1. Reproductive Health of Refugees Progress and Challenges Henia Dakkak, MD, MPH International Medical Corps Director of International Relief and Development Programs UCLA – School of Public Health Nov.6 -2003

2. Issues to be covered: Definition of refugees Definition of conflict International Conference on Population and Development (Cairo 1994) Progress (Pre – ICPD and Post ICPD) Challenges

3. Definition of Terms Terms “ Refugee” and “internally displaced person” have wide implications for people concerned regarding (Rights to Protection and Assistance) Refugees have crossed International Border Internally displaced persons have not crossed the border of their own country

5. United Nations High Commissioner for Refugees (UNHCR) was created in 1950 by UN General Assembly resolution Convention on the status of Refugees was drawn up in 1951 and is ratified by at least 120 countries

6. UNHCR Mandate Encourage countries to receive refugees Prevent refugees from being forcibly returned Provide assistance Provide protection Seek lasting solutions to the core problem

7. Statistics Global refugee population is estimated to be 11-12 million “Internally Displaced Persons" (IDPs) are today estimated to number over 50 million worldwide (of which 25-30 million have lost their homes due to conflict)

8. Refugees are Women and Children 75% of most displaced people are women and children 25% are women of reproductive age (WRA) 20% of WRA are pregnant About 30% of refugees are adolescents

9. Phases of Conflict according to Aid workers Four Phases from the point of view of giving assistance to the displaced Pre-conflict (deterioration of economic and social circumstance, civil disturbance Conflict – (Relative stability, Intense fighting, Flight, emergency phase) Stabilization Post conflict (return – spontaneously or part of resettlement, reconstruction)

10. Emergency Assistance in Large Scale Population Movement Priority is to meet/provide the most basic human needs Food Shelter Safe clean water Sanitation Medical Care

11. Refugees waiting to be resettled in shelters and camps in Albania

12. Bench Marks highlighting Reproductive Health among War Affected populations Cairo 1994 - International Conference on Population and Development Beijing 1995 Fourth World Conference on Women Study published in 1994 – New York by WCRWC “Refugee Women and Reproductive Health Care: Reassessing Priorities”

13. Why Address RH in Refugee Situations? RH is a human right Significant cause of morbidity and mortality Part of the protection mandate

14. Safe Motherhood 15% of pregnant refugee women will experience complications of pregnancy or delivery that will require emergency obstetric care In a study conducted among Burundian refugees in Tanzania found that neonatal and maternal deaths accounted for 16% of all deaths

15. Causes of Increased HIV risk in Complex Emergencies Mass population displacement Disruption of societal structures and norms Disruption of family units Disruption of sexual networks Sexual interaction with military Economic vulnerability of women and UAC Commercial sex work Sexual violence/coercive sex Psychological trauma Disruption of preventive and curative services Unsafe transfusion practice Increase intravenous and other drug use High prevalence of STIs

16. Factors Affecting Epidemic HIV Transmission in Emergencies Epidemic maturity in host and refugee population HIV seroprevalence rates in host and refugee population Prevalence/type of STIs Level and type of sexual interaction Context specific factors Level and quality of health services

17. Follow-Up from ICPD Cairo Meeting Inter-Agency Working Group on Refugee Reproductive Health (IAWG) was formed: UN agencies (UNHCR, WHO, UNICEF and UNFPA) NGOs Governments

18. IAWG role Production of manual specific to refugee setting that served as a basic guide to reproductive health services. Setting-up standards and policies Minimum Initial Service Package (MISP) Annual meetings to discuss progress and identify areas of needs

19. Minimum Initial Service Package The MISP is a minimum set of priority interventions (reproductive health activities) to be put in place and implemented at the onset of humanitarian emergency. The aim of the MISP is to reduce short and long term reproductive health related morbidity and mortality

20. Reproductive Health Care services that need to be in place: Safe Motherhood including Emergency Obstetrical Care (EmOC) Family planning or Child Spacing Sexual Transmitted Infections including HIV/AIDS Sexual and Gender Based Violence Cross cutting issues: Adolescent reproductive health needs, FGC, PAC

21. UNFPA - Reproductive Health Kits (commodities) to address the emergency phase UNFPA based on IWGA recommendation created the Reproductive health kits 12 kinds of Kits designed to address different aspects of Reproductive Health Clean delivery kits for pregnant women Kits for treatment of STIs Kits for Family Planning

22. Block 1 – Six sub-kits to be used at community and PHC level for 10,000 persons /3 months Sub-Kit 0AdministrationOrange Sub-kit 1Condom sub-kit (part A+B)Red Sub-Kit 2Clean Delivery sub-kit (individual ) (Part A+B)Dark Blue Sub-Kit 3Post Rape sub-kitPink Sub-Kit 4Oral and Injectable Contraception sub-kit White Sub-Kit 5STI sub-kitTurquoise

23. Block 2 Five sub-kits to be used at PHC or referral hospital level for 30,000 persons /3 months Sub-kit 6Delivery sub-kit (Health facility) Brown Sub-kit 7IUD sub-kitBlack Sub-kit 8Management of complications of abortion sub-kitYellow Sub-kit 9Suture of Tears (cervical and vaginal) and vaginal examination sub-kitPurple Sub-kit 10Vacuum Extraction for Delivery (manual) sub-kitGrey

24. Block 3 Two Sub-Kits to be used at referral hospital level for 150,000 persons per 3 months Sub-kit 11Referral level sub-kit for Reproductive Health (Part A+B) Fluorescent green Sub-kit 12Blood Transfusion sub-kitDark green

25. Applied Research Conferences Two conferences were held for researchers to present their findings Dec. 2000 in Washington DC October 2003 in Brussels - Belgium

26. Challenges Adolescent Reproductive Health Programming among war affected populations Emergency Obstetric Care Logistics and commodities HIV/AIDS Sexual Exploitation and Gender Based Violence

27. Contact: www.imcworldwide.orgwww.imcworldwide.org Helpful websites: www.reliefweb.org www.unfpa.org www.rhrc.org www.unhcr.org www.idpproject.org www.globalhealth.org