Stephen Tomlin, Vice President of Program Policy & Planning, International Medical Corps March 6, 2007

1. Bixby Program in Population & Reproductive Health, March 2007
Stephen Tomlin, VP Program Policy & Planning, International Medical Corps
stomlin@imcworldwide.org www.imcworldwide.org
The Challenge ofThe Challenge of
Reproductive Health in Complex EmergenciesReproductive Health in Complex Emergencies

2. COMPLEXCOMPLEX
EMERGENCIES:EMERGENCIES:
1985:1985: 55
1992:1992: 1717
1999:1999: 3434
2006:2006: 3838

3. COMPLEX HUMANITARIANCOMPLEX HUMANITARIAN
EMERGENCIESEMERGENCIES
• Civil conflictCivil conflict
• Weak or non-existentWeak or non-existent
central governmentcentral government
• Mass populationMass population
movementsmovements
• Massive economicMassive economic
dislocationdislocation
• Food insecurity leadingFood insecurity leading
to famineto famine

4. Complex Emergency SettingsComplex Emergency Settings
• People in need ofPeople in need of
humanitarian assistance:humanitarian assistance:
– 1989: 36 million1989: 36 million
– 1996: 50 million1996: 50 million
– 2004: 39 million2004: 39 million
• Many more IDPs:Many more IDPs:
– 25 m. IDPs / 49 countries25 m. IDPs / 49 countries
– 14 m. Refugees14 m. Refugees

5. Since 1984…Since 1984…
…providing health care through
training / developing local capacity
…supporting health care
delivery through logistic
management systems

6. IMC Relief, Recovery,IMC Relief, Recovery,
& Development Programs - 2007& Development Programs - 2007
• AfghanistanAfghanistan
• AzerbaijanAzerbaijan
• BurundiBurundi
• ChadChad
• DR CongoDR Congo
• EritreaEritrea
• EthiopiaEthiopia
• IndonesiaIndonesia
• Ingushetia/ChechnyaIngushetia/Chechnya
• IraqIraq
• KenyaKenya
• LiberiaLiberia
• PakistanPakistan
• Sierra LeoneSierra Leone
• SomaliaSomalia
• northern Sudan (Darfur)northern Sudan (Darfur)
• southern Sudansouthern Sudan
• Sri LankaSri Lanka
• UgandaUganda
• USA (Louisiana)USA (Louisiana)

7. Humanitarian Space ShrinkingHumanitarian Space Shrinking
View from IMC driver’s seat, Darfur, Feb 28 ‘07View from IMC driver’s seat, Darfur, Feb 28 ‘07

8. Humanitarian Space is ShrinkingHumanitarian Space is Shrinking
1997-20051997-2005
• Over 9 year period:Over 9 year period:
major acts of violencemajor acts of violence
against aid workers doubledagainst aid workers doubled
annuallyannually
• 408 acts of major violence408 acts of major violence
947 victims947 victims
434 fatalities434 fatalities
• Today, most victimsToday, most victims
deliberately targeted, w/deliberately targeted, w/
political targeting on the rise.political targeting on the rise.
2006:2006:
83 aid workers killed83 aid workers killed
78 aid workers wounded78 aid workers wounded
52 aid workers kidnapped52 aid workers kidnapped
• #1. Afghanistan (26 killed)#1. Afghanistan (26 killed)
#2. Sri Lanka (23 killed)#2. Sri Lanka (23 killed)
#3. Sudan (15 killed)#3. Sudan (15 killed)
• Sudan accounted for 40% ofSudan accounted for 40% of
incidentsincidents

9. Approach to Security ManagementApproach to Security Management
The Evolving Security EnvironmentThe Evolving Security Environment
-- Greater exposure, new threats, diminishing respect for IHLGreater exposure, new threats, diminishing respect for IHL
The Acceptance StrategyThe Acceptance Strategy
- E- Establishing, and then fiercely defending, relationships withstablishing, and then fiercely defending, relationships with
local actorslocal actors
- Built on trust, transparency, and predictability…as- Built on trust, transparency, and predictability…as
perceived by localsperceived by locals
- Protection and Deterrence strategies also employed, but- Protection and Deterrence strategies also employed, but
secondarysecondary
- At IMC, underpinned by strong security management policy and- At IMC, underpinned by strong security management policy and
proceduresprocedures
ArmsArms
-- Humanitarians do not themselves carry weaponsHumanitarians do not themselves carry weapons
- With some noteworthy exceptions, they do not employ or- With some noteworthy exceptions, they do not employ or
accept armed protection in the course of their workaccept armed protection in the course of their work

