There are more than 45 million displaced people in the world, 80% of them women and children. UNHCR, Displacement: The New 21st Century Challenge: UNHCR Global Trends 2012, https://www.guttmacher.org/pubs/tgr/01/5/gr010510.html. Disasters, natural and manmade, typically destroy medical facilities, displace medical personnel and erode support structures. In these circumstances an unplanned pregnancy can be fatal, and between a quarter and a half of maternal deaths in crisis situations are due to complications from unsafe abortions. UNFPA, Reproductive Health for Refugees and Displaced Persons: State of World Population 1999, https://www.unfpa.org/swp/1999/chapter3f.htm. Family planning and post-abortion care are proven, essential and cost-effective interventions that save women’s lives. Susan A. Cohen, Family Planning and Safe Motherhood: Dollars and Sense, Guttmacher Institute Policy Review, 2010. Nonetheless, they have been long neglected in emergencies in favour of conventional priorities such as water, sanitation, shelter, basic healthcare and food. This article examines the International Rescue Committee (IRC)’s experience initiating an emergency reproductive health response in Yemen, with a strong emphasis on family planning and post-abortion care. We argue that these services are both necessary and feasible during emergencies, and commonly perceived barriers, such as socio-cultural norms, lack of supplies and trained providers and politically turbulent environments, can be overcome by establishing appropriate, good-quality services.
Prioritising family planning and post-abortion care in emergencies
In order to most effectively respond to reproductive health needs in crises, the IRC is committed to implementing the Minimum Initial Service Package for reproductive health (MISP), including family planning and post-abortion care. The MISP, a priority set of life-saving reproductive health activities, should be implemented at the onset of every humanitarian crisis and, with family planning and post-abortion care, provides essential interventions to prevent maternal and new-born deaths; prevent and manage sexual violence and subsequent trauma; prevent and treat sexually transmitted infections, including HIV; and prevent unwanted pregnancies and unsafe abortions. The IRC has an emergency contingency fund that ensures that activities can be implemented immediately when an emergency strikes, for a period of up to six months, and employs a Senior Emergency Reproductive Health Coordinator (RHC), who can be deployed within a week of an emergency.
In recent years, Yemen has faced a serious humanitarian crisis marked by internal armed conflict, separatist movements and growing Islamist militancy. Recurrent drought, food shortages and high levels of poverty further compound these problems. The crisis has resulted in over 300,000 internally displaced people (IDPs) as of January 2014. Yemen is also home to some 240,000 refugees. Conflict between the government and Islamist militants in the southern governorate of Abyan between 2011 and 2012 displaced over 200,000.
Reproductive health in Yemen and the IRC response
The average woman in Yemen has six children, modern contraceptive prevalence is estimated at only 28% and 39% of women have an unmet need for family planning. The maternal mortality ratio, previously recorded at 370/100,000 live births (20082012), is likely to have increased with the severe disruption of the health system during the current crisis, and unsafe abortions are one of the three leading causes of maternal death. The 2012 Yemen Health Cluster Response Strategy found inadequate reproductive health services, unhygienic delivery conditions and a lack of referral systems for emergency obstetric and neonatal care. OCHA, 2012 Yemen Humanitarian Response Plan. In June 2012, informed by discussions with other humanitarian actors, the IRC co-led a multi-sector rapid assessment in Aden and Abyan governorates. The assessment’s objective was to determine the need for, and feasibility of, an integrated primary health, reproductive health, nutrition, and hygiene emergency response in neighbourhoods hosting internally displaced people (IDPs).
