducted. Women completed a quantitative survey for every pregnancy experienced since the start of the Syrian Civil War, followed by a qualitative interview structured around a timeline. Participants described factors influencing fertility intentions over time including the facilitators and barriers to accessing reproductive healthcare and contraception. Findings will be used to improve reproductive healthcare access and uptake for women that are refugees in the United States and globally. Paper Three: Interviews with women from Syria were utilized to reconstruct a gender-informed migrant theory using extended case methodology. These interviews enabled deeper theorization of the work of women and the temporality of the refugee. This theory will be used to guide future research, policy, and clinical interventions for women who are refugees, specifically with the goal of improving reproductive healthcare access and uptake. Future Directions: The results of this dissertation aim to improve understanding of the relationship between life stressors and pregnancy intention and planning, and to identify barriers to providing quality reproductive healthcare to vulnerable populations. Results will be used to inform future work to develop policy and healthcare interventions aimed at assisting women in seeking congruence between their reproductive intentions and outcomes both in the United States and globally.
... WHO has also identified that there are risks related to genderbased and domestic violence because of negative psychological effects of quarantine (post-traumatic stress symptoms, confusion and anger) [15,16]. A historical analysis of global epidemic response has described a toxic mix of blaming, exploitation of social divisions and government deployment of authority, with potential for social conflict and power imbalances [17]. ...
... Approximately 2 percent of global humanitarian funding goes to education, and early childhood development programming accounts for only a tiny fraction of that. Additionally, issues related to the mental health and wellbeing of caregivers are often overlooked, despite evidence that attending to their needs is essential in effective interventions (Casey 2015;Chynoweth et al. 2018). ...
In this Commentary, authors Bernadette Daelmans, Mahalakshmi Nair, Fahmy Hanna, Ornella Lincetto, Tarun Dua, and Xanthe Hunt bring attention to the cascading effects of caregivers’ mental health for children’s development and outline an agenda for interagency priority-setting and research to support mothers’ and newborns’ mental wellbeing.
... Evidence shows that, quarantine leads to negative psychological effect, including post-traumatic stress symptoms, confusion and anger [38]. Quarantine might, therefore, increase the risk of gender-based violence and domestic abuse, which have been observed in other major disease outbreaks [39]. ...
Background: COVID-19 is a serious global pandemic with more than 1 million confirmed cases and 64,000 deaths. Cases of coronavirus disease 2019 (COVID-19) are rapidly increasing and infected millions globally. Violence against women and girls is also a global human rights violation and public health problem in lockdown period. Methods: A systematic review of studies were conducted to show the relationship between impacts of COVID-19 and violence against women, and their impacts on women's health and human rights globally. The systematic selection of case reports, clinical trials, health institutions guidelines (e.g. WHO, CDC), review reports by experts, commentators reports, editor's letters, and available indexed articles/journals were undertaken. The author conducted the literature search on March 20 up to 02 May2020, where existing quantitative and qualitative data are included in this review. Results: COVID-19 is a serious global pandemic with more than 1 million confirmed cases and 64,000 deaths. The COVID-19 pandemic has been the fastest-moving global public health crisis in a century, causing significant mortality and morbidity and giving rise to daunting health and human rights violations. As the findings demonstrate, there is an increase of violence during the period of lockdown. As a result of COVID-19, violence against women can result in injuries and serious physical, economical, mental, sexual and reproductive health problems, including sexually transmitted infections, HIV, and unplanned pregnancies in lockdown. Hence, the health and human rights of women generally is adversely impacted globally due to COVID-19. Conclusions: As COVID-19 pandemic deepens economic and social stress coupled with movement restriction and social isolation measures, gender-based violence is increasing exponentially, and trap women and girls. The physical and psychological costs of violence against women and girls are substantial. Globally, the estimated global cost of violence against women and girls is 1.5 Trillion women where nearly 1/2 amount of the world population in lockdown due to COVID-19. Hence, it has a relationship of violence against women and girls and surveillance of COVID-19 outbreak globally. In line with problems identified, civil society organizations and governments should work collaboratively with the whole society at home, institutions and public in general.
... Not all required interventions are made available to communities in humanitarian crises, including communities affected by conflict. 12,21,[23][24][25] Different humanitarian contexts pose different chal lenges, and those organisations and agencies delivering health, nutrition, and other interventions in each context must make crucial decisions about what they can and cannot provide under prevailing conditions and to whom, essentially practicing public health triage. 26 Given this need to triage in varying contexts, we present a systematic approach to identifying packages of recommended interventions for women and children that should be prioritised for implementation in different conflict contexts. ...
