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RHO archives : Topics : Refugee Reproductive Health

Annotated Bibliography

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General

Girard, F. and Waldman, W. Ensuring the reproductive rights of refugees and internally displaced persons: legal and policy issues. International Family Planning Perspectives 26(4):167-173 (December 2000). Available at: www.agi-usa.org/pubs/journals/2616700.html.
This article examines the legal and policy framework for the reproductive rights of refugees and internally displaced persons. International human rights law, refugee law, and humanitarian law—which largely consist of treaties binding on the nations that have signed them—create a broad legal framework for refugee rights. In addition, international consensus documents agreed on at the 1994 ICPD and 1995 World Conference on Women have helped define the sexual and productive rights of all women and men, including the displaced. These rights have been translated into working policies and field manuals by the Inter-agency Working Group on Refugee Reproductive Health, the Sphere Project, relevant UN agencies, and various non-governmental organizations. While there is a clear mandate and growing interest in meeting the reproductive needs of refugees, the policies, procedures, and staff of humanitarian agencies do not always correspond to international human rights standards.

Gururaja, S. Gender dimensions of displacement. Forced Migration Review 9 (December 2000). Available at: www.fmreview.org/FMRpdfs/FMR09/fmr9.5.pdf.
After outlining the different consequences of displacement for women and men, this article discusses UNICEF's priorities in developing programs to address women's issues. These include breaking down entrenched discriminatory attitudes against women, viewing women as survivors rather than as victims, involving both women and men in peace building and conflict resolution activities, sensitizing camp leaders and workers to gender issues to protect women, and reaching youth. The article also discusses the role and results of the Beijing conferences for female refugees.

Refugee Studies Centre. Reproductive health for displaced people: investing in the future. Forced Migration Review. 2004; Volume 19. Available at: www.fmreview.org/FMRpdfs/FMR19/FMR19full.pdf
The articles in the feature section of this issue hint at the breadth of reproductive health research and programming being carried out in conflict and post-conflict settings around the world. Forced Migration Online also prepared a useful supplementary resource guide to sources of information on reproductive health issues for refugees and internally displaced persons available at www.forcedmigration.org/browse/thematic/reproductivehealth.htm.

Schreck, L. Turning point: a special report on the refugee reproductive health field. International Family Planning Perspectives 26(4):162-166 (December 2000). Available at: www.agi-usa.org/pubs/journals/2616200.html.
This article traces the growing awareness of refugees' reproductive health needs by the international community, which was stimulated by new methods of gender analysis, emergencies in Yugoslavia and Rwanda, a seminal report by the Women's Commission for Refugee Women and Children, and the 1994 ICPD. Key UN agencies, bilateral donors, and NGOs responded by creating the Reproductive Health for Refugees Consortium and the Inter-agency working Group. These groups have played a key role in the development of a field manual and emergency service package for refugee reproductive health. Remaining challenges include coordinating a response in emergency situations, placing reproductive health coordinators, developing an effective monitoring system for reproductive health indicators, and bridging the gap between humanitarian and development assistance.

U.S. Committee for Refugees. World Refugee Survey 2004. Washington, DC: USCR; 2004. Available at: www.uscr.org/wrs04/main.html.
This annual report provides statistics on the numbers of refugees and internally displaced populations, their geographic distribution, and numbers of people granted asylum and resettled abroad or repatriated to their country of origin. This years report focuses on the issue of detention of refugees in prison like conditions.

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Impact of displacement and conflict on reproductive health

Bartlett LA et al. Maternal mortality among Afghan refugees in Pakistan, 1999-2000. Lancet. 2002;359:643-649.
This retrospective cohort study reports on 66 deaths among women refugees of reproductive age living in Pakistan. The deaths were identified by a census conducted in 12 Afghan refugee settlements. Verbal autopsies found that the leading cause of death was maternal causes. Compared with women who died of other causes, women who died of maternal causes faced significantly more barriers to health care, and their deaths were more likely to be preventable. Maternal mortality is likely to be an even greater burden among new refugees, who lack the stable camps and established health care services that these women enjoyed.

Berthiaume, C. Refugee women: do we really care? Refugees Magazine 100 (1995). Available at: www.unhcr.ch/cgi-bin/texis/vtx/home/opendoc.htm?tbl=MEDIA&id=3b542c634&page=.
An interview with UNHCR's coordinator for refugee women highlights recent changes in the organization's approach to meeting the needs of refugee women. The article describes the battle to develop a new policy on women refugees and to implement "people-oriented planning"—a new training program designed to encourage staff to perceive and address the needs of all refugees, including women and children. Changing the attitudes of UNHCR staff and sensitizing them to women's issues has proven to be a slow process.

