Delivering Quality Reproductive Health in Conflict
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This document discusses a project to increase access to modern family planning and post-abortion care in conflict-affected settings in Pakistan, Chad, and the Democratic Republic of Congo. It outlines challenges like limited resources, safety concerns, and conservative opposition. The project adapted approaches by providing training, supportive supervision, and improving supply chains. Outcomes included high sustained demand, with over 39,000 new family planning users and increased use of long-acting reversible contraceptives over time. Recommendations focus on further building training capacity, team-based quality improvement, and respectful care dialogues. The document concludes that reproductive health is a basic right that can be attained even in crisis settings.
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Delivering Quality Reproductive Health in Conflict
- 1. Delivering High Quality Reproductive Health Services in Conflict-Affected Settings
- 2. Supporting Access to Family Planning and PostAbortion Care • Project goal – Increase women’s access to modern family planning with a special focus on long-acting reversible contraception and post-abortion care in crisis-affected settings. Presentation outline • Realities of providing FP, especially LARC, in a crisis context • How we adapted approaches and met challenges • What we accomplished 1 January 31, 2014
- 3. Helping fragile systems meet a basic need: Sexual and reproductive health services • “I like the Jadelle. It avoids conflict in my marriage. I tell my husband now we can have sex any time and he is very happy.” FP user in Maro district, Southern Chad 2 January 31, 2014
- 4. Crisis Settings • Pakistan - 4.8 million affected by 2010 monsoon floods in Punjab and Sindh, continued periodic flooding and insecurity • Chad - 58,000 refugees from CAR, chronic emergency level food insecurity • DRC - 1.4 million affected by resurgence of conflict in North and South Kivu 3 January 31, 2014
- 5. Working in crisis • Safety of staff • Population movements • Limited to non-existent accountability mechanisms • Dynamic populations not always easily identified 4 January 31, 2014
- 6. Some basic challenges - exacerbated • Challenged, underresourced systems • Logistics / Supply chain management • Training • Social norms and misinformation/rumors • Other vertical initiatives • Conservative Catholic leadership opposed to FP 5 January 31, 2014
- 7. Our Model Stable • Emergency preparedness • Disaster risk reduction w/gov’t Acute • SRH assessment • MISP • SRH integration into other programs • After action reviews Transition, Fragile,Chronic • Training • Supply chain • Supportive supervision • Data use • Community action Rights approach as underlying guiding principle 6 January 31, 2014
- 8. BCS+* as a foundation for respectful care 7 7 January 31, 2014 * Population Council, 2008
- 9. Supporting Providers • Regular visits, ideally monthly from clinical and M&E project staff • A major challenge! • Skills assessment, within 3 months of training and bi-annually afterward • Quarterly district meetings for cross-learning with other facilities 8 January 31, 2014 • Data quality checks • Data use
- 10. 9 January 31, 2014 Monthly total Cumulative total 2013_06 2013_05 2013_04 5000 2013_03 10000 2013_02 2013_01 2012_12 2012_11 2012_10 2012_09 2012_08 2012_07 2012_06 2012_05 40000 2012_04 45000 2012_03 2012_02 2012_01 2011_12 2011_11 2011_10 2011_09 2011_08 2011_07 2011_06 High, sustained demand 39586 cumulative total new users 35000 30000 25000 20000 15000 1583 per month, up from 203 0
- 11. 2011_06 2011_07 2011_08 2011_09 2011_10 2011_11 2011_12 2012_01 2012_02 2012_03 2012_04 2012_05 2012_06 2012_07 2012_08 2012_09 2012_10 2012_11 2012_12 2013_01 2013_02 2013_03 2013_04 2013_05 2013_06 IUD use over time Monthly Percentage of IUD among new FP users by country 100.0% 80.0% 60.0% -20.0% 10 January 31, 2014 Chad DRC 40.0% PAK Linear (Chad) Linear (DRC) 20.0% Linear (PAK) 0.0%
- 12. Where do we go from here? Recommendations and next steps • Training capacity and skills assessment (logistics!) • Team-based quality improvement based on data-driven supportive supervision (client exit interviews) • Dialogue about rights and respectful care meeting providers and others where they are 11 January 31, 2014
- 13. Reproductive health services in crises A need, a right, and attainable goal - not a luxury 12 January 31, 2014
- 14. Contact Information • Dora Ward Curry, dcurry@care.org (STA, M&E) • Jesse Rattan, jrattan@care.org (Project Director) • http://familyplanning.care2share.wikispaces.net/SAF-PAC 13 January 31, 2014