Existing global guidance for addressing women's and children's health and nutrition in humanitarian crises is not sufficiently contextualised for conflict settings specifically, reflecting the still-limited evidence that is available from such settings. As a preliminary step towards filling this guidance gap, we propose a conflict-specific framework that aims to guide decision makers focused on the health and nutrition of women and children affected by conflict to prioritise interventions that would address the major causes of mortality and morbidity among women and children in their particular settings and that could also be feasibly delivered in those settings. Assessing local needs, identifying relevant interventions from among those already recommended for humanitarian settings or universally, and assessing the contextual feasibility of delivery for each candidate intervention are key steps in the framework. We illustratively apply the proposed decision making framework to show what a framework-guided selection of priority interventions might look like in three hypothetical conflict contexts that differ in terms of levels of insecurity and patterns of population displacement. In doing so, we aim to catalyse further iteration and eventual field-testing of such a decision making framework by local, national, and international organisations and agencies involved in the humanitarian health response for women and children affected by conflict.
... On the one hand, one can be driven to action as a Bionian form of defense (Bion, 1962); on the other, one can escape from desire until it is neutralized. Libidinal introversion risks of being fatally reactivated over time; in fact, the danger of increased intra-family gender violence is reported in the quarantine literature (Chynoweth, Amsalu, Casey, & McGinn, 2018;Mazza et al., 2020b;Tang, Gaoshan, & Ahonsi, 2020). ...
... 37 Moreover, quarantine and lock-down applied during this pandemic not only lead to negative psychological effects but also increase the risk of domestic violence, divorce, and separation. 21,[38][39] Being pregnant and giving birth during this undetermined pandemic period, therefore increase uncertainty and worries for many women and may further add to Although Topalidou et al. 16 have argued that there is limited evidence to conclude that the COVID-19 pandemic has negative impact on maternal mental health, they believe that the psychological impact of COVID-19 should be acknowledged as a serious public health concern which requires appropriate care and support. This current review adds that depression and anxiety experienced by antenatal women are significantly linked to suicidal thoughts. ...
The widespread transmission of the new coronavirus disease COVID-19 has caused great psychological distress across diverse populations in many countries. Antenatal women are at greater risk of emotional instability and vulnerability due to hormonal changes, and multiple maternal roles. This paper aims to determine the common types of psychological distress and potential interventions amongst antenatal women during COVID-19 outbreak. This review was conducted as a rapid review in response to the COVID-19 outbreak. The PubMed, Scopus, and Google Scholar databases were searched using keywords namely "novel coronavirus", "COVID-19", "nCoV", "maternal mental health", "pregnant", "psychology", "anxiety", "depression" and "stress" in various permutations and combinations. A total of five papers were included in the final analysis. Thematic analysis was used to analyse the selected papers. Findings from the papers reviewed showed that COVID-19 has independently increased the prevalence of psychological distress among antenatal mothers. The most common types of distress were anxiety (57%-83.3%), followed by worry (50.7%) and depression (34.2-37%). The distress experienced by the antenatal women with COVID-19 was found to be associated with suicidal thought. Social support, psychological hotlines, and online counselling have been suggested to alleviate the symptoms of mental distress among antenatal women. The COVID-19 pandemic has independently caused psychological distress among antenatal women to rise. Maternal mental health should be prioritised during the pandemic, and mental support should be made available and accessible during and after the COVID-19 outbreak in ensuring the ongoing provision of mental health services.
... Evidence shows that quarantine leads to negative psychological effect, including post traumatic stress symptoms, confusion and anger [19]. Quarantine might, therefore, increase the risk of gender-based violence and domestic abuse, which have been observed in other major disease outbreaks [20]. Stigma and discrimination associated with COVID-19, their effects on clients and health care providers, and how these affect the uptake of SRH services should also be of significant research interest judging by lessons learnt from previous epidemics [21]. ...
The novel coronavirus disease (COVID-19) outbreak was first declared in China in December 2019, and WHO declared the pandemic on 11 March 2020. A fast-rising number of confirmed cases has been observed in all continents, with Europe at the epicentre of the outbreak at this moment.