Carballo, M. et al. Women and migration: a public health issue. World Health Statistics Quarterly 49:158-164 (1996).
This article compares the impact of voluntary and involuntary migration on health. The physical and psychosocial conditions under which people move are associated with adverse health outcomes, especially for women's reproductive health. The authors urge that the health of women migrants be more closely monitored and receive more attention from policy makers.

Carballo, M. et al. Health in countries torn by conflict: lessons from Sarajevo. Lancet 348:872-74 (1996).
This study of 3,000 pregnancies among women besieged in Sarajevo found that the number of live births decreased from 10,000 per year before the war to 2,000 per year during the war. Contraceptive use during the siege decreased to about 5 percent, while the number of abortions increased until there were more than two abortions for every live birth. The data also document increases in perinatal mortality (from 15.3 to 38.6 per 1,000 live births), low birth weight (from 5.3 to 12.8 per 1,000), and congenital abnormalities (from 0.37% to 3.0%). The authors ascribe the increases in morbidity and mortality to chronic stress, poor food intake, and reduced access to health services.

De Jong, J.P. et al. Lifetime events and posttraumatic stress disorder in 4 postconflict settings. JAMA 286(5):555-562 (2001).
Epidemiological surveys were conducted in Algeria, Cambodia, Ethiopia, and Gaza to examine the prevalence of and risk factors for post-traumatic stress disorder (PTSD) in post-conflict developing countries. Refugees made up a large proportion of those studied. The overall rate of PTSD ranged from 16 percent in Ethiopia to 37 percent in Algeria. Women had more symptoms than men in Cambodia and Algeria; men had more symptoms in Gaza; and there were no gender differences in Ethiopia. The only risk factor for PTSD common to all four countries was conflict-related trauma. Other important risk factors included torture (in Algeria, Ethiopia, and Gaza), psychiatric history and current illness (in Cambodia and Ethiopia), poor quality of camp housing (Algeria and Gaza), daily hassles (in Algeria), and youth domestic stress, death or separation in the family, and alcohol abuse in parents (in Cambodia). The authors conclude that PTSD is associated with multiple lifetime traumatic events in nonwestern conflict situations and that the determinants of PTSD are context dependent.

De Jong, J.P. et al. The prevalence of mental health problems in Rwandan and Burundese refugee camps. Acta Psychiatrica Scandinavica 102:171-177 (2000).
As part of a mental health intervention program in four refugee camps in Tanzania, a survey was conducted to determine how many people were in need of services. Because of the paranoid atmosphere in the camps, the survey used a General Health Questionnaire (GHQ) instead of an instrument that directly asked about traumatic events. Approximately half of the refugees had mental health problems serious enough to impede their ability to cope and to require psychosocial support. Poor scores on the GHQ were associated with older age and less education, but not with gender. The authors conclude that, given the large numbers of refugees in need of help, individual counseling is not feasible. Rather, they recommend psychosocial interventions that strengthen community structures and that are directed at groups, for example, mass psycho-education campaigns and therapeutic activity centers. The authors also conclude that the GHQ is useful in identifying groups in need of special attention.

Gardner, R. and Blackburn, R. People who move: new reproductive health focus. Population Reports, Series J, No. 45 (1996). Available at: www.jhuccp.org/.
This extensive literature review compares and contrasts the reproductive health needs of voluntary migrants, refugees, and internally displaced persons, and reviews international efforts to offer reproductive health services to these special populations. The report examines the characteristics of voluntary and involuntary migrants, including their fertility levels and knowledge and use of family planning. It reviews their reproductive health concerns and examines the challenges in delivering reproductive health information and services to them.

Holmes, W. HIV and human rights in refugee settings. Lancet 358:144-146 (2001). Available at: http://pdf.thelancet.com.
The author explores how a human rights framework can (1) help us understand the vulnerability of refugees to AIDS by enabling the collection of data, and (2) generate new ways of addressing the problem by focusing on the disparate roles and responsibilities of men and women.

Isis-Womens International Cross Cultural Exchange (Isis-WICCE). Womens Experiences of Armed Conflict in Uganda Gulu District, 1986-1999. Kampala, Uganda: Isis-WICCE (December 2000). Available at: www.isis.or.ug/gulureportone.htm).
To examine the impact of the long-running war in northern Uganda on women, researchers conducted interviews and focus group discussions with internally displaced people living in camps. Womens responsibilities increased as the men were lost to deaths, abductions, emigration, and military service. Many women were exposed to traumatic experiences, which contributed to a host of health problems, including untreated fevers, reproductive health complications, STIs, broken and severed limbs, and psychosocial problems. Marital break-ups, forced early marriages, rapes, and unwanted pregnancies were frequent. Girls education has suffered, further depressing the status of women.

