The Global Health Cluster established a strategic partnership in January 2018 with the Ministry of Foreign Affairs of the Netherlands to deliver integrated Sexual and Reproductive Health (SRH) services to vulnerable groups in humanitarian crises in three countries: the Democratic Republic of the Congo (Kasaï), Bangladesh (Cox’s Bazar) and Yemen. These countries were selected due to current challenges in SRH service availability for the vast number of refugees and internally displaced people (IDPs) that they are hosting. As a first step to the partnership, the Global Health Cluster is working with local research organizations to conduct a situation analysis, which will gather information on the expressed needs of the target populations in order to design evidence-informed interventions.
Bangladesh
The situation analysis in Cox’s Bazar was conducted in 10 randomly selected Rohingya refugee camps in Ukhiya and Tekhnaf upazila of Cox’s Bazar district starting in July 2018. The primary objectives were to understand the demand- and supply-side challenges to seeking and providing SRH services and to capture the expressed needs of adolescent girls and women aged 12-59 in Rohingya refugee camps. To this end, a mixed-methods study design that combined a community-based survey with qualitative methods of in-depth interviews, key informant interviews and focus group discussions, and facility assessments was conducted. This situation assessment covered a broad ranged of SRH issues from: Topics of discussion included menstrual health and hygiene, antenatal care (ANC), delivery care, postnatal care (PNC), family planning, menstrual regulation or safe abortion care and SRH needs of Rohingya adolescent boys and men.
Based on the findings, the primary recommendations for improving demand for SRH services were centred around increased risk communication and community engagement (RCCE) work to reduce stigma, distrust and shift behaviours away from cultural practices with negative health outcomes. For example, community-based strategies to involve husbands and other male family heads of households are critical to addressing the barriers to women in accessing family planning and safe abortion care services that they seek. For example, some health facilities require consent from parents or husbands to seek SRH services, which can pose a significant barrier if that was the only health care facility accessible by foot (the primary transportation method identified). Many women also noted that they were unaware of the SRH services available to them at their local health facility and were unaware that services were free of cost. There was also a greater use of informal care for labor and delivery services – providers such as Burmese doctors, Trained Birth Attendants (TBAs), spiritual healers and local herbalists – rather than care at a health facility. The reported stillbirths and neonatal deaths from study participants indicates that these informal providers may be ill equipped to deal with any resulting complications.
On the supply side, both health facility staff and members of the Rohingya community noted that the current number and spread of health facilities providing SRH services was insufficient to meet demand. More remote parts of the camps faced difficulties in accessing a health facility that provided SRH services, and those that did, sometimes did not have access to the full range of services needed. There were an insufficient numbers of fully functional 24/7 health centers to provide emergency obstetric and newborn care. This has lead to a substantial delay in managing mothers and infants with critical complications. Another critical gap identified is that only 5 (17%) of the 29 health facilities analyzed have a dedicated room for visual inspection with Acid test (VIA) for Post Abortion Care (PAC) in their facilities, only 8% of facilities had the capacity to manage eclampsia cases and only 38% were equipped to manage cases with postpartum hemorrhage.
The study identifies, moreover, several opportunities to leverage on existing community assets. First, the migration of Burmese doctors, trained birth attendants, traditional healers (Boiddyo) and herbalists (Kabiraz) from Myanmar to the camps and the existing high levels of trust placed in these figures can be an opportunity to enhance community-level referrals following adequate and periodic training. The collaboration with and training of these community leaders could enhance trust in health facilities and increase the demand for SRH services in a health facility. Some organizations reported using trained birth attendants (TBAs) as community volunteers to bridge the gap between the health facilities and the communities. This assessment recommends recruiting local Rohingya TBAs or other Rohingya women who can also speak Bangla as interpreters to ensure culturally sensitive translation services are available to enhance trust of and increase referrals to formal health care providers.
