This analysis provides an overview of important RH trends over the seven-year study period. For some indicators (births attended by a skilled birth attendant, caesarian section, syphilis screening, and PEP), improvement from 2007 is clear. For other indicators (MMR, NNMR, and condom distribution), more information is needed to explain current trends and why or if improvement is lacking. In several instances standards were not met. Regardless of improvements made in each country for each indicator studied, this analysis demonstrates that more needs to be done to ensure women in refugee camp settings are receiving high quality RH care, as this will decrease morbidity and mortality within the study population. It is often thought that analysis from the HIS is complete, reliable, and of high quality. This analysis demonstrates a need for improved reporting, as many countries were dropped from the study. To close this gap UNHCR and its health partners need to improve strategies and programs to derive maximum benefit from the HIS.
We suspect that HIS is not capturing some of the maternal and neonatal deaths of the camp populations rather than over reporting live births or consistently achieving very low maternal and neonatal mortality in these refugee camp settings. Several previous studies on maternal and infant mortality in refugee camps discussed underreporting of maternal and neonatal mortality ; two recent studies that examine the extent of underreporting of neonatal deaths have been completed in camps in Tanzania and Chad [Idowu R, Morof D, Blanton C, Tappis H, Cornier N, Tomczyk B. Using capture-recapture methods and verbal autopsy to understand the incidence of neonatal mortality, stillbirths and live births in UNHCR refugee camps in Chad 2013. Unpublished report.]. Both neonatal and maternal mortality can fluctuate within refugee camps, particularly when influxes of refugees due to an acute emergency occur during a protracted setting. An outbreak such as Hepatitis E that occurred in Dadaab, Kenya disproportionally affected pregnant women . The maternal death audit system is a UNHCR strategy that has been implemented successfully in Dadaab and includes community sensitization to report deaths that occur at home . Other interventions were also included such as improvement of infrastructure, transport, supplies, skilled staffing and mother incentives. This strategy could be replicated in other camps.
Ensuring SBA at delivery is efficacious in contributing to the reduction in maternal and perinatal mortality and helping to reach the post 2015 MDGs 4 and 5 targets [22, 23]. Overall, the significant increase across countries in this study is encouraging. Some refugee camps in this study had a low use of SBAs; this may be due to a lack of SBAs at the facility level. Additionally, the proportions may have exceeded 100 % in some instances because the live births were inaccurately recoded in the monthly reports or because host community women came to deliver and were misclassified as refugees, but more information is needed to determine the root of the inaccuracies. An important consideration for maternity wards at all camps is that they are staffed, 24 h a day, with a professional midwife capable of responding to common obstetric emergencies. It is also important that UNHCR and its partners provide refresher training and supportive supervision, as needed.
Caesarian section was introduced in emergency obstetric care as a lifesaving procedure both for the mother and baby. Overall, there is a positive trend toward meeting the UNHCR standard of caesarean section rates. It is known that the global picture indicates an uneven distribution of caesarian section that shows underuse in low income settings and adequate or even unnecessary use in middle and high income settings , and our analysis shows an uneven distribution depending upon the country. The findings from Nepal are counterintuitive since it showed caesarian section rates that would reflect a high income setting. Two studies have shown an inverse association at population level between caesarian section rates and maternal and infant mortality in low income countries where large sectors of the population lack access to basic obstetric care [25, 26], making this indicator an important morbidity and mortality measure. In refugee camps where health care is provided and access to emergency obstetric care may be disproportionately available, this study indicates there are still gains to be made in maternal and infant mortality by increasing access to and use of improved birth technologies, including cesarean delivery. In addition, concerted actions need to be taken to offer timely caesarian section to women who need it and to advocate for a rationale use of caesarian section in camps with a surplus. In Chad and Zambia where caesarian section rates were low more detailed field assessments would help to contextualize the issue and determine the best course of action. Lastly, other important contributing factors that may increase caesarian rates such as previous caesarian sections, and maternal or fetal causes if captured by the HIS could help to interpret this indicator.
Several factors could decrease the syphilis screening rate in refugee camps. For instance, syphilis screening although a routine part of ANC in refugee settings may be missed due to a lack of supplies, equipment and trained staff. Broader ANC may also be lacking, which indirectly leads to women not being screened for syphilis as regularly as they should be. Finally, health care providers may not be prepared in syphilis prevention, and how to prevent re-infection during pregnancy by promoting condom use. Commodities may be in short supply for testing and laboratories require appropriately trained staff for testing [27, 28]. Improvements in UNHCR syphilis screening programs have included implementation of a decentralized program of syphilis screening involving nurses trained in education, counselling and the provision of on-site testing using the Rapid Plasma Reagin test and partner tracing .
Condom distribution was inadequate for the majority of camps (6 of 9 camps were less than 50 % in 2013). When looking more directly at the data, condom distribution was sporadic and indicated months with high condom distribution and months with very low to no condom distribution. This indicator may not provide distinct value as a measurement because distribution does not necessarily equate to use, especially where the product is given away free of charge. Refugee populations may also have a varying proportion of children and/or females, making comparisons across refugee countries difficult without adjusting for the number of people who do not need condoms . Logistical difficulties in obtaining and delivering of supplies due to camp location do occur are major obstacles.
Refugee women who have experienced sexual violence should be referred for health services as soon as possible after the incident. The large number of missing data in this analysis points to the fact that either very few women reported a rape in refugee settings or the rapes were reported but not recorded in the HIS, or women are not willing to report a rape as a majority of the monthly reports did not indicate any rapes. The number of rapes reported in each country fall far below global statistics on sexual violence . Legal reforms, protection policy and high quality services available to rape victims have been influential in increasing the likelihood that women will report. Therefore, a multi-sectoral approach is needed in each refugee setting in order to improve services.
There were a number of limitations in this analysis . Underreporting, lack of representativeness, lack of timeliness, and inconsistency of case definitions are four of the most common limitations of many surveillance systems . The HIS has been implemented since 2006 and the quality and completeness of data is known to be somewhat variable during the first months of using the system and may be variable depending on conditions in the individual camps and availability of human resources. A number of countries were excluded from this analysis because the data was too variable. Camps from countries that were not included in the analysis had a higher variance of reporting variability. Some camps rarely reported and other camps within the same country reported fairly regularly. Another limitation is that data quality may be influenced by a number of factors that we did not measure such as newly opened camps versus long term camps, size of camps, availability of RH services and staffing. The inclusion criteria were designed to limit the amount of poor quality data, but they do not ensure that all the monthly reports for 56 camps were of high quality. It also should be noted that we present the average monthly camp estimates by year within a country, but there is variation within a camp and between camps within a country. Sensitive subjects, such as sexual violence may not be reported accurately.
The UNHCR HIS in this study was limited to refugee camps and is facility-based. It may be biased because populations that do not seek care are excluded (survivors of sexual violence, certain RH patients, and deaths occurring outside of health facilities). It is recognized that in refugee camp settings, women may have better access to quality RH care than is available in their country of origin. The Global Evaluation of RH Services for Refugees and Internally Displaced People, conducted in 2004 found that internally displaced persons had worse access to RH services than refugees . Thus we may anticipate that the results may suggest more positive findings than we might find among the surrounding host population or internally displaced persons . Ideally it would have been potentially helpful to have information on how the data were collected in each health facility in each refugee camp in order to improve our understanding of the HIS RH data from this analysis to provide context to the results.