Jamieson, D.J. et al. An evaluation of poor pregnancy outcomes among Burundian refugees in Tanzania. JAMA 283(3):397-402 (2000). Available at: http://jama.ama-assn.org/cgi/reprint/283/3/397.pdf.
This study used a cross-sectional record review and survey to measure pregnancy outcomes over a five-month period among Burundian refugees living in a refugee camp in Tanzania. Poor pregnancy outcomes were common: the fetal death rate was 45.5 per 1000 live births; the neonatal mortality rate was 29.3 per 1000 live births; and 22.4 percent of all live births were low birthweight. Three factors significantly increased the risks of all three outcomes: high socioeconomic status prior to becoming a refugee, first or second pregnancy, and three or more episodes of malaria during pregnancy. Neonatal and maternal deaths together accounted for 16 percent of all deaths in the refugee camp during the study period, which made reproductive health problems the third leading cause of death, after malaria and acute respiratory infections. The authors caution that their findings probably underestimate the true extent of poor pregnancy outcomes, including deaths, because of difficulties in data collection.

Kalpieni, E., and Oppong, J. The refugee crisis in Africa and implications for health and disease: a political ecology approach. Social Science and Medicine 46(12):1637-1653 (1998).
This article reviews the geographical patterns of refugee flows in Africa and their historical causes. The authors describe how the violence that produces refugee flows also disrupts livelihoods and health services, creating conditions that promote the transmission of infectious disease, including outbreaks of dangerous new viruses. Refugee status also is linked with reproductive health and mental health.

Khaw, A.J. et al. HIV risk and prevention in emergency-affected populations: a review. Disasters 24(3):181-197 (2000).
During complex emergencies, rape, the use of sex as a survival strategy, host-refugee interactions, high rates of STIs, mother-to-child HIV transmission, and transfusion risks all contribute to the transmission of HIV. At the same time, the silent nature of the epidemic, the stigma associated with the diagnosis, limited attention by assistance organizations, the lack of a functioning health care system, and the lack of data on HIV prevalence have all discouraged the problem from being addressed. The authors argue that after the initial phase of an emergency, HIV-prevention activities must be far more extensive than those offered as part of the Minimal Initial Services Package (MISP) in order to prevent an epidemic. The authors identify priority areas for research and intervention.

Marshall, R. Refugees, feminine plural. Refugees Magazine 100 (1995). Available at: www.unhcr.ch/.
Interviews with UNHCR staff illustrate how conditions in refugee camps, such as the distribution of supplies or the location of latrines, can affect women by limiting their access to food and shelter, or by increasing their vulnerability to violence. UNHCR is trying to improve services for refugee women, for example, by including sanitary towels in family supply packs and by improving protection for women foraging for firewood.

McGinn, T. Reproductive health of war-affected populations: what do we know? International Family Planning Perspectives 26(4):174-180 (December 2000). Available at: www.agi-usa.org/pubs/journals/2617400.html.
This thorough review article presents all available data on how displacement affects women's reproductive health status. Fertility levels may go up or down in these populations. In the short term, they may be affected by the severity of the emergency; in the long term, however, they may be affected by broader social and demographic factors. While the risks and outcomes of pregnancy are poor during the active stages of conflict, once the situation stabilizes refugees may receive better health care, with better outcomes, than in their home country. Displacement and the presence of the military increase the spread of STIs during conflicts; this affects host communities as well as refugees. While refugee women probably experience rape and other forms of sexual violence more often than settled women, it may not affect them in the same way because of the multiple traumas they suffer.

Mollica, R.F. et al. Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. JAMA 286(5):546-554 (2001).
This follow-up study was conducted three years after an initial study of the mental health status of Bosnian refugees living in a refugee camp in Croatia. In order to investigate the long-term psychological consequences of the refugee experience, those still living in the region were reinterviewed as were relatives of those who had died. Among participants who were diagnosed with depression or post-traumatic stress disorder during the first study, 45 percent continued to have the disorders three years later. Among those who were asymptomatic in the original study, 16 percent had since developed one or both disorders. Mortality was associated with social isolation, male sex and older age, but not with psychiatric disorders. Healthier, better educated refugees were more likely to emigrate.

Rasekh Z et al. Women's health and human rights in Afghanistan. JAMA. 1998;280:449-455. Available at: www.ama-assn.org/.
Respondents to this cross-sectional survey include 80 Afghan women living in Kabul and 80 Afghan women who migrated to Pakistan. Most women reported a decline in their physical and mental health status and their access to health care in the two years after the Taliban regime took power in Afghanistan. Based on self-reported symptoms, 42 percent met diagnostic criteria for post-traumatic stress disorder, 97 percent for major depression, and 86 percent for anxiety. Refugee women in Pakistan reported worse physical and mental health status than women who remained in Afghanistan. The authors conclude that the health of Afghan women is inextricably bound to their human rights status.

