Emergency Contraception Among Refugees and the ...

Emergency Contraception Among Refugees and the Displaced LORELEIGOODYEAR,MPH THERESE MCGINN, MPH In 1994, the international relief community began to recognize and address the reproductive health needs of refugees and displaced populations. A minimum initial service package of reproductive health services for refugees and the displaced, which includes emergency contraception (EC), was developed and recommended for use in refugee settings. This paper describes the experience of one international relief organization, the International Rescue Committee (IRC), in introducing EC into its worldwide reproductive health program. A recent IRC survey found that EC is available in 4 out of 14 settings where it provides reproductive health services. A case study from Ta.mania demonstrates the modes of delivery, the demand for EC by women who have experienced sexual violence, and the community responses to this method of contraception. More information, education, and communication directed at refugee communities; more donor support for supplies; and institutional commitment to train staff are needed to expand refugee access to EC.

According ro the very specific definition set forth in international agreements, a refugee is "a person who, owing ro a well-founded fear of being persecuted for reasons of race, religion, nationality, membership [in] a particular social group, or political opinion ... is outside the country of his nationality. "1. 2 Those fleeing conflict but not crossing international borders are considered "internally displaced." Ms. Goodyear is reproductive health program officer ar the Inrernational Rescue Committee, and Ms. McGinn is assistant clinical professor of public health at The Joseph L Mailman School of Public Health at Columbia University.

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In 1996, there were an estimated 14.5 million refugees in the world, down from a high of 17.6 million in 1992. Refugees have fled more than 40 countries worldwide, 19 of them in Africa. The greatest number of refugees are from Palestine (3.7 million) , Afghanistan (2.6 million), Bosnia and Herzegovina (1 million), Liberia (750,000), and Iraq (600,000). 3 ln addition, there are at least 20 million internally displaced people in 35 countries. Sudan has the greatest number at 4 million; Afghanistan, Angola, Bosnia and Herzegovina, Liberia, and Turkey each have a million or more. 3 It should be noted that estimates may vary widely by source. Refugees and the internally displaced have much the same health, social, and economic needs. Because some agencies and funding are expressly intended for refugees, however, they are more likely ro have access to needed services, including protection. Many agencies serve both refugees and the displaced, and the term "refugees" is used here ro cover both groups unless otherwise noted. Many within and outside refugee service organizations have begun ro question several long-held assumptions about refugees and their needs in recent years. One such assumption is that refugee crises are short-lived emergencies, requiring short-term response. If this assumption were ever true, it is not.now. Refugees do not quickly return home. An estimated 1.2 million Afghan refugees have lived in camps in Pakistan for almost 2 decades. The Palestinians have been refugees for 50 years. Even many of the "recent" refugee crises have been long lasting. For instance, many of the 200,000 Burundian refugees still in Tanzania have been there for 4 years. The Bosnian refugees in Yugoslavia and elsewhere in Europe have been away from their homes for about the same length of time. Another assumption, which follows from the first, is that the only services necessary are those basic to short-term

emergency situations. Thus, adequate food, shelter, water, sanitation, and basic health services are made available relatively quickly ro refugees (though not necessarily to the displaced) . Health services focus on prevention of or response to infectious diseases, emergency medical services, and child survival, and are generally planned for 6 to 12 months. There is no question that these are critical services, but other services are also critical for physical and mental health. Unwanted pregnancy, maternal mortality and morbidity, sexually transmitted diseases (STDs), domestic violence, and rape exist in virtually every refugee and displaced population. In a study conducted in 1993-1994, Wulf found that there were virtually no reproductive health services available to refugees in most sites-not even basic family planningand that most of the refugee service organizations did not particularly see the need for them. 4 Emergency contraception (EC) was not available in any of these refugee settings.