10. Levels of Activity
(community-based/grassroots)
Ministry of Health
Tertiary referral
hospital
Provincial Hosp
District Hosp
Health Center
Community Health Workers
Health Post
Charitable
hospitals
Charitable
hospitals
clinics
Charitable
hospitals
clinics
clinics
For profit
hospitals
doctorsdoctors
doctors
doctors
doctors
Primary
Health Care doctors

11. Community-based Relief & RecoveryCommunity-based Relief & Recovery
HealthHealth
• Under-5 Child HealthUnder-5 Child Health
• Reproductive HealthReproductive Health
• Immunization (EPI)Immunization (EPI)
• NutritionNutrition
• Mental HealthMental Health
Recovery &Recovery &
DevelopmentDevelopment
• MobilizationMobilization
• PsychosocialPsychosocial
• Water & SanitationWater & Sanitation
• LivelihoodsLivelihoods
• Micro-financeMicro-finance
SUSTAINABLE WELL-BEING
TRAINING

12. Uganda: Therapeutic & Supplementary Feeding Programs

13. What is Reproductive Health?What is Reproductive Health?
• RH is a state of complete physical, mental andRH is a state of complete physical, mental and
social well-being, and not merely the absence ofsocial well-being, and not merely the absence of
disease or infirmity, in all matters relating to thedisease or infirmity, in all matters relating to the
reproductive system and its functions andreproductive system and its functions and
processes.processes.
• RH implies that people are able to have aRH implies that people are able to have a
satisfying and safe sex life and that they havesatisfying and safe sex life and that they have
capability to reproduce and the freedom tocapability to reproduce and the freedom to
decide, if, when and how often to do so.decide, if, when and how often to do so.
1

14. RH Rights Include:RH Rights Include:
• The right to health in generalThe right to health in general
• The right to reproductive choiceThe right to reproductive choice
• The right to RH servicesThe right to RH services
• The right of men and women to marryThe right of men and women to marry
and found a familyand found a family
• The right of the family to have specialThe right of the family to have special
protectionprotection
• Special right in relation to motherhoodSpecial right in relation to motherhood
and childhoodand childhood

15. Cycle of Reproductive Ill-HealthCycle of Reproductive Ill-Health
Source: WHO. Reproductive Health during Conflict and Displacement: A Guide for Program Managers. Geneva: World Health
Organization, Department of Reproductive Health and Research, 2000. 5

16. Life Span Profile of Discrimination Against WomenLife Span Profile of Discrimination Against Women
Source: WHO. Reproductive Health during Conflict and Displacement: A Guide for Program Managers. Geneva: World Health
Organization, Department of Reproductive Health and Research, 2000. 7

17. Key Components of RH ProgramKey Components of RH Program
• Gender-based violenceGender-based violence
prevention and responseprevention and response
• Safe motherhoodSafe motherhood
• STIs, including HIV/AIDSSTIs, including HIV/AIDS
• Family planningFamily planning
1
IMC MCH Clinic, Liberia

18. New Orleans

19. Iraq – Vulnerable Populations

20. IDPs
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
2/2/06 3/24/06 5/13/06 7/2/06 8/21/06 10/10/06 11/29/06 1/18/07 3/9/07
Date
DisplacedFamilies
IMC
MoDM
IOM inc. KRG
IOM
UNHCR
Displacement Trends, IraqDisplacement Trends, Iraq

21. Gender-based ViolenceGender-based Violence
• Sexual violenceSexual violence
– Rape, attempted rapeRape, attempted rape
– Sexual coercionSexual coercion
– Sexual harassmentSexual harassment
• Physical violencePhysical violence
– Domestic violence,Domestic violence,
spouse beatingspouse beating
– AssaultAssault
• Emotional,Emotional,
psychological and socialpsychological and social
abuseabuse
– HumiliationHumiliation
• Harmful traditionalHarmful traditional
practicespractices
– Female genital cuttingFemale genital cutting
(FGC)(FGC)
– Early, forced marriageEarly, forced marriage