Waldman, R. and Martone, G. Public health and complex emergencies: new issues, new conditions. American Journal of Public Health 89(10):1483-1485 (1999).
This article describes four basic changes in the response to humanitarian emergencies, which are increasingly complex political emergencies rather than natural disasters. First, the epidemiological profile has changed so that protecting life with dignity has become as important as minimizing mortality. As part of this trend, the consequences of violence and reproductive health services have taken on new importance. Second, NGO relief organizations increasingly must work alongside the military, who can offer protection and logistics, and human rights workers, who collect legal evidence of violations. Third, more attention is being paid to the quality of relief services offered, and the field is becoming professional. Fourth, the inadequacy of our knowledge of what should be done during emergencies, for example, in the areas of reproductive and mental health, is increasingly recognized.

Wali, S. et al. The impact of political conflict on women: the case of Afghanistan. American Journal of Public Health 89(10):1474-1476 (1999).
This article uses the case of Afghanistan to illustrate how the political circumstances that cause humanitarian disasters impedes their resolution and undermines women's health and human rights. Under the Taliban regime, Afghan women have lost their ability to work, are frequent victims of abuse, and are denied access to food, health care, and other resources. The authors call on the international community to give higher priority to human rights concerns when addressing conflicts.

Walker B. The question of gender: refugee participation. Refugee Participation Network. 1995;20. Available at: www.fmreview.org/rpn202.htm.
This article contends that gender considerations are essential in offering effective and equitable assistance to refugees and other people affected by disasters. It describes a complex interaction between gender issues and health. For example, when conventional gender roles place refugee men in charge of the distribution of scarce resources, women do not receive their fair share of food, shelter, and health care. Unless program managers appreciate the impact of gender and take action to mitigate it, refugee relief activities may worsen existing gender inequalities. The author argues that refugee relief programs should take advantage of the disruption of displacement to fight existing gender inequalities and help women make gains.

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Assessing the reproductive health needs of displaced populations

Busza, J. and Lush, L. Planning reproductive health in conflict: a conceptual framework. Social Science & Medicine 49:155-171 (1999).
The conceptual framework presented here allows program managers to predict the reproductive health outcomes of an emergency and configure services without going through a lengthy needs assessment. The first step is to review existing data on the demographic characteristics, reproductive health status, available health services, and attitudes and beliefs of the population before the emergency occurred. The second step is to analyze how the nature of the conflict (including the levels of violence, social breakdown, and reduced access to services) will affect the refugees' reproductive health status. The authors apply their framework to two cases: the flow of Rwandan refugees to Tanzania and the ongoing conflict in Cambodia.

McGinn, T. and Purdin, S. Monitoring and Evaluation Tool Kit: Draft for Field Testing. Reproductive Health for Refugees Consortium (January 2003). Available at: www.rhrc.org/resources/general_fieldtools/toolkit/index.htm.

Palmer, C. Rapid appraisal of needs in reproductive health care in southern Sudan: qualitative study. British Medical Journal 319(7212):743-748 (1999). Available at: www.bmj.org/cgi/content/full/319/7212/743).
Interviews and group discussions were conducted to assess the reproductive health needs of internally displaced and settled communities in an area of conflict in Sudan. Community members clearly recognized certain reproductive health needs, especially STIs and miscarriages. They acknowledged the existence of several problems, including abortions, domestic violence, and maternal mortality, that service providers denied or downplayed. Perceived needs varied by age, sex, and the degree of displacement; settled communities viewed health as a greater threat than displaced communities, which were focused on basic subsistence. The author favors community participation in this type of needs assessment because it overcomes limitations on information provided by leaders and service providers, reveals differences in the views of disparate community groups, shows how traditional beliefs and attitudes may decrease the use of health services, and raises community awareness of health issues.

Reproductive Health Response in Conflict Consortium. Emergency Obstetric Care: Critical Need among Populations Affected by Conflict. New York: RHRCC; 2004. Available at: www.rhrc.org/pdf/EmOC_03-10-04.pdf.
This report documents the availability of emergency obstetric care (EmOC) services in selected sites in nine countries: Bosnia-Herzegovina, Kenya, Liberia, Pakistan, Sierra Leone, Southern Sudan, Tanzania, Thailand and Uganda. The purpose of the report is to provide summary information on the status of EmOC in these locations. In addition, this information may be used to guide assessments used to design and implement future EmOC programs and as a tool to advocate for better quality EmOC for conflict-affected women and girls.