Shifts in Reproductive Health Policy and Service In the mid- to late 1990s, a number of factors combined to create a substantial change in how refugee service and other organizations viewed programs and, specifically, reproductive health programs for refugees. Wulfl provided the first concerted look at the reproductive health status of women refugees and the services available to them. That their status was extremely poor and the services virtually nonexistent motivated many in refugee service organizations to address the issue. They were joined by reproductive health professionals from international and local organizations with long experience in providing services to nonrefugee populations. Prior to this time, there had been virtually no collaboration between refugee and reproductive health groups. Second, these events unfolded at the time of the 1994 International Conference

Reproductive Health Services Available in International Rescue Committee Programs

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on Population and Development (!CPD) and rhe Fourth World Conference on Women held in Beijing one year lacer. Both conferences strongly endorsed human rights and women's rights in all forms, including their right co reproductive health services. The rights of refugees were specifically noted. The !CPD Programme of Action asserted char "Scares have responsibilities with respect to refugees ... " as one of its principles and called for protection and assistance co internally displaced persons. 5 The Beijing Platform for Action addressed violence in all forms, including "rape in rimes of armed conflict," and specifically declared that this "can constitute a war crime and a crime against humanity and ... an act of genocide."6 These statements, endorsed by the community of nations, strengthened the resolve within refugee service and other organizations co promote reproductive health services for refugees. Third, sexual violence targeted at refugees became a major topic in world events, largely as a result of the wars in the former Yugoslavia and, to a lesser degree, in Rwanda. For the first time in history, rape was widely recognized as a weapon of war and genocide. This was reported and codified both in official documents, such as rhe Beijing Platform for Action as noted above, and in rhe popular press. 7• 11 The sheer volume of

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cases and debasement of human rights stimulated interest in and investigation of sexual violence. 12•13 le should be noted that most of rhe discussion focused on prevention of rape, punishment of perpetrators, and, co some degree, counseling of survivors. 1 Very little attention was paid to providing EC, especially in Rwanda and other developing countries. While sexual violence is hardly unique to refugee populations, refugee women and girls are at particularly high risk because families are splintered by war and displacement, a greater percentage of households are headed by women and children , combatants attempt to demoralize che enemy by raping and impregnating women and children, those with control of food and ocher means of survival may demand sex, and disenfranchised refugee men may resort co violence against refugee women. 10 These shifts provoked changes in reproductive health policy and service delivery, in which the need for EC was specifically addressed , largely due co the high visibility of sexual violence. In 1995, the United Nations High Commission for Refugees, the UN agency with primary responsibility for refugee health and safety, cook rhe lead in developing a field manual 15 to guide staff in service provision. It proposes that a "minimum initial service package" (MISP) for reproductive health, includ-

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ing EC, be implemented at the start of every refugee emergency. The manual describes oral contraceptives and the copper-bearing intrauterine device as methods of EC and stresses that EC "should never be seen as a substitute for other contraceprive methods." In 1997, the United Nations Population Fund (UNFPA), agreed ro fund MISP kits, thus removing the cost barrier for several field sites. Ir is still up to field staff to order them and track their arrival and distribution, however, tasks char may be neglected in the hectic first days of an emergency. This extra step has been eliminated by the recent inclusion of EC in the New Emergency Health Kit, the package of basic commodities assembled by the World Health Organization {WHO) and delivered immediately co every newly identified emergency site worldwide. Various agencies are collaborating in smalJer groups. The Reproductive Health for Refugees (RHR) Consortium, formed in 1994 and composed of seven nongovernmental organizations (CARE, the International Rescue Committee, John Snow Research and Training Institute, Marie Scopes International, the Women's Commission for Refugee Women and Chi ldren, the American Refugee Committee, and the Center for Population and Family Health at Columbia University) , advocates the

