26. Sexual and Reproductive Health

During an emergency, health is one of the most important issues for the population’s survival. Health care is a basic right for all. This right includes equal access to health care to treat and prevent excess mortality and morbidity. During the first stages of an emergency, health and sexual and reproductive health services must be prioritised as part of a rapid multi-sectoral response. Health-related interventions determined to be priorities should be addressed in coordination with local authorities and other responding agencies, as well as in collaboration with the other priority sectors of water, food security and shelter.

Reproductive health (RH) is an essential component of basic health service provision in crisis and there are many aspects to good quality sexual and reproductive health in humanitarian crisis settings. As of 2015, of the more than 100 million people in need of humanitarian assistance, 26 million are women and adolescent girls of reproductive age (UNFPA, State of the World Population, 2015). Women and children make up about 80% of the world’s displaced population, (The Lancet, 2015). In conflict settings, three out of five of all maternal deaths occur and one out of five women will die from childbirth in their lifetime– much higher than the global average even within the developing world, (WHO, 2015). Sexual activities continue even in crisis settings. Additionally, rates of sexual assault and gender-based violence (GBV) are likely to increase in the forms of intimate partner violence, rape as a weapon of war, or facilitated by unsafe living conditions, (UNFPA, 2015). Further, women and girls are more vulnerable in emergencies and have specific health needs that must be addressed if we want to ensure equity in health service delivery. Therefore, during an emergency, reproductive health is one of the most important issues for the population’s survival and well-being and must be an integral component of primary health care provision.

The crude mortality rate (CMR) is the most specific and useful health indicator to monitor the health of a population. When the CMR doubles, it means an immediate response is required. Each region has a baseline reference for mortality and can be found in the Sphere handbook (Annex 26.5.1). When baseline rates are unknown, the CMR should be maintained below 1.0/10,000/day. Baseline references for children under five years of age (Under 5) are also region-specific. When regional data is unavailable, a rate below 2.0/10,000/day for U5s should be maintained.

In an emergency, the model for health infrastructure and system delivery should be based on the knowledge that 50% to 95% of mortality will be caused by the following communicable diseases: diarrhoeal diseases, acute respiratory infections, measles and malaria; with malnutrition as an underlying factor that aggravates illness.

In large emergencies the health cluster or another coordinating mechanism is frequently put in place and organizations are encouraged to coordinate their assessments with all implementing partners.  The IASC developed Multi Sector Initial Rapid Assessment (MIRA) tool to be used for initial rapid assessment within 24-48 hours. The tool may be modified to contextual relevance. Guidance on the use of the tool is provided in MIRA Guidance July 2015.  http://interagencystandingcommittee.org/system/files/mira_2015_final.pdf . Please refer to Chapter 13 Assessment for tools for a link to the MIRA field assessment tool.

The following checklist is adapted from the Sphere health services assessment checklist and may be used to help prioritise health issues and to consider what interventions the country office may contribute to the overall health response.

Checklist for emergency preparedness and planning for SRHR services

Emergency Preparedness

• Participate in country office emergency preparedness planning (EPP) process. This process highlights key items to be reviewed organized for a country office before embarking on providing services.
• Integrate preparedness for health or specific aspects of health based upon the capacity of the country office and current programming.
• Identify health and sexual, reproductive health (SRHR) interventions based upon the most likely types of scenarios (i.e. natural disaster such as flooding, earthquake, civil conflict, or other public health emergencies of international concern).
• Ensure CO staff are represented and participating in UN/WHO Health Cluster related coordinating activities such as SRH and GBV sub-working groups
• Prepare and complete the CARE SRHR EPP Matrix as part of the planning process. Annex 26.15.19
• Preposition RH supplies identified in the EPP

Preparation for Humanitarian Response

• Obtain available information on the crisis-affected population and resources from the host country and international sources.
• Obtain available maps and aerial photographs of the affected areas.
• Obtain demographic and health data from the host country and international sources.

Security and access

• Determine the existence of ongoing natural or human-generated hazards.
• Determine the overall security situation, including the presence of armed forces or militia.
• Determine the access that humanitarian agencies have to the affected population.

Demographics and social structure

• Determine the total disaster-affected population and proportion of children under five years of age.
• Determine the age and sex breakdown of the population.
• Identify the groups at increased risk, for example, women, children, older people, disabled people, people living with HIV/AIDS, people who identify as LGBT, members of certain ethnic or social groups.
• Determine the average household size and estimates of female- and child-headed households.
• Determine the existing social structure, including positions of authority/influence and the role of women.

Background health information

• Identify pre-existing health problems and priorities in the crisis-affected area before the humanitarian crisis. Find out local disease epidemiology.
• Identify pre-existing health problems and priorities in the country of origin if refugees are involved. Find out disease epidemiology in the country of origin.
• Identify existing risks to health, for example, potential epidemic diseases.
• Identify previous sources of health care in crisis affected areas.
• Determine the strengths and coverage of local public health programs for the affected community, internally displaced populations (IDPs) as well as in refugees’ country of origin.

