Reproductive Health among Conflict-Affected Populations

Complex humanitarian emergencies caused by armed conflict are characterized by social disruption, population displacement and collapse of public health infrastructure [1]. Humanitarian assistance for refugees and internally displaced persons (IDPs) requires specific attention to ensure that the reproductive health (RH) rights of the population are recognized. Women living in conflict and post-conflict settings are faced with many RH concerns including high risk of death or disability due to pregnancy-related causes, lack of information about and access to family planning (FP), complications following unsafe abortion, gender-based violence and sexually transmitted infections (STIs) including HIV [2]. Women and men affected by armed conflict have the right to RH-related information and access to safe, effective, affordable and acceptable FP methods as well as appropriate and effective health care services that will enable women to experience safe pregnancies and childbirth [3].

The Minimum Initial Services Package (MISP) for RH in Crisis Situations establishes a set of priority RH interventions to be implemented during the earliest days of a humanitarian crisis and calls for early planning for the introduction of comprehensive RH services once the emergency situation has stabilized. Although implementation of the MISP is a standard in the Sphere Project's Humanitarian Charter and Minimum Standards in Disaster Response[4], emergency obstetric care (EmOC) and FP services are still rarely available to populations affected by armed conflict [2, 5].

The largest public health disparity between developed and developing countries is maternal mortality [6]. Progress towards achieving the fifth Millennium Development Goal (MDG) to reduce maternal mortality by three-quarters by 2015 is inadequate [7]. Evidence suggests that conflict-affected countries are even further from achieving this goal [8]; nine of the ten lowest-ranked countries in Save the Children's 2009 Mothers' Index are either currently affected by armed conflict or emerging from recent conflict [9].

Most maternal deaths in developing countries result from direct obstetric complications, which include hemorrhage, sepsis, pre-eclampsia and eclampsia, prolonged or obstructed labor and complications of abortion [10, 11]. Most direct obstetric complications are treatable and maternal deaths may be avoided if complications are treated properly and in time. The majority of maternal deaths occur during labor, delivery or the first 24 hours postpartum and many can be attributed to at least one of the "three delays" that occur before a woman receives a life-saving intervention: delay in deciding to seek care on the part of the woman and/or her family; delay in reaching a facility that provides EmOC; and delay in receiving good quality care at the facility [12]. Since most obstetric complications cannot be predicted or prevented [6], access to safe and effective obstetric services, including EmOC, is crucial to averting maternal morbidity and mortality.

The lack of infection prevention practices in the health facility environment is a common barrier to providing good quality RH services. Sepsis is one of the leading causes of maternal deaths in developing countries and is the second leading cause of maternal deaths in the Democratic Republic of the Congo (DRC) [15]; it is also one of the most preventable of all postpartum morbidities [6, 16]. Infection prevention practices in the hospital setting, including disinfection and sterilization of surfaces and equipment in the delivery room and operating theatre, use of protective devices such as aprons and gloves and use of aseptic techniques before and during delivery (cleansing with soap, disinfectant, chlorine bleach), can reduce the risk of infection to mothers and newborns [16, 17]. In addition, treatment of antepartum infections plays an important role in reducing postpartum infections [16].

Family planning provides women and men with the opportunity to enjoy their reproductive rights and plays an important role in reducing maternal mortality through the prevention of unwanted pregnancy and unsafe abortion. FP also contributes to a reduction in both maternal and infant mortality by changing the structure of childbearing (age and parity of pregnant women and the time between pregnancies) [3, 18]. Evidence regarding fertility preferences among conflict-affected populations is mixed, with studies showing both a desire to replace lost family members and a reluctance to become pregnant in the unstable conditions of war [19]. Despite this variance, the demand for FP services exists among nearly all conflict-affected populations, making the availability of good quality FP services critical [19]. A global evaluation of RH services in conflict-affected settings found that although 90% of sites had at least one FP method available, only half of the sites reported offering long-term methods such as the intra-uterine device (IUD) and one-third reported that sterilization was available [5].

Reproductive Health in the Democratic Republic of the Congo

After nearly a decade of civil war, the DRC remains in the midst of a complex humanitarian emergency, faced with a devastated health infrastructure, high mortality rates and a disrupted civil society. Between 1998 and 2004, an estimated 3.9 million excess deaths occurred as a result of the conflict in the DRC [20]; the crude mortality rate in 2006 was more than 70% higher than that reported in the 1984 census [21]. The effects of the conflict on women's health and well-being are profound, with the country ranking as the worst conflict zone in the world in which to be a woman or child [22].