Salama, P. and Dondero, T.J. HIV surveillance in complex emergencies. AIDS 15 (Suppl. 3):S4-S12 (2001).
Because forced migration can change HIV transmission patterns, it is important to track HIV levels in refugee populations. Rapid population movements, however, make it difficult to evaluate trends over time using conventional sentinel surveillance systems. Also, the national AIDS control programs that conduct routine HIV surveillance may consider refugees to be outside their responsibility. In the absence of sentinel surveillance systems, the authors outline alternative approaches to HIV surveillance in complex emergencies that use population-based surveys and secondary data sources. Their approach is illustrated with detailed descriptions of HIV/AIDS assessments conducted among Somali and Sudanese refugees.

Wulf, D., ed. Refugee Women and Reproductive Health Care: Reassessing Priorities. New York: Women's Commission for Refugee Women and Children, International Rescue Committee (1994).
This landmark report focuses attention on the reproductive health needs of refugee women by describing health conditions and services in refugee communities around the world in a series of case studies. The editor concludes that the comprehensive reproductive health needs of refugee and displaced women are not being met in the majority of refugee sites. Many pregnancies in refugee settings are high risk because of close spacing, the mother's age or number of previous pregnancies, or because the mother suffers from serious physical depletion, endemic diseases, and/or poor nutrition. The editor stresses the need for health professionals, paramedics, traditional birth attendants, and community health workers commonly found in refugee settings to be trained to emphasize effective and adequate birth spacing for refugee women.

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Designing reproductive health services for refugees

Benjamin, J. AIDS prevention for refugees: the case of Rwandans in Tanzania. AIDScaptions 3(2) (1996). Available at: www.fhi.org/. This case study describes the experience and lessons learned by AIDS prevention efforts in Tanzanian refugee camps. The project promoted behavioral change, including condom use, fewer sexual partners, loyalty to one partner, and aggressive treatment and follow-up of STIs. Multiple NGOs collaborated on project activities, which included a network of AIDS community educators, STI treatment and health education sessions at outpatient clinics, and home-based care for HIV-positive refugees. Challenges to reducing AIDS transmission included the high rate of sexual assault, difficulties in reaching vulnerable young people, and gaining acceptance by the refugee community.

Bosmans M, Temmerman M. Towards a Comprehensive Approach of Sexual and Reproductive Rigths and Needs of Women Displaced by War and Armed Conflict: A Practical Guide for Programme Officers. Ghent, Belgium: International Centre for Reproductive Health, Ghent University; 2003. Available at: www.rhrc.org/pdf/idp_rights.pdf.
This guide provides an overview of the key issues in conflict situations that affect the sexual and reproductive health rights (SRH) needs of women. It is intended for program officers providing humanitarian assistance who are not necessarily medically trained and may not be familiar with all aspects of SRH needs of refugees and internally displaced populations.

Brundtland, G.H. Mental health of refugees, internally displaced persons, and other populations affected by conflict. Acta Psychiatrica Scandinavica 102:159-161 (2000).
Individual psychiatric care has a limited impact in refugee settings because of the large number of people in need and the lack of resources. Emergency interventions and ongoing health care systems for refugees should instead employ community-based psychosocial care that helps prevent morbidity and improves psychosocial functioning. This approach requires adapting Western theories, instruments, and interventions to refugee settings and different cultural contexts, providing training and support for non-mental health professionals, and the development of user-friendly tools. The author describes WHOs contributions to this effort.

Byrne, B. and Baden, S. Gender, Emergencies and Humanitarian Assistance. BRIDGE Report No. 33. Brighton, U.K.: Institute of Development Studies (November 1995). (www.ids.ac.uk/bridge/Reports/re33c.pdf)
This paper urges relief organizations to employ gender analysis to make their programs more sensitive to gender concerns and to ensure that their interventions do not further marginalize women. After analyzing differences in women's and men's vulnerabilities, coping strategies, and power relations during emergencies, the authors recommend that relief organizations: take proactive and creative measure to consult women, take special measures to protect women from violence, strengthen women's organizations, consider gender relations when designing aid distribution systems, and include women and girls in all educational and training opportunities. The report also addresses constraints on integrating gender into emergency policy. Appendices include UNHCR policy on refugee women and Oxfam gender guidelines on emergencies.

Davidson S, Lush L. What is reproductive health care? Refugee Participation Network. 1995;20. Available at: www.fmreview.org/rpn201.htm.
This article describes the emerging consensus on refugee reproductive health needs. Refugees need reproductive health services in five key areas: safe motherhood, sexual violence, family planning, abortion, and STIs. The authors review each of these health needs and the best way to offer services in each area.