Editor's Notes
- LARC – IUDs and implantsPAC – because of maternal mortality due to unsafe abortion; MVA because of low rate of complication compared to standard of care in these settings D&C.Crisis affected – acute emergency, in transition/post-conflict or in chronically unstable environments
- This quote came from a program participant in Southern Chad on the border with Central African Republic and home to CAR refugees. The Jadelle is the brand of hormonal implant used there.First and foremost, women have the need and right to choose if, when and how many children to bear. In addition, we are all well aware of the public health impact of family planning on the health and survival of women and their children. These needs do not disappear when famine, drought or war appear.Providing high quality family planning services is challenging in any setting. In humanitarian crises those challenges grow. In 2011, 61 million people were affected by humanitarian crises. Countries with the highest maternal mortality rate are disproportionately countries experiencing conflict or other crises. With women of reproductive age comprising at least a quarter of the population, over 15 million women may need family planning in high-maternal mortality, crisis-affected settings. Developing the capacity to include family planning in the context of acute emergencies and chronically crisis-affected countries is increasingly being recognized as a critical part of a comprehensive humanitarian response.With funding from a large, anonymous donor, CARE and other INGO partners facilitating women’s access to FP in spite of the obvious challenges of working in settings affected by crisis. (CARE’s arm of this program is known as Supporting Access to Family Planning and Post-Abortion Care.) The greatest part of SAFPAC’s effort concentrates on chronically crisis-affected settings, where women and their families may have the responsibilities of farming and keeping a home while simultaneously coping with chronic food insecurity, refugees populations, flood recovery or active conflict. .
- The Supporting Access to Family Planning and Post-Abortion Care in Emergencies (SAFPAC) initiative operates in crisis-affected areas of Chad, Democratic Republic of Congo, Pakistan and other emergency settings to provide family planning services. In Pakistan, 4.8 million people have been affected by monsoon floods in Punjab and Sindh. We serve communities in Punjab where most services and transportation routes had been destroyed and much economic activity including farming had been severely disrupted by flooding when the project began in 2011. The area has continued to be affected by smaller floods and periodic insecurity largelyl from banditry.In the south of Chad, 58,000 refugees have fled conflict in neighboring Central African Republic. We serve two refugee camps as well as the surrounding host communities and referral facilities. In addition, southern Chad experiences chronic moderate food insecurity.In the Democratic Republic of Congo, in North and South Kivu alone, 1.4 million people have been affected by the resurgence of conflict. CARE works in Maniema and North Kivu, both of which continue to experience significant conflict. The CARE office in Goma has been evacuated once during the project and the project areas have experience significant displacements related to conflict,In a 2011 report by Women’s Refugee Comission, CPR was generally lower among displaced populations than the background rate in the host country, although that’s less true in settings, like our, where background CPR is extremely low. Thus it is important to address needs of surrounding communities where possible.Without access to family planning and a crude birth rate of 50/1000; 5,000 women per year would be pregnant in a pop. of 100,000; Dadaab refugee camp is nearing 500,000 people. In 2011, 62 m/ In 2012, 61 m people were in need of humanitarian assistancehttp://www.globalhumanitarianassistance.org/wp-content/uploads/2012/07/GHA_Report_2012-Websingle.pdf
- Staff safety – kidnapping, evacuationPopulation movements – floods, conflict, famineWhile the more general problem of under-resourced governments is common in many LMIC settings, a situation with significant disruption to government structures lacks accountability mechanisms available in poor but stable settings.In major, complex emergencies, at least during the acute phase, the population affected is clearly defined. In chronic crisis settings, the lines become blurred. (Populations displaced and returning multiple times in DRC/Rwanda and in Chad, access to clinics is probably better inside camps because of geographical proximity, for example.