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inclusion of reproductive health services as a standard part of basic health care for refugees and has developed standardized instruments for program development. 16 The International Rescue Committee Experience Founded in 1933 at the request of Albert Einstein, the International Rescue Committee (IRC) is one of the world's leading refugee assistance organizations. The IRC's priority is to respond rapidly with life-saving primary and preventive health care, water, and sanitation services. Once a crisis is stabilized, programs are established that enable refugees to cope with life in exile through training, education, shelter, income generation, and selfreliance projects. For chose who cannot safely return to their countries of origin, the IRC helps arrange permanent resettlement in the United States. The IRC's refugee health services have been traditionally limited to emergency trauma treatment and primary health care, including basic maternal and child health care. Since 1992, the IRC has increasingly integrated reproductive health care services, such as family planning, STD and acquired immune deficiency syndrome education, emergency obstetrics, and gender violence prevention and response, in its health and education programs. The IRC now offers reproductive health services in 14 countries (see table). The IRC supports making EC available to refugee women, with their informed consent. A March 1998 survey of the 14 IRC reproductive health projects found chat EC is available in only 4 of the 8 sites chat responded to the survey. In all 4 settings, respondents were aware of oral contraceptives, but not copperbearing intrauterine devices, being used as EC. In Cote d'Ivoire, government health clinics provide EC to Ivorians and Liberian refugees, and it can be purchased in the market without a prescription. In August 1996, the National Council of Churches of Kenya and the IRC introduced EC into the Kakuma refugee camp in northern Kenya. One woman has used chis service following a rape. In Congo-Brazzaville, EC was available before the conflict in 1997, while afteiward it could be

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obtained only through a few private clinics due to drug shortages. Within three months after arriving in Brazzaville, the IRC obtained EC supplies from UNFPA as part of the MISP. This Sllpply was too late to help the women raped during the war, but is still of use to women raped in times of peace. The IRC has conducted training on the use of EC with rape survivors in one government ho pita! and has approval from the Ministry of Health to train an additional 250 health workers from 5 hospitals, 21 health centers, and 7 private clinics. The EC training is part of a four-day training to raise awareness of rape survivors' needs. In Tanzania, the IRC had provided EC on a limited basis, but in 1997, one-dose packages (EC4) were made available with informed consent to women who requested services within 72 hours of a reported rape. In the other four settings from which survey responses were received, the IRC respondents said that to the best of their knowledge EC was not available to refugees. The primary reasons were lack of demand, limited drug supplies, and insufficient knowledge or misinformation among staff. Staff indicated chat most refugee women either are not aware of the existence of EC or are misinformed about its mode of action, or that cultural taboos prevent them from seeking assistance after rape. In Cote d'Ivoire, women reportedly seek EC after the 72-hour limit and do not understand char it does not terminate an established pregnancy. Twenty-six percent of 1,000 people surveyed by the IRC in Core d'Ivoire during 1998 reported knowledge of EC, but some were poorly informed. In Thailand, the IRC's efforts to introduce contraceptives into Burmese refugee camps met resistance from the Karenni government in exile, which is predominantly Christian. Supplies are often a problem, for reasons of funding or logistics. In Liberia, the IRC ordered EC as part of the drug supply needed to restock the clinics after the war, but the US Office of Foreign Disaster Assistance (OFDA) does not supply contraceptives, so this part of the grant was not funded. This OFDA policy limits the ability of relief organizations to

respond quickly and thoroughly to the emergency reproductive health needs of refugees. Thus, supplemental funds are needed to make EC available. It cook three months for EC to reach CongoBrazzaville because of the extreme logistic difficulties inherent in introducing new servics in emergency settings. The third hindrance to EC use appears to be limited knowledge among IRC field staff. Although EC information packages from the RHR Consortium have been provided to IRC field sites, survey responses indicated that some staff are still misinformed about the safety and simplicity of the method.17 One staff member reported, "The main reason we have not introduced it is because it is a relatively expensive and sophisticated intervention, and in our view would have limited use." Another reported, "The principal problem has been people seeking (the) method when ic's too lace co do any good and may do some harm." These responses indicate chat the staff do not fully understand the lack of harmful side effects either to the health of the woman or to an already established pregnancy. Countering Sexual Violence: The Tanzania Case Since a primary indication for EC is rape, especially in refugee populations, we report a case study from che IRC project in che Kibondo camps in Tanzania. In October 1996, the IRC expanded its reproductive health program to address sexual violence among the refugees, who are from Burundi, and co offer EC co rape survivors. Phase one of the project used two methods for assessing the prevalence and nature of violence against women in the camps. In-depth qualitative interviews and a household, systematic survey of women age 12 to 49 were conducred by women leaders trained by IRC staff. The survey 18 found chat 27% of respondents had been raped since becoming refugees. The findings from the in-depth interviews were consistent with the survey results and yielded information on ocher forms of gender violence, such as domestic violence, sexual harassment, and forced marriage. Phase two attempted to reduce the