Ecker, N. Where there is no village: teaching about sexuality in crisis situations. SIECUS Report 26(5):7-10 (1998).
Based on her experience in the Great Lakes region of Africa, the author describes how living in refugee camps exacerbates young people's reproductive health problems at the same time that it reduces their access to accurate information on sexuality and reproductive health matters. The author proposes a series of actions to raise awareness of adolescent refugees' social, emotional and health needs, to mobilize support for adolescent sexuality education, and to implement sexuality education as part of refugee health services.

Goodyear L, Hynes M. Integrating reproductive health into emergency response assessments and primary health care programs. Journal of Prehospital and Disaster Medicine. 2001;16(4):223-230. Available at: http://pdm.medicine.wisc.edu/Goodyear.htm.
This article examines currently available resources for conducting rapid assessments of health needs and services during complex emergencies. Their respective strengths and weaknesses are discussed, particularly for assessing a population’s reproductive health needs, and for fostering the integration of reproductive health and primary health-care services, and for designing health services delivery.

Hafeez A et al. Integrating health care for mothers and children in refugee camps and at district level. BMJ. 2004;328:834-836. Available at: http://bmj.bmjjournals.com/.
Health care for mothers and children is inadequate in most refugee situations and in poorly resourced countries. The authors argue that, as well as providing primary (home-based) care for basic health care, there is a need to integrate primary care with adequately functioning hospital-based care for a healthcare system to succeed.

Hynes, M. et al. Reproductive health indicators and outcomes among refugee and internally displaced persons in postemergency phase camps. Journal of the American Medical Association 288(5):595-603 (2002). Available at: http://jama.ama-assn.org/cgi/reprint/288/5/595.pdf.
This retrospective study examines data on 688,766 refugees and internally displaced persons living in 53 camps in Azerbaijan, Ethiopia, Mynamar, Nepal, Tanzania, Thailand, and Uganda. Reproductive health outcomes (defined as neonatal and maternal mortality rates, percentage of low-birthweight newborns, and incidence of complications of unsafe or spontaneous abortions) are compared for refugees, the populations of the host countries, and the countries of origin. Generally, reproductive health outcomes were better in the refugee camps than in either the host country or country of origin. Better outcomes were associated with camps that had been longer, higher numbers of health personnel, and supplementary feeding programs. The authors attribute these results to camp residents better access to health services, food, water, and sanitation. They conclude that health programs in post-emergency phase refugee camps may provide guidance to improving reproductive health outcomes among host country populations.

Krause, S. et al. Programmatic responses to refugees' reproductive health needs. International Family Planning Perspectives 26(4):181-187 (December 2000). Available at: www.agi-usa.org/pubs/journals/2618100.html.
This article reviews reproductive health programs implemented in varying refugee contexts. The Minimum Initial Service Package (MISP) is a set of priority health activities to be implemented in the earliest days of an emergency. While health kits developed by UNFPA have filled the need for emergency supplies, it has proven more difficult to find experienced personnel to staff MISP programs. In the area of safe motherhood, field staff skilled in manual vacuum aspiration are needed, and more needs to be done to ensure that obstetric care is available in refugee settings. Family planning services face several challenges, including rapid deployment during the emergency phase, bureaucratic resistance, and maintaining a consistent supply of commodities. The biggest obstacle to addressing sexual and gender-based violence is the social stigma that silences survivors and inhibits refugee service providers. As for STIs, they remain a sensitive issue in most cultures so that HIV/AIDS services are best integrated into broader health programs.

Mayaud, P. The challenge of sexually transmitted infections control for HIV prevention in refugee settings: Rwandan refugees in Tanzania. Transactions of the Royal Society of Tropical Medicine and Hygiene 95: 121-124 (2001).
This article describes the design and implementation of a large-scale HIV/AIDS and STI intervention in camps for Rwandan refugees in Tanzania from 1994 to 1996. A rapid needs assessment found a high potential for an epidemic spread of HIV/AIDS and STIs given the refugee population mix. A four-part intervention was mounted, including mass educational campaigns, peer educators working among bar and brothel workers, condom distribution, and STI services at outpatient clinics. Repeat rapid surveys were used to measure trends in key indicators. Although there was little change in sexual behavior patterns, HIV/AIDS rates remained lower and more stable in the refugee camps than among other populations of displaced Rwandans.

McGinn T, Casey S, Purdin S, March M. Reproductive Health for Conflict-affected People: Policies, Research and Programmes. London: Overseas Development Institute; 2004. Humanitarian Practice Network Paper, No. 45. Available at: www.rhrc.org/pdf/networkpaper045.pdf.
This paper aims to equip humanitarian practitioners with essential information for delivering effective reproductive health services to people in crises.