- Many issues are really the same issues we always face but exacerbated.The biggest challenge, most impacted by crisis and most similar to stable settings, is working with the government. Same need and imperative to work within the system, yet the system itself is overburdened even moreStock outs and limited choice of method is a common issue for crisis affected areas, just getting previously under-utilized methods (IUDs and implants) in country, and covering the last mile reliably. This can affect stable settings, but becomes even more acute when transport is disrupted. Lack of trained providers, while a common problem, also becomes more acute in this setting, as trained providers may be more likely to have the resources to leave the affected area. Our turnover in Pakistan is nearly non-existent, while in Chad and DRC it is approximately 20%. Highly visible health problems may be nmore likely to affect crisis-affected countries; i.e., polio. Can provide an opportunity, though.The religious leaders in refugee camps in Chad, the seyanibethak councils in pakistan , relaiscommaunitaires and PDQ/SAA
- Our comprehensive model uses SRHR as a guiding principle throughout the continuum from emergency through transition into development and EPP/DRR.The key activities in this presentation focus on the third box, the transition/fragile/chronic setting, although others within SAFPAC also address the first twoStrengthening provider skills in FP and PAC. (PAC is an integral component of a comprehensive approach to SRH-E largely because maternal mortality related to unsafe abortion may be higher when women have even more barriers to accessing FP.)Procurement of FP commodities and post-abortion care supplies and equipmentTraining of providers with follow-up supportive supervisionCommunity engagementMaximum integration whatever local health infrastructure existsCARE works within the existing structure, providing training and additional supervision to MOH doctors, nurses and midwives, wherever possible. CARE staff serve as clinical supervisors, overseeing quality improvement and provider motivation and attitude, as well as behavior change communication officers, facilitating community engagement and participatory governance activities. CARE provides training in contraceptive technology and FP counseling and conducts follow-up skill s assessment and supportive supervision. In addition our M&E officers provide support in enhancing data quality and utilizing data for program improvement.Initially, CARE conducted procurement of FP commodities and general supplies and equipment as well as anatomical models for training and continuing skills building. Now CARE continues that where needed and has begun to engage in participatory governance and logistics training to enhance gov’ts ability to procure and distribute FP commodities and other basic supplies.Training in contraceptive technology including long-acting reversible contraception (implants and IUDs); post-abortion care including manual vacuum aspiration; Pop council’s balanced counseling strategy plus We translated BCS+ to French and it’s available at our wiki. External experts conducted initial trainings in clinical skills, and as the project matures it continues to develop training capacity so that now some of out contraceptive technology and counseling trainings are conducted by in-country clinical trainers. Our community engagement approach reflects CARE’s commitment to rights-based empowerment rather than passive health education; we bring communities and facility teams together through Partner Defined Quality-style participatory governance and use CARE’s Social Action and Analysis approach to open community dialogue about social norms underlying reproductive health.Significant adaptation is required in each country to achieve some level of integration with government services. Chad has been characterized by a generally receptive but overtaxed government system, Pakistan by the complexity of a system partially but not completely decentralized and underfunded, DRC by a non-functional state coping with active conflict which does not consistently provide salaries, supplies, or transport. SAFPAC’s level and kind of integration with the government system has varied accordingly.(Extra thoughts on work with governments - In Chad, to some extent an overextended health system but relative governmental stability has led to a fairly high level of integration; for example, SAFPAC has worked with the MOH to designate the gov’t hospital and national MCH hospital as training centers for FP/PAC, and district level supervisors regularly attend quarterly reviews in both districts. DRC faces the challenge of ongoing armed conflict as well as many different non-governmental actors, but data systems are fully integrated and CARE in partnership with other INGOs partners in this broader initiative has been in negotiation with the Gov’t regarding data systems and SRH policy issues. SAFPAC-Pakistan illustrates the complexities of the Pakistani context well. SAFPAC started working with a local partner with considerable experience and success running its own private low-cost, sliding-scale clinics; due to both the donors request and CIP’s commitment to strengthen local government as the duty bearer SAFPAC is now developing an approach to working directly with the MOH. The strong indigenous non-governmental community combined with a gov’t system still re-aligning after decentralization and with FP specifically in limbo creates a sensitive environment.)