Sexual and reproductive health (SRH) and rights is a significant public health issue during the epidemics. The novel coronavirus (SARS-CoV-2) is new to humans, and only limited scientific evidence is available to identify the impact of the disease COVID-19 on SRH, including clinical presentation and outcomes of the infection during pregnancy, or for persons with STI/HIV-related immunosuppression. Beyond the clinical scope of SRH, we should not neglect the impacts at the health system level and disruptions or interruptions in regular provision of SRH services, such as pre- and postnatal checks, safe abortion, contraception, HIV/AIDS and sexually transmitted infections. Furthermore, other aspects merit attention such as the potential increase of gender-based violence and domestic abuse, and effects of stigma and discrimination associated with COVID-19 and their effects on SRH clients and health care providers. Therefore, there is an urgent need for the scientific community to generate sound clinical, epidemiological, and psycho-social behavioral links between COVID-19 and SRH and rights outcomes.
Background
Humanitarian assistance standards mandate specific attention to address the sexual and reproductive health (SRH) needs of conflict-affected populations. Despite these internationally recognised standards, access to SRH services is still often compromised in conflict settings. CARE in collaboration with the RAISE Initiative strengthened the Ministry of Health (MOH) to provide contraceptive services in Maniema province, Democratic Republic of the Congo. This study evaluated the effectiveness of this support for MOH health facility provision of contraception.
Methods
Cross-sectional surveys in 2008 (n = 607) and 2010 (n = 575) of women of reproductive age using a two-stage cluster sampling design were conducted in Kasongo health zone. Facility assessments were conducted to assess the capacity of supported government health facilities to provide contraceptive services in 2007 and 2010. Data on the numbers of clients who started a contraceptive method were also collected monthly from supported facilities for 2008–2014.
Results
Current use of any modern contraceptive method doubled from 3.1 to 5.9% (adjusted OR 2.03 [95%CI 1.3–3.2]). Current use of long-acting and permanent methods (LAPM) increased from 0 to 1.7% (p < .001), an increase that was no longer significant after adjustment. All current users except a few condom users reported a health facility as the source of the method. The 2010 facility assessments found that most supported facilities had the capacity to provide short-acting and long-acting methods. Service statistics indicated that the percentage of clients who accepted a long-acting method at supported facilities increased from 8% in 2008 to 83% in 2014 (p < .001).
Conclusions
This study demonstrated that contraceptive prevalence doubled between 2008 and 2010; service statistics indicate that utilization of long-acting methods continued to increase to a majority of new clients after 2010. Strengthening the health system to provide contraceptive services enabled individuals to exercise their right to prevent unintended pregnancies. These results suggest that demand for contraception, including long-acting methods, is present even in humanitarian settings, and that women will use them when they are available and of reasonable quality. It is critical that the humanitarian community ensure that such services are available to women affected by crises.
Background:
Despite remarkable progress in the improvement of child survival between 1990 and 2015, the Millennium Development Goal (MDG) 4 target of a two-thirds reduction of under-5 mortality rate (U5MR) was not achieved globally. In this paper, we updated our annual estimates of child mortality by cause to 2000-15 to reflect on progress toward the MDG 4 and consider implications for the Sustainable Development Goals (SDG) target for child survival.
Methods:
We increased the estimation input data for causes of deaths by 43% among neonates and 23% among 1-59-month-olds, respectively. We used adequate vital registration (VR) data where available, and modelled cause-specific mortality fractions applying multinomial logistic regressions using adequate VR for low U5MR countries and verbal autopsy data for high U5MR countries. We updated the estimation to use Plasmodium falciparum parasite rate in place of malaria index in the modelling of malaria deaths; to use adjusted empirical estimates instead of modelled estimates for China; and to consider the effects of pneumococcal conjugate vaccine and rotavirus vaccine in the estimation.
Findings:
In 2015, among the 5·9 million under-5 deaths, 2·7 million occurred in the neonatal period. The leading under-5 causes were preterm birth complications (1·055 million [95% uncertainty range (UR) 0·935-1·179]), pneumonia (0·921 million [0·812 -1·117]), and intrapartum-related events (0·691 million [0·598 -0·778]). In the two MDG regions with the most under-5 deaths, the leading cause was pneumonia in sub-Saharan Africa and preterm birth complications in southern Asia. Reductions in mortality rates for pneumonia, diarrhoea, neonatal intrapartum-related events, malaria, and measles were responsible for 61% of the total reduction of 35 per 1000 livebirths in U5MR in 2000-15. Stratified by U5MR, pneumonia was the leading cause in countries with very high U5MR. Preterm birth complications and pneumonia were both important in high, medium high, and medium child mortality countries; whereas congenital abnormalities was the most important cause in countries with low and very low U5MR.