The destruction of the health infrastructure during the war has led to insufficient capacity to meet the health needs of the population [23] and has resulted in poor RH status and avoidable deaths. The maternal mortality ratio in the DRC is estimated to be between 549 and 1100 maternal deaths per 100,000 live births, among the highest in the world [24, 25]. The major causes of maternal mortality in the DRC are hemorrhage (25%), sepsis (15%), eclampsia/pre-eclampsia (13%) and unsafe abortion (13%) [15]. Contraceptive prevalence is very low, with 6.7% of women of reproductive age reporting current use of a modern method of FP, ranging from 3.3% in rural areas to 9.5% in urban areas [24].

Also underlying the poor health infrastructure are the poor compensation and motivation of currently-employed health workers and the deterioration of the health worker education system. Many health workers have not been paid for decades and many rural health workers migrate to the cities or go to work for international agencies to seek paid employment with a regular salary [23]. In addition, little commitment to continuing professional development and in-service training is evident in the public sector, unless specifically funded by an external donor. Few health workers receive continuing medical education or training on updated medical practices or are exposed to updated medical information, such as journal articles.

Although many of the same problems can be found in other developing countries, evidence suggests that the long-term damage that armed conflict causes to health systems and to the health status of the population persists well after the conflict has ended and that women and children are disproportionately affected [26].

The RAISE Initiative in the DRC

The Reproductive Health Access, Information and Services in Emergencies (RAISE) Initiative collaborates with partner agencies to bring together the tools needed to make comprehensive RH care in emergencies a basic standard of care. Established by the Heilbrunn Department of Population and Family Health in the Columbia University Mailman School of Public Health and Marie Stopes International, the RAISE Initiative aims to address the full range of RH needs for refugees and IDPs by building partnerships with humanitarian and development agencies, governments, United Nations (UN) bodies, advocacy agencies and academic institutions [2]. In 2007, the RAISE Initiative began working with the International Rescue Committee (IRC) and CARE in the DRC to ensure that good quality comprehensive facility-based RH care would be available to conflict-affected populations. Facility assessments were conducted to evaluate the existing capacities of health facilities to meet the RH needs of the population and to determine the availability, utilization and quality of RH services, including EmOC and FP, at supported facilities.

Facility Assessment

A functioning health infrastructure at the facility level is crucial to the delivery of RH services. It is important, therefore, to measure facility level data [27]. Research has shown that in order to reduce maternal mortality, three facility level components need to be in place: application of good quality medical technology and use of skilled clinical providers; good management and organization within the facility including personnel, equipment, drugs and supplies; and a respect for human rights efforts to improve functioning at the facility level [28, 29].

The Averting Maternal Death and Disability (AMDD) Program's EmOC Building Blocks Framework (Figure 1) includes a plan for upgrading a facility from initial preparation through increasing utilization of services. This framework serves as a blueprint for organizing program priorities and has also proved useful in conflict settings [29, 30]. As a first step in the process of improving RH care, it is important to have a clear understanding of the service delivery environment. Facility assessments provide crucial information about the content and delivery of RH services and can also identify gaps and obstacles to providing those services [31] both prior to and during program implementation [32–34]. They provide useful evidence from which to make concrete recommendations to governments and other key stakeholders for improving policies and structures.

General Infrastructure

Emergency Obstetric Care

Although none of the nine hospitals met the criteria for a functioning EmOC facility (either basic or comprehensive), all of the hospitals reported having provided the following signal functions in the preceding three months: administration of parenteral antibiotics and uterotonic drugs, removal of retained products of conception, blood transfusion and cesarean delivery (Figure 2). Only one hospital reported having performed an assisted vaginal delivery in the preceding three months, while four reported having performed neonatal resuscitation.

Aside from failing to perform all of the signal functions, the hospitals did not satisfy the criteria for functioning EmOC facilities primarily due to a lack of trained staff, limited availability of services (less than 24 hours a day) or lack of supplies and equipment for performing the signal functions to a quality standard. For example, no hospital possessed the complete package of essential supplies, equipment and staff to provide manual removal of the placenta, removal of retained products, assisted vaginal delivery or neonatal resuscitation.