risk of sexual violence and to minimize its physical, social, and psychological consequences. 19 Refugee women who are elecred leaders in the camps were trained to do community education and to counsel survivors. Traditional birth attendants and social services paraprofessionals were given violence sensitivity training, which includes basic information on EC. A rape response medical protocol was developed using the UNHCR guidelines for the prevention of sexual violence. to Medical staff were trained to provide EC counseling and STD screening and prophylactic treatment to rape survivors, along with necessary trauma treatment. In coordination with the VNHCR protection officer, police reporrs are filed if a woman chooses to press charges. IRC staff encourage refugee leaders and local law enforcement officers to apprehend more perpetrators of violence. Anecdotal evidence provided by staff suggests that the refugees perceive EC as helpful to women, as it reduces the number of pregnancies resulting from rape, and maintain rhac it is accepted by che community. The major barrier identified by sraff is chat some women do not know they need co seek services within 72 hours of unprotected intercourse. This is particularly true of new arrivals. In-depth interviews indicated that women risk rape by soldiers when crossing the border into Tanzania. They arrive in the camp exhausted and traumatized by the flight. IRC community health workers now discuss the availability of EC in the orientation healch talk delivered to new arrivals. As of March 1998, 19 women in the Kibondo camps had used EC after receiving rape counseling and medical referrals, only 6% of the 316 rape survivors identified during the recall period of three years since the Burundian refugees came to Tanzania. An additional 5 young women who were forced into early marriages used EC after nonconsensual unprotected intercourse. The women's representatives and health workers follow up with each woman who reports being raped to offer support and referrals for further assistance. To date, none of the women who used EC conceived within three months of follow-up.

Discussion Prior to 1994, few reproductive health services were available to refugees, and EC was virtually nonexistent. indeed, the topic was hardly discussed. In 1998, major mulcilateral, bilateral, and nongovernmental refugee and reproductive health agencies endorsed the provision of comprehensive reproductive health services, including EC; produced joint and organization-specific policy statements; developed tools to facilitate planning and service delivery; and initiated service programs. Thus, some refugees, in some sites, may now receive some reproductive health services. While this situation is not yet satisfactory, it represents remarkable and rapid progress. Continued progress faces programmatic and policy challenges. The Tanzania case study suggests that the three major challenges in providing EC are women's lack of knowledge of the method, the lack of supplies, and the need for staff training. It is likely that programs in other sites, run by other organizations, will face the same concerns. Emergency contraception is largely unknown among refugees, so raising awareness is of great importance. Contraception in general is not well known among refugees, who are often among the most marginal groups in their countries of origin. A particular challenge is to identify means of reaching new arrivals who may be traumatized. How does one communicate the availability of this treatment to women who do not know about hormonal contraception? Providing basic information about EC to refugee health workers helped disseminate information to new arrivals in Tanzania. Since rape is known to be widely underreported in all settings, it is critical that refugee women learn that services are available. The availability of counseling, EC, and follow-up support may give them some incentive to report the rape, use the services, and improve their physical and psychosocial health. On the provider side of the equation, it is critical that rraining and supplies are made available to meet the demands of women who choose to use EC. The recent inclusion of EC in WHO's New Emergency Healch Kit is a great gain. Many major relief donors such as the US

State Department Bureau of Population, Refugees, and Migration, VNHCR, and UNFPA fund reproductive health programs for refugees and the displaced, including funds for contraceptive supplies. However, the OFDA, the primary US government donor for emergency relief, has to date funded only condoms for STD and human immunodeficiency virus prevention and not purchase of any contraceptives. Given the degree of sexual violence experienced during conflict and flight, it is critical that EC be made available from the beginning of an emergency response. But drug supplies are not enough. All levels of staff need to understand the difference between EC and abortion as well as the critical time frame for its use so they can provide effective services or referrals. How do we train health staff to deliver sensitive counseling on EC while they are managing a major emergency response? Clearly, training must be done in advance of the emergency or by a dedicated reproductive health advisor after it begins. Ir is critical that field staff learn the mechanisms of action and rhe fundamentals of informed consent counseling. The traumatized stare of rape (and war) survivors makes sensitivity training especially critical. Women deserve to receive clear, nonjudgmental information about their health and treatment options. Relief organizations need to make an institutional commitment to providing training and resources to enable field staff to provide good quality care to rape survivors, especially in the early phases of a displacement when violence against women is all too common. . Continued attention must also be paid to the need for policy and structural changes in refugee settings. Emergency contraception is a critical service for survivors of rape. Ir is not, however, an adequate response to the atmosphere of violence and intimidation that begets rape and other forms of gender violence, or to the insecurity that characterizes too many refugee camps. It does not obviate the need for legal recourse for rape survivors, or the need for safe environments where women, men, and children can begin to recover from the trauma of the violent conflicts they fled. lliil