In late July 2012, in coordination with the Aden Health Department, the IRC selected Al-Buraiqa polyclinic (an outpatient facility) and the adjacent maternity centre in Aden to implement reproductive health programming. Aden lacked reproductive health services and supplies, and no other humanitarian actors were operating in the area. Further into the response, the IRC provided support to ten additional facilities in Aden with reproductive health training, drugs and equipment. Ultimately the IRC served a catchment population of almost 800,000 people, including 200,000 women of reproductive age (1549 years old). (Due to security and accessibility concerns IRC did not initiate programming in Abyan.) The intervention was conducted from July to December 2012, and was led by the IRC’s Reproductive Health Coordinator, with a Yemeni obstetric/gynaecologist (OB/GYN) as the project’s Reproductive Health Manager. Project implementation, particularly coordination with local partners, was greatly aided by the RHC’s fluency in Arabic and high cultural competency.
The polyclinic and maternity centre lacked family planning commodities (oral contraceptive pills, injectables, implants and intrauterine devices (IUDs)), and the IRC worked closely with the Ministry of Health to procure, distribute and monitor these commodities. The majority of health providers had not received family planning training in five or more years. IRC, with Aden governorate’s Reproductive Health Programme and the Office of the Director of Health, conducted training on family planning at Al-Wahda Teaching Hospital in Aden. Sixty-four health providers were trained on IUD insertion, follow-up and removal, and 32 were trained on contraceptive implant service provision.
In all, 21,002 women (approximately 10% of women aged 1549 in the catchment population) accepted a modern family planning method. Of those, 18,066 women chose oral contraceptive pills, 2,316 injectables, 369 IUDs and 251 implants. IUD and implant uptake was low because training took place in the latter half of the intervention. In addition, Ministry of Health guidelines prohibit midwives from providing implants, so while implants may be available in facilities, without an OB/GYN present they cannot be used. These factors also contributed to the large uptake of short-term methods in the project period an area for future monitoring and improvement.
Post-abortion care reduces deaths and injuries from incomplete and unsafe abortions and miscarriages. Through years of programming experience in conservative societies, IRC has consistently encountered high demand for good-quality, confidential and compassionate post-abortion care. In 2013, IRC provided post-abortion care services to nearly 15,000 displaced women in 13 different countries, including Pakistan, the Democratic Republic of Congo and Sudanese refugee camps in Chad.
In Yemen, abortion is legally permitted only to save the life of the mother. Although recent data on abortion prevalence is lacking, the 1997 Demographic Health Survey found that 30% of women aged 28 years and above had ever had an abortion. T. S. Sunil and V. K. Pillai, Age at Marriage, Contraceptive Use and Abortion in Yemen, Canadian Studies in Population, vol. 31(1), 2004. Yemen’s abortion rate is on a par with rates in many other countries because Yemeni women, like women around the world, want to limit their family size: if contraception is not available, women will turn to abortion even when it is illegal. Amy Deschner and Susan A. Cohen, Contraceptive Use Is Key to Reducing Abortion Worldwide, The Guttmacher Report on Public Policy, vol. 6, no. 4, October 2003, http://www.guttmacher.org/pubs/tgr/06/4/gr060407.html. For Yemeni women with large families, abortion is the commonest method of family limitation.
Post-abortion care was available at the Al-Wahda Teaching Hospital before the IRC intervention, but providers were using the outdated and invasive method of Dilation & Curretage (D&C). The number one training request the IRC received was for manual vacuum aspiration (MVA), the World Health Organisation-recommended method of providing post-abortion care. Training in post-abortion care, conducted in December at the Al-Wahda Teaching Hospital, included the application of MVA, counselling on post-abortion family planning, infection identification and prevention and key messages that placed the provision of post-abortion care within the context of preventing maternal deaths. Five female OB/GYNs from five separate facilities attended, ensuring that post-abortion care was available at both intervention sites as well as other facilities in Aden, and the IRC distributed MVA kits at facilities with trained providers. Between July and December 2012, 227 women received post-abortion care at IRC-supported facilities. Following the MVA training in December, health providers began to phase out D&C and replace it with MVA.