Morrison, V. Contraceptive need among Cambodian refugees in Khao Phlu Camp. International Family Planning Perspectives 26(4):188-200 (December 2000). Available at: www.agi-usa.org/pubs/journals/2618800.html.
To understand why contraceptive use was so low at a camp for Cambodian refugees in Thailand, interviews and focus groups were conducted with women, men, midwives, and traditional birth attendants. While 82% of married women wanted to stop or delay childbearing, only 12% used modern contraception. Obstacles reported by the women included fear of side effects, discomfort over seeking contraception, and lack of information. Men also knew little about contraception. Both midwives and men held restrictive attitudes about which women should have access to family planning. The author concludes that the stress of the refugee situation intensified existing cultural barriers to the use of contraception and recommends educational efforts to dispel misperceptions and make women aware of available services. Having traditional birth attendants distribute contraceptives might also overcome problems of shyness and transportation.

Nersesian P, Brady B. Controlling STD/HIV with dynamic refugee settings. Refugee Participation Network. 1995;20. Available at: www.fmreview.org/rpn208.htm.
After briefly reviewing the factors that increase the risk of STIs and HIV in displaced populations, this article discusses how to tailor successful approaches to STI and HIV control to refugee settings. Emphasis is placed on addressing STI/HIV transmission in the initial stages of an emergency, using syndromic approaches to STI management, and building an adequate logistical system to procure, store, and distribute drugs.

Nieves-Grafals, S. Brief therapy of civil war-related trauma: a case study. Cultural Diversity and Ethnic Minority Psychology 7(4):387-398 (2001).
Brief treatment of individuals, couples, and families is especially well-suited to refugees who have developed post-traumatic stress disorder (PTSD) as a result of exposure to violence and torture. Over the course of 10 to 20 sessions, short-term psychotherapy can relieve symptoms, reinforce refugees coping skills, help them regain their capacity to trust people, help them develop a support system, expedite adaptation to the host country, reduce barriers to full functioning, and establish a therapeutic bond that will facilitate future therapy. This article details what the therapist should do in each phase of therapy, and discusses therapeutic concerns and techniques that are specific to certain cultures.

Ostea K. Prioritizing reproductive health for refugees. Initiatives in Reproductive Health Policy. 1999;3(1):1-3. Available at: www.ipas.org/.
This brief article reviews the progress made in strengthening reproductive health planning and services for refugees, especially in the area of unwanted pregnancy and abortion. It lists recent developments in equipment supply, technical materials, policy and advocacy, research and monitoring, and programmatic action.

Palmer, C. Reproductive health for displaced populations. Relief and Rehabilitation Network (RRN) Paper No. 24. London: Overseas Development Institute (1998).
This report analyzes why it is so difficult to implement the reproductive health agenda in emergency settings. After presenting data on the reproductive health status of refugees and internally displaced persons, the paper reviews current reproductive health programs and policies for displaced populations and presents six brief case studies. The author concludes that program managers implementing refugee reproductive health services face three key issues: prioritizing various reproductive health services, assessing the needs of the refugee community, and ensuring a high quality of care.

PATH. Meeting the reproductive health needs of refugees. Outlook. 1999;17(4):1-5. Available at: www.path.org/files/eol17_4.pdf.
This review article describes how conditions faced by displaced populations undermine their health and outlines the response of relief organizations. Different services are needed during each phase of a refugee situation. Minimal reproductive health interventions can reduce mortality during an emergency, while refugees living in stable situations require comprehensive services. When refugees return home, planning and support can help ensure the continuity of services. Essential reproductive health services for displaced populations consist of safe motherhood, HIV/AIDS and other STIs, family planning, gender-based violence, and adolescent needs. Actively involving the refugee community, tapping local resources and the expertise of the wider public health community, and increasing coordination between relief agencies can improve the effectiveness, quality, and sustainability of reproductive health services for refugees.

Poore P. Delivering reproductive health care: an examination of constraints. Refugee Participation Network. 1995;20. Available at: www.fmreview.org/rpn205.htm.
This article examines the practical, logistical, and socio-cultural constraints on delivering adequate reproductive health services to refugees. The author suggests that services could be improved by making better preparations, creating an international code of conduct to ensure coordination between relief agencies, standardizing the management of reproductive disorders, acknowledging which reproductive health needs take priority, protecting women from sexual violence, investing in the capacity of the host government, investing in the social services of developing countries, and reaffirming the right to health for all.