Lack of medicines, supplies and equipment was a frequent barrier to the hospitals' provision of obstetric services. Of the five hospitals that lacked the full package to provide parenteral antibiotics and uterotonic drugs, three had no ampicillin, three had no oxytocin and four lacked needles and/or syringes. In addition, none of the hospitals was able to perform manual removal of the placenta because they lacked such basic supplies as dextrose or glucose as well as the RH-specific drugs oxytocin or ergometrine to aid the process. None of the hospitals had long gloves for use during the procedure.

Only one hospital was able to consistently and safely provide surgery for obstetric complications. The remaining hospitals did not have the appropriate and necessary equipment, surgical instruments, drugs or oxygen to safely perform a cesarean section.

Two of the nine hospitals possessed adequate equipment and supplies to provide safe blood transfusions. Of the seven remaining hospitals, five did not have a blood bank, four did not have airway needles and five did not have a functioning refrigerator. In addition, several hospitals did not have the kits to test transfused blood for Hepatitis B (one), Hepatitis C (three) or syphilis (two); all nine hospitals did, however, have HIV test kits.

Despite lacking equipment to provide cesareans or safe blood transfusions, all nine hospitals reported having performed these procedures in the three months prior to the assessment.

Family Planning

Family planning services were lacking in most of the hospitals assessed; only two hospitals provided a range of methods. Contraceptive implants were not offered at any of the hospitals; IUD and emergency contraception were offered at only one hospital; oral contraceptive pills and injectables were offered at two hospitals; and male and female condoms were offered at three hospitals. Six hospitals reported providing tubal ligation, but this was determined to be only when the procedure was recommended for medical reasons and performed during a cesarean; tubal ligation was not performed as an elective, scheduled FP procedure in any hospital. Of the two hospitals that provided multiple FP methods, only one had FP information (leaflets or a flipchart) available to assist with counseling. As with EmOC services, essential supplies such as needles, syringes or specula were missing from the outpatient room in which FP services were provided at both hospitals that offered FP services. One of these hospitals had no FP methods available in the outpatient room, although they were available in the pharmacy.

The main reasons reported for not providing FP methods were a lack of training for providing counseling to clients or for performing the procedures, closely followed by a lack of necessary supplies or equipment. Policy issues, related to religious beliefs, were cited by the Catholic hospital as the reason for not providing any FP services.

Infection Prevention

Infection prevention practices were found to be inadequate in the delivery room, maternity ward and laboratory at all assessed facilities. Poor and nonexistent infection prevention practices were also documented in the operating theatre (seven) and outpatient areas (eight). The gaps in infection prevention were mainly due to the lack of equipment and supplies such as soap, washing stations, disinfectant solution, bleach, sharps containers or covered contaminated waste bins. Two hospitals had no functioning autoclave with which to sterilize equipment. Waste disposal was a notable issue: three hospitals had no incinerator, one had an incinerator too full to use and five hospitals did not separate clinical waste from other waste.

Routine monitoring system

No facility had an adequate monitoring system for EmOC. Very few facilities recorded obstetric complications or the treatment provided in response, with the exception of cesarean sections. A lack of clear case definitions, such as for a complicated abortion, was also noted. Neither maternal deaths nor the causes thereof were clearly or consistently documented. In the two hospitals that offered FP, utilization data were more routinely recorded; however, neither facility had a system to track clients using short-term methods who defaulted.

General infrastructure

Issues of general infrastructure such as renovations to physical structures; re-organization of client flow through the facility; and installation or improvement of power, water, sanitation and waste management systems must be addressed to facilitate effective infection prevention and the provision of good quality RH services [27]. It is imperative for all facilities to maintain an adequate and sufficient water supply and to have clean water available inside the hospital. All hospitals must have at least two sources of electrical power, to ensure that power is available at all times without (or with minimal) interruption. Both primary and backup power systems require regular maintenance so that power outages are avoided.