Additional reproductive health programming
Having a skilled attendant present during childbirth is the single most critical intervention for ensuring a safe birth, and is a core reproductive health priority for IRC. Before the IRC intervention, the maternity centre was operating one four-hour shift per week; if a woman went into labour outside this period she would have to give birth at home, without skilled assistance, or risk a lengthy journey to give birth at the Al-Wahda Teaching Hospital. The IRC provided the maternity centre with a generator to ensure a continuous supply of electricity, allowing it to operate around the clock, and rented an ambulance to transport emergency cases to the hospital. Approximately 2,700 deliveries were carried out during the intervention period.
Increasing community awareness and stimulating behaviour change requires sensitivity and patience, particularly when family planning and post-abortion care are involved. The IRC trained 24 Community Health Volunteers (CHVs) and two Community Health Supervisors to carry out health awareness activities, including information on where to access family planning and post-abortion care. CHVs integrated reproductive health messages into larger health discussions that covered core nutrition, child health and hygiene information, providing comprehensive health information and mitigating any potential backlash that could have arisen from a stand-alone information campaign on family planning and post-abortion care. Between August and December 2012 CHVs visited 1,913 households, stimulating demand and encouraging families to access reproductive health services. IRC also identified family planning/post-abortion care advocates within communities: one champion, an influential leader who was married to a midwife, not only understood the importance of access to family planning and post-abortion care but was also in a position to assist the IRC in gaining community trust and initiate discussions concerning these issues.
The Safety Committee
Galvanised by IRC-led training, 22 female OB/GYNs formed a ‘Safety Committee’ at the Al-Wahda Teaching Hospital. The training enabled committee members to recognise the gap between globally recognised standards of care for sexual assault survivors and current practice in Yemen. The committee uses the IRC-developed training module ‘Clinical Care for Sexual Assault Survivors’ to train providers on procedures for addressing the physical, psychological and legal needs of survivors.
Coordination with the Ministry of Health, NGOs and agencies
Close coordination with the Ministry of Health was essential to the success of the programme. From the beginning, the RHC attributed achievements to the Ministry and included it in key decisions. Ministry staff participated in health facility visits and were invited to give the opening speech at many training sessions and workshops. IRC was also able to identify and engage with family planning/post-abortion care advocates within the Ministry and other government agencies, highlighting the importance of family planning and post-abortion care within national medical protocols and Yemen’s national strategy for reducing maternal mortality. Additional coordination included engagement with the Health and WASH clusters in South Yemen and Sana’a, UN agencies and the Aden Executive Committee, which is responsible for monitoring support to displaced people in the south.
Emergencies are innately sudden and unpredictable. Funding for emergency activities often lags behind need, especially in the first days and weeks of a crisis and particularly for life-saving reproductive health services. Investing in family planning and post-abortion care prevents maternal deaths and is cost-effective, yet even when emergency funding is secured family planning and post-abortion care are not typically a priority for governments or donors during emergency responses; conflict-affected settings receive 57% less funding for reproductive health programming than more stable settings. Inter-Agency Working Group for Reproductive Health in Crises, 20122014 Global Evaluation, forthcoming. The ongoing challenge, for the IRC as well as the larger humanitarian community, lies in finding donors who will provide the contingency funding that ensures implementation of reproductive health activities when disaster strikes, and securing longer-term funding to sustain emergency reproductive health programmes beyond the initial emergency intervention.
IRC’s experience in Yemen confirms that women need and will utilise family planning and post-abortion care services in emergencies, despite perceived social, political and religious barriers. A dedicated staff member to lead responses, coupled with funding for emergency reproductive health, has enabled the IRC to respond quickly and efficiently to acute emergencies. In Yemen, strong programme leadership, along with dedicated family planning and post-abortion care advocates within the government and the wider community, helped ensure that women in Aden had access to good-quality emergency reproductive health services, including competent and compassionate family planning and post-abortion care.
Dr. Abdelhadi Eltahir is the IRC’s Senior Reproductive Health Coordinator. Nathaly Spilotros is the Emergency Reproductive Health Program Manager at the IRC, and Kate Hesel is the IRC’s Reproductive Health Specialist.