Community-based assessment of human rights in a complex humanitarian emergency: the Emergency Assistance Teams-Burma and Cyclone Nargis.

INTRODUCTION: Cyclone Nargis hit Burma on May 2, 2008, killing over 138,000 and affecting at least 2.4 million people. The Burmese military junta, the State Peace and Development Council (SPDC), initially blocked international aid to storm victims, forcing community-based organizations such as the Emergency Assistance Teams-Burma (EAT) to fill the void, helping with cyclone relief and long-term reconstruction. Recognizing the need for independent monitoring of the human rights situation in cyclone-affected areas, particularly given censorship over storm relief coverage, EAT initiated such documentation efforts. METHODS: A human rights investigation was conducted to document selected human rights abuses that had initially been reported to volunteers providing relief services in cyclone affected areas. Using participatory research methods and qualitative, semi-structured interviews, EAT volunteers collected 103 testimonies from August 2008 to June 2009; 42 from relief workers and 61 from storm survivors. RESULTS: One year after the storm, basic necessities such as food, potable water, and shelter remained insufficient for many, a situation exacerbated by lack of support to help rebuild livelihoods and worsening household debt. This precluded many survivors from being able to access healthcare services, which were inadequate even before Cyclone Nargis. Aid efforts continued to be met with government restrictions and harassment, and relief workers continued to face threats and fear of arrest. Abuses, including land confiscation and misappropriation of aid, were reported during reconstruction, and tight government control over communication and information exchange continued. CONCLUSIONS: Basic needs of many cyclone survivors in the Irrawaddy Delta remained unmet over a year following Cyclone Nargis. Official impediments to delivery of aid to storm survivors continued, including human rights abrogations experienced by civilians during reconstruction efforts. Such issues remain unaddressed in official assessments conducted in partnership with the SPDC. Private, community-based relief organizations like EAT are well positioned and able to independently assess human rights conditions in response to complex humanitarian emergencies such as Cyclone Nargis; efforts of this nature must be encouraged, particularly in settings where human rights abuses have been documented and censorship is widespread.

Community-based delivery of maternal care in conflict-affected areas of eastern Burma: perspectives from lay maternal health workers.

In settings where active conflict, resource scarcity, and logistical constraints prevail, provision of maternal health services within health centers and hospitals is unfeasible and alternative community-based strategies are needed. In eastern Burma, such conditions necessitated implementation of the "Mobile Obstetric Maternal Health Worker" (MOM) project, which has employed a community-based approach to increase access to essential maternal health services including emergency obstetric care. Lay Maternal Health Workers (MHWs) are central to the MOM service delivery model and, because they are accessible to both the communities inside Burma and to outside project managers, they serve as key informants for the project. Their insights can facilitate program and policy efforts to overcome critical delays and insufficient management of maternal complications linked to maternal mortality. Focus group discussions (n=9), in-depth interviews (n=18), and detailed case studies (n=14) were collected from MHWs during centralized project management meetings in February and October of 2007. Five case studies are presented to characterize and interpret the realities of reproductive health work in a conflict-affected setting. Findings highlight the process of building supportive networks and staff ownership of the MOM project, accessing and gaining community trust and participation to achieve timely delivery of care, and overcoming challenges to manage and appropriately deliver essential health services. They suggest that some emergency obstetric care services that are conventionally delivered only within healthcare settings might be feasible in community or home-based settings when alternatives are not available. This paper provides an opportunity to hear directly from community-based workers in a conflict setting, perspectives seldom documented in the scientific literature. A rights-based approach to service delivery and its suitability in settings where human rights violations are widespread is highlighted.

Access to essential maternal health interventions and human rights violations among vulnerable communities in eastern Burma.

BACKGROUND: Health indicators are poor and human rights violations are widespread in eastern Burma. Reproductive and maternal health indicators have not been measured in this setting but are necessary as part of an evaluation of a multi-ethnic pilot project exploring strategies to increase access to essential maternal health interventions. The goal of this study is to estimate coverage of maternal health services prior to this project and associations between exposure to human rights violations and access to such services. METHODS AND FINDINGS: Selected communities in the Shan, Mon, Karen, and Karenni regions of eastern Burma that were accessible to community-based organizations operating from Thailand were surveyed to estimate coverage of reproductive, maternal, and family planning services, and to assess exposure to household-level human rights violations within the pilot-project target population. Two-stage cluster sampling surveys among ever-married women of reproductive age (15-45 y) documented access to essential antenatal care interventions, skilled attendance at birth, postnatal care, and family planning services. Mid-upper arm circumference, hemoglobin by color scale, and Plasmodium falciparum parasitemia by rapid diagnostic dipstick were measured. Exposure to human rights violations in the prior 12 mo was recorded. Between September 2006 and January 2007, 2,914 surveys were conducted. Eighty-eight percent of women reported a home delivery for their last pregnancy (within previous 5 y). Skilled attendance at birth (5.1%), any (39.3%) or > or = 4 (16.7%) antenatal visits, use of an insecticide-treated bed net (21.6%), and receipt of iron supplements (11.8%) were low. At the time of the survey, more than 60% of women had hemoglobin level estimates < or = 11.0 g/dl and 7.2% were Pf positive. Unmet need for contraceptives exceeded 60%. Violations of rights were widely reported: 32.1% of Karenni households reported forced labor and 10% of Karen households had been forced to move. Among Karen households, odds of anemia were 1.51 (95% confidence interval [CI] 0.95-2.40) times higher among women reporting forced displacement, and 7.47 (95% CI 2.21-25.3) higher among those exposed to food security violations. The odds of receiving no antenatal care services were 5.94 (95% CI 2.23-15.8) times higher among those forcibly displaced. CONCLUSIONS: Coverage of basic maternal health interventions is woefully inadequate in these selected populations and substantially lower than even the national estimates for Burma, among the lowest in the region. Considerable political, financial, and human resources are necessary to improve access to maternal health care in these communities.

The MOM Project: delivering maternal health services among internally displaced populations in eastern Burma.

Alternative strategies to increase access to reproductive health services among internally displaced populations are urgently needed. In eastern Burma, continuing conflict and lack of functioning health systems render the emphasis on facility-based delivery with skilled attendants unfeasible. Along the Thailand-Burma border, local organisations have implemented an innovative pilot, the Mobile Obstetric Maternal Health Workers (MOM) Project, establishing a three-tiered collaborative network of community-based reproductive health workers. Health workers from local organisations received practical training in basic emergency obstetric care plus blood transfusion, antenatal care and family planning at a central facility. After returning to their target communities inside Burma, these first-tier maternal health workers trained a second tier of local health workers and a third tier of traditional birth attendants (TBAs) to provide a limited subset of these interventions, depending on their level of training. In this ongoing project, close communication between health workers and TBAs promotes acceptance and coverage of maternity services throughout the community. We describe the rationale, design and implementation of the project and a parallel monitoring plan for evaluation of the project. This innovative obstetric health care delivery strategy may serve as a model for the delivery of other essential health services in this population and for increasing access to care in other conflict settings.