Sexual and reproductive health is recognised as a global health, sustainable development and human rights priority.+M. Temmerman et al., ‘Sexual and Reproductive Health and Rights: A
Global Development, Health, and Human Rights Priority’, The Lancet,
348:9941, 2014 During a disaster, women and girls’ essential reproductive health needs, including access to contraception, are often forgotten, leaving them vulnerable to unplanned pregnancies and associated maternal morbidity and mortality through complications of pregnancy and unsafe abortion.
Food, water and shelter are often seen as the most important elements of humanitarian aid, but essential lifesaving sexual and reproductive health services are also a core component of any humanitarian response. Globally, one in four women experience an unmet need for modern contraceptives. In emergencies this figure increases as clinics are damaged and destroyed, health workers leave the area and populations become displaced. For women and marginalised groups,
emergencies are particularly dangerous. The basic protective structures normally in place around women – such as the family unit or family home – are disrupted, and police resources are
diverted to the disaster response. The cumulative effect is an increase in unintended pregnancies, maternal mortality and morbidity, sexually transmitted infections, HIV and sexual and gender-based violence.
In Vanuatu, as part of a localised emergency response, nurses and midwives offered contraceptive options to women and girls in remote areas affected by a catastrophic volcanic disaster. The number of women who accepted the contraceptive services and their stories demonstrate how making
contraceptives available during an emergency can empower women and transform lives, particularly in a context like Vanuatu, where the use of contraception is low and large families are the norm. A woman, on average, will have 4.2 children during her life.+The 2013 Vanuatu DHS (https://vnso.gov.vu/index.php/component/advlisting/?view=download&fileId=2967) Almost half of Vanuatu women (48%) have experienced non-partner physical or sexual violence or both since turning 15, substantially higher than the global average.+Global statistics on violence against women show that, on average, 35% have experienced physical and/or sexual violence by someone who is an intimate partner or sexual violence by someone who is not a partner. Stories from women in Vanuatu highlight the common practice of reproductive coercion, with male partners influencing and limiting women’s contraceptive choices.
The Mt Monaro eruption
Vanuatu comprises 80 islands in the South Pacific, with a population of around 280,000. Located on the Pacific Ring of Fire, it has nine active volcanos. It is also regularly affected by cyclones, earthquakes, tsunamis and floods, making it one of the most disaster-prone countries in the world.+The World Risk Index 2018 (https://reliefweb.int/sites/reliefweb.int/files/resources/WorldRiskReport-2018.pdf) Disasters pose a particular risk to women, with women and children 14 times more likely to die than men.+Gender and Disasters (www.undp.org/content/dam/undp/library/crisis%20prevention/disaster/7Disaster%20Risk%20Reduction%20-%20Gender.pdf)
On 26 September 2017, Mt Monaro Volcano on the Island of Ambae began to erupt, spewing ash, volcanic rocks and acid rain over the island. The government declared a state of emergency
and ordered an unprecedented evacuation of the entire population. Over 10,000 people were moved to surrounding islands, including around 2,500 women of reproductive age and pregnant women. Six weeks later the government ordered people to return to their homes, but the situation remained
unstable. Volcanic ash and acid rain had contaminated water sources, ruined crops and made large areas of the island uninhabitable. Residents also returned to reduced health services as many health workers had elected not to go back. Meanwhile, the volcano remained extremely active and volatile.
The entire population faced an uncertain future.
The VFHA response
The Vanuatu Family Health Association (VFHA), an International Planned Parenthood Federation (IPPF) Member Association and a key provider of sexual and reproductive health and rights (SRHR) services in Vanuatu in stable times, responded to the call for assistance from the government.
With funding from the Australian government, VFHA launched a Minimum Initial Service Package (MISP)[footnote]The MISP is a series of essential lifesaving reproductive health services to
be delivered at the onset of an emergency response (http://iawg.net/areasof-focus/misp/) response that prioritised the provision of SRHR, including contraception.
VFHA worked in collaboration with the Ministry of Health and provincial health workers, the National Health Cluster, community leaders and volunteers. This was a locally led response to provide essential SRH services targeting women in the affected area. Female service providers were at the centre of the response.
In order to reach the affected population on Ambae, VFHA teams had to transport medical supplies and aid in small boats, which then had to be offloaded on rocky beaches. Medical teams hiked through steep bush terrain on tracks circling the volcano to reach remote villages, carrying their equipment and supplies with them. There were two outreach teams, each comprising medical and non-medical staff. The teams were led by Leias, a senior VFHA midwife. In total, they visited 23 villages over a three-week period.
Leias started each clinic by conducting awareness sessions with affected communities on the importance of reproductive health in women’s lives. This was an opportunity to address common myths and misconceptions surrounding family planning, increasing acceptance and uptake of services. Sessions covered topics such as preventing STIs and HIV, teenage and unintended pregnancies, unsafe abortion and information about modern methods of contraception. Men and women participated in awareness sessions separately – as is culturally appropriate in Vanuatu. As reproductive coercion is common, increasing knowledge and acceptance of contraception among men in these remote communities is particularly important to counter opposition to women accessing SRH services.
Once the awareness sessions were complete, nurses and midwives provided SRH consultations and contraceptive counselling to all clients seeking SRHR services. Esther, 31, is one of the 42 women who received a contraceptive implant from the VFHA team. Esther (not her real name) is a single mother with eight children, one of whom has cerebral palsy, and it was extremely difficult for her to evacuate the island with so many children. The disaster made her realise the importance of contraceptives and spacing her children – and the difference this would make in her own life. She decided to get a contraceptive implant provided free of charge through the humanitarian response. The nurses in the VFHA mobile clinic travelled to her village, helping her to overcome the enormous barriers she faced in accessing contraceptives due to her remote location. Esther’s story highlights that women in humanitarian settings both want and need contraceptives, even those who have never used them before. Without VFHA bringing the services to Esther and providing counselling to support her choice, she would have remained one of the many women around the world with unmet contraceptive needs.
Leaving no one behind means making the effort to reach these small communities, no matter how remote.
Vanuatu is a small country with a small population, so focusing on numbers alone can underplay the impact of the response. Of the 10,000 people affected on Ambae Island, 834 accessed the SRHR services provided through VFHA, of whom 177 received contraceptives. For many women, this was their first time accessing modern contraceptive methods. Forty two women chose long-acting contraceptive implants. The success of the response was centred on the localised approach implemented by VFHA, involving local expert female service providers who were able to take SRHR services to women in remote villages facing significant barriers to accessing contraceptive services. Effective quality services and counselling delivered in a culturally appropriate and contextually responsive way is essential to enabling access to contraception for women. When there is trust and confidence in the provider and service delivery model, women will choose to use contraceptives, even for the first time, and even during a humanitarian response.
Contraceptives are in demand by women in times of disaster. They are also an essential component in fully meeting the needs of women and girls in emergencies. The Sustainable Development Goals (SDGs) cannot be met without increasing access to modern methods of contraception. There is an urgent need for governments, decision-makers and influencers to acknowledge access to contraception as a human right, both in stable contexts and in disaster settings.
Sadly for the people of Ambae, Mt Monaro volcano became increasingly unstable in the weeks and months that followed the response. The entire population, including Esther and her eight children, were evacuated for a second time in April 2018 to nearby islands, where they remain a year later. VFHA
continues to provide SRHR services targeting women and girls in this protracted crisis setting.
Jane Newnham is the Sexual and Reproductive Health Advisor for the Pacific Humanitarian Team with the International Planned Parenthood Federation.