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References

Classifieds

I. United Nations. Co11ventio11 Relating to the

Status ofRefi,gus,July 28, 1951. 2. United Nations. Protocol Relating to the Status of

&fogm, Jam,ary 31, I967. 3. US Committee for Refugees. World Refi,gee

Survey 1997: An Am111alAssessmmt ofConditiom Affecti11g Refi,gm, Asylum Seekers a11d lmer11ally Displaced People. Washington, DC: Immigration and Refugee Services of America; I 997. 4. Wulf D. Refugee Women a11d Reprod11ctive Health Care: Reassessi11g Priorities. New York, NY: Women's Commissioner for Refugee Women and Children; June I 994.

5. Population and Development: Programme of Acrio11 Adopted at the !ntemational Co11ference 011 Pop11lation and Development, Cairo, 5-13 September, 1994. Vol I . New York, NY: United Nations Deparcmenr of Economic and Social Information and Policy Analysis; March 1995. ST/ESA/SER.A/149.

6. The &ijing Declaration and The Platform far Action, The Fourth World Conference on Women, Beijing, Chi11a, 4-15 September 1995. New York, NY: United Nations; 1995. 7. Policy far Refi,gee Women Geneva: United Nations High Commissioner for Refugees; 1990. 8. G11ideli11es on the Protection of&fi,gee Women. Geneva: United Nations High Commissioner for Refugees; 1991 .

9. The Declaration on the Elimination of Violence Against Women. New York, NY: United Nations, General Assembly Resolution 48104, December 20, 1993. 10. Sexual Violence Agaimt Refi,geer: Guidelines 011 Prevention and Respome. Geneva: United Nations High Commissioner for Refugees; 1995. I I . Report 011 the Situation of H11ma11 Rights in the Territory ofthe Fornier Yugoslavia. Geneva: United Nations; 1993. United Nations Document E/CN.4.1993/50. 12. Shattered Lives: Sexual Violence During the Rwandan Genocide and Its Aftermath. New York, NY: Human Righrs Watch, Africa; 1996. 13. Richter-Lyonene E. Missio11 011 Gender-Based

War Crimes Against Women and Girls During the Genocide i11 Rwa11da. Geneva: The Coordination of Women's Advocacy, Ancien-College; 1995. 14.Swiss S, Giller JE. Rape as a crime of war: A medical perspective. JAMA. 1993; 270:6 I 2615. 15. An Inter-agency Field Ma111111l far Reprod11cti11e Health in Refi,gee Situations. Geneva: United Nations High Commissioner for Refugees; 1995. 16. Refi,gee Reprod11ctive Health Needs Assessment Field Tools. New York, NY: Reproductive Health for Refugees Consortium; I 997. 17. Emergency Comraceptive Pills: A Reso11rce Packet

for Health Care Providers and Programme Managers. Welcome, Md: Consortium for Emergency Contraception; I 996. 18. Nduna S, Goodyear L. Pain Too Deep for Tears:

Assessing the Prevalence ofSex11al and GenderBased Violence Agaimt B11r1mdian Refi,gm i11 Tam,mia. New York, NY: International Rescue Committee; 1997. 19. Nduna A, Rude D. A Saft Place Created By and

For Women: Sexual and Gender-BaseaViolmce Program Phase II Report. New York, NY: International Rescue Committee; I 998.

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Conference The National lnscicuce for the Clinical Application of Behavioral Medicine announces the 3,