Mortality rates

For populations affected by the emergency (affected community, IDPs or refugees):

• Calculate the crude mortality rate (CMR).
• Calculate the ‘under 5′ mortality rate (U5MR: age-specific mortality rate for children under five years of age).
• Calculate cause-specific mortality rates including number of maternal deaths.
• Calculate the proportional mortality rate by dividing cause-specific mortality by total mortality.

Morbidity rates

• Determine the incidence rates of major diseases that have public health importance.
• Determine age- and sex-specific incidence rates of major diseases.

Sector Specific Assessment

• After the initial rapid assessment (IRA) during the first stage of an emergency, sector-specific assessments should occur to ensure key health, especially sexual and reproductive health needs are addressed.
• The CARE SRHR program tool for health facility assessment helps to get a more focused information on SRH capacity. See Annex 26.5.18
• The CDC Reproductive Health Assessment Toolkit includes a useful RH assessment titled “CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE FOR CONFLICT-AFFECTED WOMEN 2011.” See Annex 26.5.17
• This assessment can inform the following indicators:

Sexual, reproductive, maternal health indicators

• Safe Motherhood
• # of visibly pregnant and lactating women in crisis-affected area
• % of pregnant women receiving ANC (2+ visits)
• # of clean delivery kits distributed
• % of pregnant women who deliver assisted by a skilled birth attendant at a health facility
• % of health facilities that provide emergency obstetric care.

• Voluntary Contraception/Family Planning
• # of contraceptive users receiving a modern method per month
• Contraceptive prevalence rate – how many people at any given moment are protected?
• % of health facilities providing contraceptive services

• Sexual violence incidence
• # of cases of sexual violence reported, formally or informally
• % of health facilities offering clinical management of rape for survivors.

Note: Refer to the Sphere Manual Minimum Standards in Health Action for information on how to calculate mortality and morbidity rates and refer to Annex 26.5.11 for information on how to calculate UN process indicators to track provision of emergency obstetric and neonatal care (EmONC)

Capacity Assessment of SRHR and health systems 

The following information may be collected by CARE, UN agencies, Ministry of Health or other organizations responding to the emergencies:

• Determine the status of sexual reproductive health practices and services (including maternal and newborn health).
• Determine the capacity of and the response by the Ministry of Health of the country/countries affected by the disaster.
• Determine the status of national health facilities, including total number, classification and levels of care provided, physical status, functional status and access.
• Determine the numbers and skills of available health staff.
• Determine the capacity and functional status of existing public health programmes, for example, Expanded Programme on Immunization (EPI), maternal and child health services, and HIV/AIDS.
• Determine the availability of standardised protocols, essential drugs, supplies and equipment.
• Determine the status of existing referral systems.
• Determine the status of the existing health information system (HIS).
• Determine the capacity of existing logistics systems, especially as they relate to procurement, distribution and storage of essential drugs, contraceptive commodities, vaccines and medical supplies.

Data from other relevant sectors

• Use findings from the multi-sectoral assessment and refer to relevant chapters in the Sphere guidelines to ensure health and SRH programming takes into account the population’s nutritional and food security status, hygiene and sanitary conditions, risk of gender based violence, and housing situation.
• Determine the needs of AIDS patients who may be experiencing ART treatment interruption and HIV+ pregnant women who will need PMTCT services.

Source: Adapted from Sphere handbook-Health Services Assessment Checklist. http://www.spherehandbook.org/en/appendix-11/ 
*Note: The Sphere handbook is undergoing revisions in 2017.

Included below is a checklist of health activities that should be implemented in an emergency response.  Recognizing the capacity of the country office, the country office should identify which areas of focus they can prioritize and coordinate with coordinating groups such as the health and protection cluster meetings, under which SGBV and RH working groups function, to determine what other actors are doing to ensure a comprehensive response.  Further information on each health issue is addressed in later sections of this chapter.

Checklist for emergency health and SRHR response

Support health systems and infrastructure

• Urgent: If health services are not available in the crisis-affected area, an urgent action is to provide or support health infrastructure and to distribute equipment and supplies to health workers to facilitate initiation of health services.
• High priority: If there is crowding and a lack of sanitation or water, a high priority action is to conduct disease surveillance and outbreak management.
• Longer-term priority: In all crisis support and (re)build capacity of health policies and systems.

Address priority communicable diseases

• Prevent and treat diarrhoeal diseases especially among children under 5.
• Acute respiratory infections (ARIs).
• Measles.
• Malaria and other vector-borne diseases.
• HIV/AIDS and other STIs.