- Easy and less- time consuming for providers to use, but based on woman’s reproductive goals. Reduces provider bias by making it easy to present facts and clear guidelines on eligibility
- We observed an immediate increase in uptake. As soon as implant were available in Chad and DRC, clients wanted them. We feared that the initial spike in demand would plateau or even diminish after the pent-up demand was met, but we have seen sustained demand in all three countries. This may be due in part to community engagement, but may also be due to the extremely high level of unmet need at the beginning of the project.Our cumulative total new users in the three core countries as of Jun 2013 was 39586 over a 25 month period, for a monthly average of 1583. The monthly figure represents an increase from 203 in Jun 201 to 1662 in June 2013, with a steep uptick in November/December 2011 as our trained providers began practice in their clinics. There is a huge unmet need in many fragile states as demonstrated by the huge surge in both Chad and DRC, and the steady rise even in Paksitan with a much higher background CPR.These figures cover users of modern methods who have not used that method at that clinic in the previous six months. These exclude condom users because of the difficulty of accounting for double method couples due to HIV prevention.
- A project focus is to increase women’s access to LARC. Decreasing barriers to IUDs has been a particular challenge, due to both misinformation and rumors and provider bias. This graph represents the percentage of monthly new users choosing IUDs out of total method mix. (Note that the very early apparent bump in IUD use in Chad is an artifact of extremely low usage. IUDs were available in the country before SAFPAC and constituted 4 – 8 clients out of 20 to 40 new users before SAFPAC providers started work.) Green is DRC, Grey chad and Blue Pak, but similar patternStarting at the beginning of SAFPAC providers’ activity in Nov 2011, you’ll notice month to month fluctuation around a general overall pattern. This trend suggests two observations . 1) Consistent with the academic literature, this seems to suggest that some provider bias is artificially depressing IUD utilization. The acceptability of LARCs was clearly high, judging by the huge uptake of implants as soon as they were available. If the demand was there, something must have stood in the way of utilization of IUDs.* 2) The SAFPAC model may be having some impact on supporting providers in providing unbiased information to clients and supporting them in their choice. In particular, the use of BCS Plus may have contributed to this as it was introduced around the time Chad and DRC began to see some real growth in the popularity of IUDs (the last half of 2012).(Note: community engagement and training both included IUDs and probably had some part in the increase in IUD uptake, so the increases in IUD utilization are due in part to these as well as BCS+ and reduction of provider bias.)
- Build training capacity. Must include direct observation of clinical skills and address retraining to account for turnover.Now that the program has matured, we have capacity to build more sophisticated QI into the program. We will support team-based quality improvement based on data-driven supportive supervision - extremely difficult but essential for quality assurance and staff motivation and retention. Specifically we plan to assess % clients satisfied with their FP services and % women at clinic for other reasons currently using contraceptives as indicators. Must include data quality review and regular feedback from supervisor based on actual program resultsCommunity engagement has a place even in the most disrupted circumstances. The religious leaders in refugee camps in Chad, the seyanibethak councils in pakistan, the participatory governance work in DRC may seem incongruous but have been cited from clients to our academic partner (Columbia University) as well done and an important aspect our success in meeting women’s FP needs. They are a key ingredient to facilitating women’s cultural and social access to FP.