Interpretation:
In the SDG era, countries are advised to prioritise child survival policy and programmes based on their child cause-of-death composition. Continued and enhanced efforts to scale up proven life-saving interventions are needed to achieve the SDG child survival target.
Funding:
Bill & Melinda Gates Foundation, WHO.
Reproductive health (RH) care is an essential component of humanitarian response. Women and girls living in humanitarian settings often face high maternal mortality and are vulnerable to unwanted pregnancy, unsafe abortion, and sexual violence. This study explored the availability and quality of, and access barriers to RH services in three humanitarian settings in Burkina Faso, Democratic Republic of the Congo (DRC), and South Sudan.
Data collection was conducted between July and October 2013. In total, 63 purposively selected health facilities were assessed: 28 in Burkina Faso, 25 in DRC, and nine in South Sudan, and 42 providers completed a questionnaire to assess RH knowledge and attitudes. Thirty-four focus group discussions were conducted with 29 members of the host communities and 273 displaced married and unmarried women and men to understand access barriers.
All facilities reported providing some RH services in the prior three months. Five health facilities in Burkina Faso, six in DRC, and none in South Sudan met the criteria as a family planning service delivery point. Two health facilities in Burkina Faso, one in DRC, and two in South Sudan met the criteria as an emergency obstetric and newborn care service delivery point. Across settings, three facilities in DRC adequately provided selected elements of clinical management of rape. Safe abortion was unavailable. Many providers lacked essential knowledge and skills. Focus groups revealed limited knowledge of available RH services and socio-cultural barriers to accessing them, although participants reported a remarkable increase in use of facility-based delivery services.
Although RH services are being provided, the availability of good quality RH services was inconsistent across settings. Commodity management and security must be prioritized to ensure consistent availability of essential supplies. It is critical to improve the attitudes, managerial and technical capacity of providers to ensure that RH services are delivered respectfully and efficiently. In addition to ensuring systematic implementation of good quality RH services, humanitarian health actors should meaningfully engage crisis-affected communities in RH programming to increase understanding and use of this life-saving care.
An estimated 43 million women of reproductive age experienced the effects of conflict in 2012. Already vulnerable from the insecurity of the emergency, women must also face the continuing risk of unwanted pregnancy but often are unable to obtain family planning services. The ongoing Supporting Access to Family Planning and Post-Abortion Care (SAFPAC) initiative, led by CARE, has provided contraceptives, including long-acting reversible contraceptives (LARCs), to refugees, internally displaced persons, and conflict-affected resident populations in Chad, the Democratic Republic of the Congo (DRC), Djibouti, Mali, and Pakistan. The project works through the Ministry of Health in 4 key areas: (1) competency-based training, (2) supply chain management, (3) systematic supervision, and (4) community mobilization to raise awareness and shift norms related to family planning. This article presents data on program results from July 2011 to December 2013 from the 5 countries. Project staff summarized monthly data from client registers using hard-copy forms and recorded the data electronically in Microsoft Excel for compilation and analysis. The initiative reached 52,616 new users of modern contraceptive methods across the 5 countries, ranging from 575 in Djibouti to 21,191 in Chad. LARCs have predominated overall, representing 61% of new modern method users. The percentage of new users choosing LARCs varied by country: 78% in the DRC, 72% in Chad, and 51% in Mali, but only 29% in Pakistan. In Djibouti, those methods were not offered in the country through SAFPAC during the period discussed here. In Chad, the DRC, and Mali, implants have been the most popular LARC method, while in Pakistan the IUD has been more popular. Use of IUDs, however, has comprised a larger share of the method mix over time in all 4 of these countries. These results to date suggest that it is feasible to work with the public sector in fragile, crisis-affected states to deliver a wide range of quality family planning services, to do so rapidly, and to see a dramatic increase in the percentage of users choosing long-acting reversible methods.
© Curry et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/. When linking to this article, please use the following permanent link: http://dx.doi.org/10.9745/GHSP-D-14-00112.