Project Counseling Services. Refugee and Returning Women: Challenges and Lessons from Guatemala. PROWID Report-in-Brief. Washington, DC: International Center for Research on Women and The Centre for Development and Population Activities (1999). Available at: www.cedpa.org/publications/PROWID/LA/refugee_guatemala.pdf.
This study examined how Guatemalan women's experiences as refugees and their eventual return home affected their daily lives, including their health care. In-depth interviews were conducted with 30 refugee women 3 to 5 years after their return from Mexican refugee camps and also with 6 women who remained in Guatemala throughout the civil war. Researchers found that the women made progress in many areas during their stay in refugee camps. For example, many learned how to read and write, participated in skills training courses, and founded women's organizations. Upon their return home, however, the women lost external support and men reasserted their dominance. In the area of health, this meant the loss of free health services, an abrupt end to training women as health workers, and active discouragement of family planning.

Reproductive Health for Refugees (RHR) Consortium. Refugees and Reproductive Health Care: The Next Step. New York: RHR Consortium (1998). Available at: www.rhrc.org under "Resources.")
Nine lengthy case studies examine refugee situations around the globe. Each case study describes the causes of the refugee flow, the agencies offering services, health conditions, reproductive health services offered, and suggestions for the future. Based on these case studies, the Consortium makes eight recommendations to improve refugee reproductive health services. These recommendations highlight the importance of refugee reproductive health specialists, effective referral systems, cultural sensitivity, tapping the experience of the wider public health community, high-level advocacy, logistics and procurement, multiple models of service delivery, and addressing refugees' broader needs. The introduction also reviews the international, NGO, and relief organizations involved in refugee reproductive health.

Reproductive Health Response in Conflict Consortium. Emergency Contraceptions for Conflict-Affected Settings: A Distance Learning Module. New York: RHRCC; 2004. Available at: www.rhrc.org/pdf/ec_module_02apr041.pdf.
The Women’s Commission for Refugee Women and Children developed this module on behalf of the RHRC Consortium. The RHRC Consortium is working to mainstream emergency contraception (EC) by increasing awareness and knowledge of EC and improving access to and demand for EC in appropriate program locations. The EC module is available in brochure form and will be available as an interactive module on the Internet, as a CD-ROM, and in different languages.

UNAIDS. Refugees and AIDS: UNAIDS Point of View. UNAIDS Best Practice Collection, Geneva: UNAIDS (1997). Available at: www.unaids.org/html/pub/publications/irc-pub04/refug-pov_en_pdf.htm or www.unaids.org/html/pub/publications/irc-pub04/refug-pov_en_pdf.pdf.
HIV/AIDS poses a special threat after disasters because of the urgent need for blood transfusions, changes in sexual behavior due to social upheaval and sexual coercion, the mixing of populations with different levels of HIV awareness and infection in refugee camps, and lack of access to condoms and health care. Top priorities to reduce the transmission of HIV/AIDS during emergencies are to create a safe blood supply, ensure that relief workers follow universal medical precautions, provide condoms, disseminate information about HIV/AIDS to refugees, protect vulnerable refugees from violence and abuse, reduce the risks of drug injecting, and increase access to health facilities. Available in English and French.

Waszak C, Tucker B. The reproductive health needs of adolescent refugees. Refugee Participation Network. 1995;20. Available at: www.fmreview.org/rpn207.htm.
This paper presents two case studies of adolescent refugees living in Thailand. The first explores the need for STI services among young male students who fled Myanmar and now live in Bangkok without their families. The second case study contrasts the reproductive health needs of two groups of adolescent girls in refugee camps: married Hmong teenagers with intact families and single lowland Laotian and Vietnamese teenagers who are separated from their parents. The authors conclude that the reproductive health needs of adolescent refugees vary widely, depending on cultural norms, patterns of adult authority, and current behavior.

Watters, C. Emerging paradigms in the mental health care of refugees. Social Science & Medicine 52:1709-1718 (2001).
This article critically examines approaches taken toward the mental health care of refugees. It argues that Western psychiatric categories have been inappropriately applied to refugee populations, and that the social, political, and economic factors that shape the refugee experience have been ignored. Even so-called "culturally sensitive" services do not address these fundamental problems. The author advocates a holistic approach that merges health and social care; takes account of refugees experience, perceptions, and expressed needs; and considers how policy issues and institutional factors relate to individual treatment programs.

Womens’ Commission for Refugee Women and Children, the Interagency Working Group on Reproductive Health in Refugee Situations. Refugees and AIDS: What Should the Humanitarian Community Do? New York: WCRWC; 2002. Available at: www.rhrc.org/pdf/aids_refugees.pdf.
The Womens’ Commission for Refugee Women and Children developed this manual to provide user-friendly guidance and mobilize humanitarian actors working in refugee settings to address HIV/AIDS. The document aims to stimulate policy makers, managers, and implementers to strengthen their response to HIV/AIDS.

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