Commodities management

Commodity security and management were clear gaps that were identified in all of the facilities. At the time of the facility assessments, most facilities lacked the essential drugs, equipment and supplies, such as ampicillin, oxytocin, needles and syringes, needed to perform signal functions. Of the two hospitals that had provided short- and long-term FP methods in the prior three months, only one hospital had any FP counseling materials. Three hospitals indicated that despite having trained staff, they never stocked FP methods. Various reasons for not procuring FP supplies were mentioned by staff: they assumed women did not want FP or they feared the religious missions that managed the hospitals would prohibit the provision of FP.

The six hospitals with the essential package to provide parenteral anticonvulsants used diazepam, a less effective treatment for eclampsia [39]. Magnesium sulfate, the simplest and most effective treatment of eclampsia, was available in only one hospital. Updated RH protocols and essential drugs lists must reflect the most modern and effective drugs, equipment and procedures; these drugs and equipment must be available to procure in the country; and staff must be trained to ensure their appropriate use.

Interventions are limited if effective and reliable medical supplies and equipment are unavailable. The lack of these inexpensive, basic supplies demonstrates the need for systems to manage drug and supply chains. Insufficient support and poorly functioning systems during years of war mean few or no staff have the skills to properly manage a supply system. Training for hospital managers and medical personnel on drug and equipment procurement and management must be prioritized.

Staffing

Implicit in the definition of an EmOC facility is that the signal functions be available to women 24 hours a day and seven days a week since demand for EmOC services cannot be predicted. The primary obstacle to the 24 hour provision of EmOC in the facilities studied was the lack of the essential health workers at the facility. According to the DRC's national protocol, a general referral hospital with 100 beds serving a population of 100,000 should have at least three doctors, one anesthetist and 16 nurses [40]. The majority of the hospitals assessed had fewer than this minimum. Unsurprisingly, the hospitals located in more remote and isolated areas had fewer staff than those in more urban or accessible areas. In many cases, the health zone medical officer (Médecin chef de zone) was counted as a doctor at the hospital despite his other non-clinical duties. The lack of a doctor is of particular importance with regards to procedures, such as cesarean deliveries, that only a doctor is authorized to perform. In some facilities, nurses were unofficially trained to perform cesareans. The researchers were unable to determine which procedures each level of provider was authorized to perform having received inconsistent responses from different MOH officials. Supporting the hiring and retention of skilled health workers at the facility (through provision of adequate housing and regular payment of salaries) and reviewing policies to expand the scope of services performed by non-physician clinicians would help improve 24 hour availability of EmOC [13, 33] and make a broader range of FP methods available at health facilities.

Training

Competency-based clinical training and continuing education are crucial to enable the health system to provide good quality care. In the nine hospitals assessed, lack of training was a barrier to the provision of both FP and EmOC services and was consistently ranked as the main reason that facilities did not provide RH services. For example, none of the nine hospitals was able to perform an assisted vaginal delivery due in part to lack of training. Conversations with Congolese physicians suggest that this signal function was often de-emphasized in physician training. Continuing education to update health workers on new more effective technologies was lacking as most facilities used outdated procedures and/or drugs. For example, all of the facilities performed dilation and curettage instead of manual vacuum aspiration (MVA), the relatively simple and safe alternative recommended by the WHO, for removal of retained products of conception.

Clinical training, including refresher training, should take into account both RH-specific and health systems approaches. An RH approach to training would provide hospital staff currently providing RH services with procedure-specific up-to-date in-service training. A health systems response to training would include a review of basic medical, nursing and midwifery training curricula to ensure the incorporation of appropriate training for the provision of FP methods, drugs and procedures to treat obstetric complications and infection prevention policies [41]. IRC is creating training centers at five supported hospitals to enable the trained staff to train clinicians from health centers in the health zone.

Infection prevention

Although infection prevention practices at all of the hospitals were inadequate, this is an area in which low cost, low technology interventions can make a difference. Infection prevention policies and procedures are effective and relatively simple to implement. It is essential that all facility staff, whether they provide clinical care or not, be trained in good infection prevention practices and that the necessary equipment and supplies, such as incinerators and sharps containers, be available so that infection prevention policies and procedures can be followed. Even where EmOC or FP services are available, failure to follow infection prevention procedures can put both staff and patients at unnecessary risk and result in poor clinical outcomes.