Refugees and internally displaced persons are highly vulnerable to sexual violence during conflict and subsequent displacement. However, accurate estimates of the prevalence of sexual violence among in these populations remain uncertain.
Our objective was to estimate the prevalence of sexual violence among refugees and displaced persons in complex humanitarian emergencies.
We conducted systematic review of relevant literature in multiple databases (EMBASE, CINAHL, and MEDLINE) through February 2013 to identify studies. We also reviewed reference lists of included articles to identify any missing sources.
Inclusion criteria required identification of sexual violence among refugees and internally displaced persons or those displaced by conflict in complex humanitarian settings. Studies were excluded if they did not provide female sexual violence prevalence, or that included only single case reports, anecdotes, and those that focused on displacement associated with natural disasters. After a review of 1175 citations 19 unique studies were selected. Data Extraction: Two reviewers worked independently to identify final selection and a third reviewer adjudicated any differences. Descriptive and quantitative information was extracted; prevalence estimates were synthesized. Heterogeneity was assessed using I2.
The main outcome of interest was sexual violence among female refugees and internally displaced persons in complex humanitarian settings.
The prevalence of sexual violence was estimated at 21.4% (95% CI, 14.9-28.7; I2=98.3%), using a random effects model. Statistical heterogeneity was noted with studies using probability sampling designs reporting lower prevalence of sexual violence (21.0%, 95% CI, 13.2-30.1; I2=98.6%), compared to lower quality studies (21.7%, 95% CI, 11.5-34.2; I2=97.4%). We could not rule out the presence of publication bias.
The findings suggest that approximately one in five refugees or displaced women in complex humanitarian settings experienced sexual violence. However, this is likely an underestimation of the true prevalence given the multiple existing barriers associated with disclosure. The long-term health and social consequences of sexual violence for women and their families necessitate strategies to improve identification of survivors of sexual violence and increase prevention and response interventions in these complex settings.
Abstract Humanitarian assistance standards require specific attention to address the reproductive health (RH) needs of conflict-affected populations. Despite these internationally recognised standards, access to RH services is still often compromised in war. We assessed the effectiveness of our programme in northern Uganda to provide family planning (FP) services through mobile outreach and public health centre strengthening. Baseline (n=905) and endline (n=873) cross-sectional surveys using a multistage cluster sampling design were conducted in the catchment areas of four public health centres in 2007 and 2010. Current use of any modern FP method increased from 7.1% to 22.6% (adjusted odds ratio [OR] 3.34 [95% confidence interval (CI) 2.27-4.92]); current use of long-acting and permanent methods increased from 1.2% to 9.8% (adjusted OR 9.45 [95%CI 3.99-22.39]). The proportion of women with unmet need for FP decreased from 52.1% to 35.7%. This study demonstrates that when comprehensive FP services are provided among conflict-affected populations, women will choose to use them. The combination of mobile teams and health systems strengthening can make a full range of methods quickly available while supporting the health system to continue to provide those services in challenging and resource-constrained settings.
Recognition of the need for evidence-based interventions to help to improve the effectiveness and efficiency of humanitarian responses has been increasing. However, little is known about the breadth and quality of evidence on health interventions in humanitarian crises. We describe the findings of a systematic review with the aim of examining the quantity and quality of evidence on public health interventions in humanitarian crises to identify key research gaps. We identified 345 studies published between 1980 and 2014 that met our inclusion criteria. The quantity of evidence varied substantially by health topic, from communicable diseases (n=131), nutrition (n=77), to non-communicable diseases (n=8), and water, sanitation, and hygiene (n=6). We observed common study design and weaknesses in the methods, which substantially reduced the ability to determine causation and attribution of the interventions. Considering the major increase in health-related humanitarian activities in the past three decades and calls for a stronger evidence base, this paper highlights the limited quantity and quality of health intervention research in humanitarian contexts and supports calls to scale up this research.
Objectives:
To identify the health outcomes of sexual violence on civilians in conflict zones between 1981 and 2014.
Study design:
Systematic review.
Methods:
For the purpose of this study, we defined sexual violence as sexual torture including, individual rape, gang rape, and sexual slavery. All types of conflicts were included (intrastate, interstate, and internationalized intrastate). Quantitative and mixed-method studies, reporting any physical, mental, and social consequences, were retrieved from Medline, Embase, Global Health, Global Health Library, WHOLIS, Popline, and Web of Sciences (n = 3075) and from checking reference lists and personal communications (n = 359). Data were analyzed using Microsoft Excel and MetaXL. Given inherent variation, the means derived from combining studies were misleading; thus, we focused on the range of values.