22. Factors Contributing to GBVFactors Contributing to GBV
• Lack of police protection and lawlessnessLack of police protection and lawlessness
• Coercion around food and other ration distributionsCoercion around food and other ration distributions
• Insecure living quarters; distance women have toInsecure living quarters; distance women have to
travel to collect firewood, to latrines, etc.travel to collect firewood, to latrines, etc.
• Political motivationPolitical motivation
• Collapse of traditional family and societal supportCollapse of traditional family and societal support
• Strains of life when displaced from homeStrains of life when displaced from home
6

23. GBV Prevention and Response (1)GBV Prevention and Response (1)
• PreventionPrevention
– Involve refugee womenInvolve refugee women
– Public informationPublic information
– Camp design, locationCamp design, location
– Food and other distributionsFood and other distributions
• ProtectionProtection
– Ensure physical safetyEnsure physical safety
• PsychosocialPsychosocial
– CounselingCounseling
– Support groupsSupport groups
– Community education toCommunity education to
decrease stigmadecrease stigma
– Justice/legal supportJustice/legal support
• Policy/managementPolicy/management
– Train and monitor authoritiesTrain and monitor authorities
and staff to reduce sexualand staff to reduce sexual
extortionextortion
– Ensure proper documentationEnsure proper documentation
for womenfor women
– Increase women protectionIncrease women protection
officersofficers
– Increase visibility of problemIncrease visibility of problem
and seriousness of responseand seriousness of response
– Document cases, care andDocument cases, care and
other responsesother responses
• LegalLegal
7

24. • MedicalMedical
– Trauma careTrauma care
– EmergencyEmergency
contraceptioncontraception
– Pregnancy testingPregnancy testing
– Voluntary testing forVoluntary testing for
HIVHIV
– Voluntary testing andVoluntary testing and
treatment for STIstreatment for STIs
– Awareness andAwareness and
sensitivity of staffsensitivity of staff
– ConfidentialityConfidentiality
– Referral for legal, socialReferral for legal, social
and other servicesand other services
GBV Prevention and Response (2)GBV Prevention and Response (2)
International Women’s Day, Refugee Camp, Chad

25. Uncomplicated pregnancy,
delivery, postpartum period
Complication
Severe
Complication
Life Threatening
Complication
Well
Recovered
short and long-term morbidity
possible
Death
Maternal Morbidity and Mortality
Survived
near miss

26. Complications are UnpredictableComplications are Unpredictable
• At least 15% of pregnantAt least 15% of pregnant
women in any population arewomen in any population are
expected to have life-expected to have life-
threatening complications.threatening complications.
• Cannot predict or preventCannot predict or prevent
complications: any deliverycomplications: any delivery
can become complicated andcan become complicated and
require emergency interventionrequire emergency intervention
• Best practice:Best practice: reduce delaysreduce delays
through training in recognitionthrough training in recognition
danger signs and referral todanger signs and referral to
health facilityhealth facility
IMC Trained Midwife, Darfur

27. Perinatal DeathsPerinatal Deaths
• 28 weeks gestation28 weeks gestation
through 7 days afterthrough 7 days after
birthbirth
• 7.6 million perinatal7.6 million perinatal
deaths/yeardeaths/year
4.3 million stillbirths;4.3 million stillbirths;
3.3 early neonatal3.3 early neonatal
deathsdeaths
• Leading causes ofLeading causes of
Perinatal DeathPerinatal Death
– SyphilisSyphilis
– Infection (sepsis)Infection (sepsis)
– AsphyxiaAsphyxia
– TraumaTrauma
– Neonatal tetanusNeonatal tetanus
– Complications of pretermComplications of preterm
deliverydelivery

28. Key Strategies for Preventing MaternalKey Strategies for Preventing Maternal
and Perinatal Deathsand Perinatal Deaths
• Prevent unwantedPrevent unwanted
pregnancies through familypregnancies through family
planningplanning
• Early recognition ofEarly recognition of
complications, with referralcomplications, with referral
• Access to skilledAccess to skilled
attendants and emergencyattendants and emergency
obstetric careobstetric care
• Management of post-Management of post-
abortion complicationsabortion complications
• Breastfeeding supportBreastfeeding support
• Essential newborn careEssential newborn care
Rabia Balki Hospital for Women, Kabul