Policies and protocols

The availability and delivery of RH services are affected by national health policies and protocols; the omission of newer, safer and easier to use drugs and procedures from the DRC's RH policies and protocols has affected the availability of RH services at the studied facilities. Misoprostol, for example, an effective, inexpensive and easy-to-administer drug which can be used to prevent post-partum hemorrhage [42], is not included in the DRC's national RH norms. Although MVA does appear in the national RH norms [43], it is not consistently referenced in national RH policy documents. Further, MVA is found only in the norms for hospitals but not for health centers despite evidence that MVA can be safely provided at the health center level and performed by non-physician clinicians [44, 45].

Even when updated RH policies were in place, some discrepancies between policy and practice were noted. Although some new drugs or procedures have been included in recent revisions of national health protocols, the lack of training or failure to procure the necessary drugs and equipment prevented their use. For example, magnesium sulfate, which is on the essential drugs list, was available in only one of the nine hospitals assessed. Non-governmental organizations (NGOs) working in the DRC have reported difficulty in identifying a local source for procurement. Likewise, differences were noted between the standard equipment for general referral hospitals designated by national policy and what was actually observed in the hospitals assessed. For example, vacuum extractors and MVA kits were included in the standard equipment list for a hospital in the DRC, yet most of the hospitals did not have this equipment [15]. In addition, neither appeared in the MOH definitive list of RH commodities to be secured [46]. Reasons for these discrepancies are not known, but could include the lack of effective equipment management and planning by the hospital or MOH or the active discouragement of the use of the procedures (for example, by encouraging the use of cesarean over assisted vaginal delivery). As noted previously, even if these equipment were available, staff in half of the hospitals lacked training to use them. It is imperative not only for updated and more effective drugs and procedures to be consistently included in national policies but also for the MOH to facilitate their use and implementation in health facilities through training and procurement.

Referral systems

Effective, functioning referral systems are critical to the accessibility of RH services. All of the hospitals assessed are local referral hospitals for EmOC, yet travel to these hospitals may not be feasible for women experiencing obstetric complications because of distance, cost of transportation or poor road infrastructure. The lack of ambulances is a serious problem throughout the DRC; however, in some of the rural areas where these hospitals are located, roads are impassable to four-wheel vehicles during rainy season. Where transport is extremely difficult, CARE is ensuring that basic EmOC is available in health centers that are furthest and least accessible to the hospital. Alternative transportation options, such as motorcycle ambulances, bicycle taxis and commercial vehicles should be explored. Community savings groups, community insurance and income generation activities are all approaches that might be used to assist women and their families to pay for these critical services [47].

Information systems, monitoring and evaluation

A key feature of a sustainable and functioning health infrastructure is the assessment, monitoring and evaluation of services [33]. The UN Process Indicators have been shown effective tools to guide the design of EmOC programs and to monitor the provision of EmOC services [13, 48]. In the nine hospitals assessed, monitoring of EmOC was virtually nonexistent. The obstetric registers were so poor that it was difficult to determine reliable baseline levels for some of the UN Process Indicators. Monitoring performance allows facility staff to better understand which service areas are not functioning and the reasons why so that they can initiate improvements. At the facility level, all staff should receive training, regular supervision and support in maintaining and using monitoring systems.

Obstetric registers should be revised so that key data are included and less important data are excluded. Standard case definitions should be shared with all staff working in the maternity; the staff must understand the importance of collecting good quality data and how to use these data. Monitoring of services can help the facility management better understand patient flow and volume, which has implications for needed program inputs [10]. Furthermore, consistent monitoring using the UN Process Indicators has proven to be an effective way to assess maternal mortality reduction and improve the functioning of EmOC facilities [49]. In addition, facilities may wish to collect other information to gain more insight into the quality of care including the time elapsed between a woman's admission to an EmOC facility and her actual receipt of treatment, and detailed case reviews of both maternal deaths and 'near misses' (i.e., women who experience an obstetric complication, are treated in the facility and survive) [13, 50].

Study Limitations

The facility assessment only provides a snapshot of staff, services, equipment and supplies that were available and functioning on the day of the assessment and cannot evaluate those that were available at any other period of time. It is feasible that a hospital may have been able to provide certain services in the past but was classified as not being capable of doing so due to the lack of essential drugs, equipment, staff or supplies on the day of the assessment. In addition, this assessment did not explore the quality of the services provided by individual health workers. Despite these limitations, it is clear that major improvements are needed at all of the hospitals assessed.