As a result of this research, the Bangladesh Health Sector is swiftly addressing some of the primary concerns raised by stakeholders. Although some planned activities had to be postponed and reimagined to ensure proper infection prevention and control measures could be put in place given the COVID-19 context, significant progress has been made. The Bangladesh Health Sector has focused first on the agreement of Standard Operating Procedures (SOPs) with the Ministry of Health and Family Welfare (MOHFW) on SRH practices and has printed 1 900 copies of the guidelines to ensure each health facility involved in the project has access to the standards for quality care. Essential medicines and reproductive health (IARH) kits are being distributed across the health facilities in Cox’s Bazar by Health Sector partners. RH kits can serve the reproductive health needs of up to 150 000 people for 3 months, and so partners have supported in strategically pre-positioning these kits around the camps in case of entry point closures. Lastly, the Bangladesh Health Sector is drafting plans to transition a Severe Acute Respiratory Infection Isolation and Treatment Centre (SARI ITC) to a 24/7 maternity facility after COVID-19 is contained to address gaps in available services.
The Bangladesh Health Sector also conducted trainings in small batches, in line with social distancing recommendations, and online, reaching a total of 90 program managers at primary health centres or field hospitals, 109 clinicians, 89 community health-care worker supervisors, 68 home-based care providers and 38 midwives. Trainings primarily used the training-of-trainers (ToT) approach and covered topics such as treatment of birth complications, antenatal, delivery and postpartum emergency services in the COVID-19 context and home-based care for sexual and reproductive health services.
The Democratic Republic of the Congo
A similar situation analysis was conducted in the Democratic Republic of the Congo (DRC) in three provinces (Kasaï, Kasaï Central and Kasaï Oriental). A mixed-methods study design that combined a community-based survey with qualitative methods of in-depth interviews, key informant interviews and focus group discussions, and facility assessments was conducted. This situation assessment also aimed to understand the demand- and supply-side challenges to seeking and providing SRH services and to capture the expressed needs of displaced adolescent girls and women aged 12-59 in the Kasaï region. The assessment also covered a broad range of SRH issues from: menstrual health and hygiene, antenatal care (ANC), delivery care, postnatal care (PNC), family planning, menstrual regulation or safe abortion care and SRH needs of Rohingya adolescent boys and men. The vast majority of respondents from all types of stakeholder groups agreed that the primary SRH concerns affecting adolescent girls and women included: unintended pregnancies, low utilization of family planning methods and unsafe abortion. Another perceived SRH concern was complications during delivery, as indicated by 85% of displaced women with recent pregnancies who reported experiencing one or more complications during delivery. The most common SRH concern indicated by adolescent boys and men were sexually transmitted infections and HIV.
Of all female respondents, only 10% were using a family planning method, despite the fact that 51% of the girls and women’s samples reporting to have heard of at least one family planning method. Condom use (39%) and birth control pills (29%) were the most commonly known as well as used methods. The primary source of knowledge on family planning options for adolescent girls came from neighbors (30%) and teachers (27%), whereas adult women were more likely to receive this information from health care professionals (60%). While the majority of health facilities do offer contraceptives (condoms, injectables, and birth control pills), the primary barrier limiting the use of family planning among women was associated with the lack of perceived need to access SRH services (42%), lack of the actual knowledge of the SRH services offered (19%) and financial concerns (10%). There was and overarching consensus among the different target population of this situation analysis that the main barriers to accessing SRH services can be mitigated by greater community engagement and awareness-raising activities regarding available services.
Another important area identified in need for improvement was training and support to health care facilities for supporting survivors of gender-based violence (GBV) as well as the management of the consequences of sexual violence. Only 27% of health centers surveyed were adequately equipped to provide post-rape care, 19% had standard operating procedures for clinical management of rape and just under 10% had a dedicated / post-abortion care room, as per the Maputo protocol on women’s rights that recommends access to abortion in the case of rape. Training on SRH more generally is recommended by respondents of the study, as only 25% of staff analyzed had received training on SRH topics over last 24 months.
To meet the immediate training needs, the DRC Health Cluster and partner Première Urgence Internationale (PUI) led a series of gender-based violence (GBV) sub-cluster meetings to review the findings and identify urgent training needs. In observation of the COVID-19 social distancing recommendations, small group trainings have begun in all three targeted provinces. To date 84 doctors, nurses and midwives were trained on safe practices for providing reproductive health in the COVID-19 context, family planning with an emphasis on long-acting methods, gender-based violence with an emphasis on frontline support for victims of intimate partner violence. Each small group was trained over the course of five days. Finally, the DRC Health Cluster has distributed a total of 400 interagency reproductive health kits to the targeted health facilities.
Training of doctors, nurses and midwives in Kasaï Oriental, DRC
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