Address sexual reproductive health needs through MISP implementation (Minimum Initial Service Package) in Humanitarian Situations

• RH coordination: identify or nominate an RH officer to coordinate SRH activities in collaboration with the health cluster, under SRH sub-cluster, if available.
• Gender-based violence: Prevent and manage consequences of GBV including treatment.
• HIV/AIDS: address HIV prevention and transmission through enforcing standard precaution, free condom distribution
• Maternal and newborn health: ensuring availability and accessibility of EmONC
• Transition to comprehensive reproductive health services including full range of contraceptive services

Address non-communicable diseases

• Trauma and injury.
• Psychosocial and mental health needs.
• Chronic diseases such as heart disease, insulin-dependent diabetes, high blood pressure.

• Do not build parallel systems with direct support and buy in from the Ministry of Health. Build systems together and support the systems that already exist.
• Do not take health staff from their already increased responsibilities. Look to volunteers from the affected community or local host community to support health system development and the promotion of interventions, in particular for outreach and community-level response.
• Do not create new surveillance systems for new indicators that require monitoring. Include them in the existing surveillance system.
• Do not forget to include the local population when responding to the needs of displaced persons in response efforts.
• Site planning, water and sanitation, food distribution, shelter, and safety and security should not work individually. Ensure that communication is taking place between these areas to facilitate the greatest impact with health interventions and prevention activities.
• Do not commit to technical responses if people are not trained or qualified to deliver. Define packages of service that are appropriate for the needs of the population and can be delivered with the capacities of the CO or CARE as an organisation globally.
• Do not rely on agency capacity or consultants for facilitation of activities or interventions. Train and build the capacity of volunteers and health workers, if they are available, to better enable them to respond to the needs of their community.
• Ensure active psychosocial screening of all people engaged in an emergency. This includes, but is not limited to, the affected population, staff engaged in emergency response, and the local community in the situation of displaced populations.
• Do No Harm: Be aware of political and armed groups that are in conflict with each other in the affected zone, and ensure that all CARE’s health responses are designed and implemented in a way that minimizes conflict between these groups. For example, do not offer health services to one group but not the other. Do not hire health program staff exclusively from one ethnic or minority group.
• Do not forget to include health system policies and services that prevent and address sexual and other forms of interpersonal violence (see Chapter 9).

A specialist should be sought when the CO does not have adequate technical health capacity in its team to be able to meet the health needs of the emergency. International technical expertise in the health sector can be requested through the CERT mechanism (refer to Chapter 21 Human resources).

CARE USA SRHR Global team is available to provide programmatic guidance for design and implementation of SRH in emergency response. The Global SRHR team is also available to help build regional and CO level capacity in SRHR in emergencies as part of emergency preparedness and planning activities.
Remote technical support and advice is available from CARE USA, including health technical support for emergencies in Sexual and Reproductive Health and basic components of primary health care. The SRHR Global team is available to provide programmatic guidance for design and implementation of SRH in emergencies support.

• Technical assistance specific to sexual and reproductive health in crises can be sought from Kamlesh Giri, Senior Technical Advisor, based in Washington, DC at kgiri@care.org
• Technical guidelines can be accessed through the technical units based in Atlanta, and through the internal and external websites referred to in sections 8   and 9.

CARE’s emergency response programmes should strive to support health infrastructure and systems to provide essential sexual and reproductive health services and care as well as treating the prevalent communicable and non-communicable diseases. It is imperative to CARE’s commitment to empowering women and girls that reproductive health remains a robust sector of service delivery. Even in emergencies, inclusive SRMH services must be maintained and promoted for the well-being and health of women, girls, men and boys. This is required for women and girls to be able to exercise not only their rights to reproductive health and a life free from violence, but also their rights to adequate food and nutrition, secure livelihood, and hope for themselves and their families.

All efforts should be made to maintain a global commitment to internationally approved guidelines and protocols for delivery and administration in these areas of health to the affected population. CARE is particularly committed to the care of women and their families, and response to comprehensive reproductive health in emergency situations. This includes a commitment to the MISP (Annex 26.5.3), being a signatory to the Inter-agency Field Manual on Reproductive Health in Humanitarian Settings (Annex 26.5.4), NGO code of practice guidelines on emergency and HIV (Annex 26.5.5) and participation in the development of the IASC Guidelines for addressing HIV in humanitarian situations.

”The strategic focus of CARE’s health and SRHR sector programming seeks to achieve more equitable access among vulnerable populations, which includes mothers, adolescent girls, and children under five years of age to affordable, high-quality health services through robust and responsive emergency program implementation with strengthened systemic approaches and improved governance.

Currently, health-related programming within CARE extends into nearly 50 countries, including over 200 projects in nutrition, child survival, sexual and reproductive health, infectious disease, and other multi-sectoral programmes. Programming includes incorporation of gender equity, social inclusion and organisational learning. Maternal health programming specifically is taking place in 46 CARE International countries and reaching 36.8 million participants (2014 PIIRS Report). CARE has demonstrated success in using sexual, reproductive, and maternal health interventions as a critical entry point to address the needs of women and girls across the ’emergency to development’ continuum.