29. Antenatal careAntenatal care
• Health assessmentHealth assessment
• Detection and management ofDetection and management of
complicationscomplications
• Maintenance of maternal nutritionMaintenance of maternal nutrition
• Health educationHealth education
• Health promotion interventionsHealth promotion interventions
such as tetanus toxoid (TT)such as tetanus toxoid (TT)
vaccinations, folic acid and ferrousvaccinations, folic acid and ferrous
sulfate supplements, malariasulfate supplements, malaria
prophylaxis or presumptiveprophylaxis or presumptive
treatment, and testing for syphilis,treatment, and testing for syphilis,
depending on the contextdepending on the context
TBA Training, Pakistan

30. Training TBAs in Darfur

31. Intrapartum/Delivery CareIntrapartum/Delivery Care
• 100% of women who100% of women who
develop a complicationdevelop a complication
should be treated by ashould be treated by a
skilled attendant in anskilled attendant in an
emergency obstetric careemergency obstetric care
facilityfacility
• Basic emergency obstetricBasic emergency obstetric
care (equipped healthcare (equipped health
center)center)
• Comprehensive emergencyComprehensive emergency
obstetric care (referralobstetric care (referral
hospital)hospital)
• Transport for deliveriesTransport for deliveries
outside an equipped healthoutside an equipped health
facilityfacility
• Support for breastfeedingSupport for breastfeeding Sudanese mother, Chad

32. Rabia Balki Hospital for Women, Kabul

33. Chad

34. Postpartum CarePostpartum Care
• Monitor for danger signsMonitor for danger signs
and referand refer
• Postpartum visitPostpartum visit
• EducationEducation
• Newborn weighing andNewborn weighing and
referralreferral
• Support for breastfeedingSupport for breastfeeding
• Promoting health ofPromoting health of
newborn, including thermalnewborn, including thermal
protection, eye care, cordprotection, eye care, cord
care, vaccinationscare, vaccinations
• Postpartum family planningPostpartum family planning

35. Sexually Transmitted Infections (STIs)Sexually Transmitted Infections (STIs)
• TrichomoniasisTrichomoniasis
• HIVHIV
• ChancroidChancroid
• Hepatitis BHepatitis B
• Genital WartsGenital Warts
• HerpesHerpes
• SyphilisSyphilis
• GonorrheaGonorrhea
• ChlamydiaChlamydia
Elders meeting, NWFP, Pakistan
In women between 15 and 44 years of age,
the morbidity and mortality associated with
STIs, not including HIV, are second only to
maternal causes.

36. Regional HIV / AIDSRegional HIV / AIDS
• WorldwideWorldwide
– 17.7 million17.7 million
– 48% Women48% Women
• Sub-SaharaSub-Sahara
AfricaAfrica
– 13.3 million13.3 million
– 59 % Women59 % Women
• South & SouthSouth & South
East AsiaEast Asia
– 2.2 million2.2 million
– 29% Women29% Women
• CaribbeanCaribbean
– 120,000120,000
– 50% Women50% Women Community Mobilizers, Kibera slum, Nairobi

37. Kibera slum, population 800,000

39. Family PlanningFamily Planning
• Saves women’s livesSaves women’s lives
– Avoids unsafe abortionAvoids unsafe abortion
– Limits exposure to the health risks ofLimits exposure to the health risks of
pregnancy and childbirthpregnancy and childbirth
– Limits births to the healthiest agesLimits births to the healthiest ages
– Limits the number of birthsLimits the number of births
• Saves children’s livesSaves children’s lives
• Offers women more choicesOffers women more choices
• Encourages adoption of safer sexualEncourages adoption of safer sexual
behaviorbehavior
Effective Programs:
Coordinated
Robust logistic systems
Extensive training & education
Discrete

40. Gender InequalityGender Inequality
Women’s autonomy andWomen’s autonomy and
decision-makingdecision-making
authority areauthority are
traqditionally limitedtraqditionally limited
45

41. Livelihoods & Micro-Finance
Micro-Finance

42. IMC Training Highly ValuedIMC Training Highly Valued