Results:
The 20 studies were from six countries, five in Africa (18 studies), and especially in Democratic Republic of Congo (12 studies). The number of subjects varied from 63 to 20,517, with 17 studies including more than 100 subjects. Eight studies included males. Gang rape, rape, and abduction were the most commonly reported types of sexual violence. Sixteen studies provided data on physical outcomes of which the most common were pregnancy (range 3.4-46.3%), traumatic genital injuries/tears (range 2.1-28.7%), rectal and vaginal fistulae (range 9.0-40.7%), sexual problems/dysfunction (range 20.1-56.7%), and sexually transmitted diseases (range 4.6-83.6%). Mental health outcomes were reported in 14 studies, the most frequent being post-traumatic stress disorder (range 3.1-75.9%), anxiety (range 6.9-75%), and depression (range 8.8-76.5%). Eleven studies provided social outcomes, the most common being rejection by family and/or community (range of 3.5-28.5%) and spousal abandonment (range 6.1-64.7%).
Conclusions:
Wartime sexual violence is highly traumatic, causing multiple, long-term negative outcomes. The number and quality of studies published does not match the significance of the problem. The findings highlight the need for care of the survivors and their relatives and raise concerns about how they and their children will be affected in the long term.
Despite considerable improvements in reproductive and newborn health throughout the world, relatively poor outcomes persist in areas plagued by conflict or political instability.
To assess the contribution of areas of conflict and instability to global patterns of stillbirths and newborn deaths and to identify opportunities for effective intervention in these areas.
Analysis of the available data on stillbirths and neonatal mortality in association with conflict and governance indicators, and review of epidemiological and political literature pertaining to the provision of health and public services in areas of conflict and instability.
Of the 15 countries with the highest neonatal mortality rates in the world, 14 are characterized by chronic conflict or political instability. If India and China are excluded, countries experiencing chronic conflict or political instability account for approximately 42% of all neonatal deaths worldwide. Efforts to address adverse reproductive and newborn outcomes in these areas must adapt recommended intervention protocols to the special security and governance conditions associated with unstable political environment.
Despite troubling relative and absolute indicators, the special requirements of improving reproductive and neonatal outcomes in areas affected by conflict and political instability have not received adequate attention. New integrated political and technical strategies will be required. This should include moving beyond traditional approaches concerned with complex humanitarian emergencies. Rather, global efforts must be based on a deeper understanding of the specific governance requirements associated with protracted and widespread health requirements. A focus on women's roles, regional strategies which take advantage of relative stability and governance capacity in neighbouring states, virtual infrastructure, and assistance regimens directed specifically to unstable areas may prove useful.
Progress in newborn survival has been slow, and even more so for reductions in stillbirths. To meet Every Newborn targets of fewer than 12 neonatal deaths and fewer than 12 stillbirths per 1000 births in every country by 2030 will necessitate accelerated scale-up of the most effective care targeting major causes of newborn deaths. We have systematically reviewed interventions across the continuum of care and various delivery platforms, and then modelled the effect and cost of scale-up in the 75 high-burden Countdown countries. Closure of the quality gap through the provision of effective care for all women and newborn babies delivering in facilities could prevent an estimated 113 000 maternal deaths, 531 000 stillbirths, and 1·325 million neonatal deaths annually by 2020 at an estimated running cost of US0·9 per person). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1·9 million [range 1·6–2·1 million]), 33% of stillbirths (0·82 million [0·60–0·93 million]), and 54% of maternal deaths (0·16 million [0·14–0·17 million]) per year. These reductions can be achieved at an annual incremental running cost of US1·15 per person), which amounts to US3·66 billion or 64%), even without the cost of new hospitals and country-specific capital inputs being factored in. The maximum effect on neonatal deaths is through interventions delivered during labour and birth, including for obstetric complications (41%), followed by care of small and ill newborn babies (30%). To meet the unmet need for family planning with modern contraceptives would be synergistic, and would contribute to around a halving of births and therefore deaths. Our analysis also indicates that available interventions can reduce the three most common cause of neonatal mortality—preterm, intrapartum, and infection-related deaths—by 58%, 79%, and 84%, respectively.