The Potential of Self-Managed Abortion to Expand Abortion Access in Humanitarian Contexts.

Refugees and displaced people face uniquely challenging barriers to abortion access, including the collapse of health systems, statelessness, and a lack of prioritization of sexual and reproductive health services by humanitarian agencies. This article summarizes the evidence around abortion access in humanitarian contexts, and highlights the opportunities for interventions that could increase knowledge and support around self-managed abortion. We explore how lessons learned from other contexts can be applied to the development of effective interventions to reduce abortion-related morbidity and mortality, and may improve access to information about safe methods of abortion, including self-management, in humanitarian settings. We conclude by laying out a forward-thinking research agenda that addresses gaps in our knowledge around abortion access and experiences in humanitarian contexts.

"You must first save her life": community perceptions towards induced abortion and post-abortion care in North and South Kivu, Democratic Republic of the Congo.

Structural barriers such as a restrictive legal environment, limited medical resources, and high-costs inhibit access to safe abortion in the Democratic Republic of the Congo (DRC); these barriers are exacerbated by two decades of conflict. Socio-normative barriers further complicate access to safe abortion and post-abortion care (PAC) in DRC, where fear of abortion-related stigma may lead women to avoid PAC services. Programme partners support the Ministry of Health to provide good quality contraceptive and PAC services in North and South Kivu, DRC. This paper presents results from focus group discussions that explored community members' attitudes towards women who induce abortion and their care-seeking behaviour in programme areas. Results indicate that while abortion stigma was widespread, community members' attitudes towards women who induced abortions were not one-dimensional. Although they initially expressed negative opinions regarding women who induced abortion, beliefs became more nuanced as discussion shifted to the specific situations that could motivate a woman to do so. For example, many considered it understandable that a woman would induce abortion after rape: perhaps unsurprising, given the prevalence of conflict-related sexual violence in this area. While community members believed that fear of stigma or associated negative social consequences dissuaded women from seeking PAC, a majority believed that all women should have access to life-saving PAC. This commitment to ensuring that women who induced abortion have access to PAC, in addition to the professed acceptability of induced abortion in certain situations, indicates that there could be an opening to destigmatise abortion access in this context.

"They Love Their Patients": Client Perceptions of Quality of Postabortion Care in North and South Kivu, the Democratic Republic of the Congo.

BACKGROUND: Postabortion care (PAC) is a lifesaving intervention that, when accessible and of good quality, can prevent the majority of abortion-related deaths. However, these services are only sporadically available and often of poor quality in humanitarian settings. CARE International, the International Rescue Committee, and Save the Children strengthened the Congolese Ministry of Health to provide PAC, including voluntary contraceptive services, in North and South Kivu, DRC. OBJECTIVE: We aimed to gain understanding of the demographic and clinical characteristics of PAC clients, the experiences of women who sought PAC at supported health facilities, and the women's perceptions of the quality of care received. We also explored how client perspectives can inform future PAC programming. METHODS: A PAC register review extracted sociodemographic and clinical data on all PAC clients during a 12-month period between 2015 and 2016 at 69 supported facilities in 6 health zones. In-depth interviews were conducted between September 2016 and April 2017 with 50 women who sought PAC in the preceding 3 months at supported health facilities. Interviews were recorded, transcribed, and translated into French for analysis. Thematic content analysis was subsequently used as the data analytic approach. RESULTS: In 12 months, 1,769 clients sought PAC at supported facilities; 85.2% were at less than 13 weeks gestation. Over 80% of PAC clients were treated for incomplete abortion, and of these, 90% were treated with manual vacuum aspiration. The majority (75.2%) of PAC clients chose voluntary postabortion contraception. All but one interview participant reported seeking PAC for a spontaneous abortion, although most also reported their pregnancy was unintended. Clients were mostly made aware that PAC was available by community health workers or other community members. Experiences at the supported facilities were mostly positive, particularly in regards to client-provider interactions. Most women received contraceptive counseling during PAC and selected a modern method of contraception immediately after treatment. However, knowledge about different methods of contraception varied. Nearly all women said that they would advise another woman experiencing abortion complications to seek PAC at a supported health facility. CONCLUSIONS: The findings demonstrate the successful implementation of good-quality, respectful PAC in North and South Kivu. Overall, they suggest that the organizations' support of health workers, including competency-based training and supportive supervision, was successful.

Using Program Data to Improve Access to Family Planning and Enhance the Method Mix in Conflict-Affected Areas of the Democratic Republic of the Congo.

Unmet need for family planning in the conflict-affected area of eastern Democratic Republic of the Congo (DRC) has been reported to be as high as 38%, and women in such conflict settings are often the most at risk for maternal mortality. The International Rescue Committee implements the Family Planning and Post-Abortion Care in Emergencies program in 3 provinces of eastern DRC to provide women and couples access to family planning, including long-acting reversible contraceptives (LARCs). This article presents routine program data from June 2011 through December 2013 from 2 health zones as well as results from a qualitative assessment of family planning clients and of male and female non-users, conducted in 2013. It then describes how these findings were used to make program adjustments to improve access to family planning services and client informed choice and assesses the effects of the program design changes on family planning uptake and method mix using routine program data from January 2014 through December 2016. Between 2011 and 2013, 8,985 clients adopted family planning, with an average 14 clients adopting a method per facility, per month. The method mix remained stable during this period, with implants dominating at 48%. Barriers to uptake identified from the qualitative research were both supply- and demand-related, including misconceptions about certain modern contraceptive methods on the part of providers, users, and other community members. The program implemented several program changes based on the assessment findings, including clinical coaching and supportive supervision to improve provider skills and attitudes, introduction of immediate postpartum insertion of the intrauterine device (IUD) and the levonorgestrel-releasing intrauterine system (LNG-IUS), and behavior change communication campaigns to raise awareness about family planning. After these program changes, the mean number of clients adopting modern family planning per facility, per month increased from 14 to 37 and the percentage of family planning adopters choosing LARCs increased from 50% to 66%. While implants continued to be the most dominant method, reaching 60% of the method mix in 2016, the percentage of clients adopting IUDs increased each year, from 3% in 2014 to 13% in 2016. In total, 39,399 clients started family planning methods during the post-program design change period (2014-2016). Our experience in eastern DRC demonstrates that women and their partners affected by conflict want family planning, and that it is feasible to deliver the full range of modern contraceptive methods when programs are adapted and sensitive to the local context.

The 2018 Inter-agency field manual on reproductive health in humanitarian settings: revising the global standards.

Since the 1990s, the Inter-agency field manual on reproductive health in humanitarian settings (IAFM) has provided authoritative guidance on reproductive health service provision during different phases of complex humanitarian emergencies. In 2018, the Inter-Agency Working Group on Reproductive Health in Crises will release a new edition of this global resource. In this article, we describe the collaborative and inter-sectoral revision process and highlight major changes in the 2018 IAFM. Key revisions to the manual include repositioning unintended pregnancy prevention within and explicitly incorporating safe abortion care into the Minimum Initial Service Package (MISP) chapter, which outlines a set of priority activities to be implemented at the outset of a humanitarian crisis; stronger guidance on the transition from the MISP to comprehensive sexual and reproductive health services; and the addition of a logistics chapter. In addition, the IAFM now places greater and more consistent emphasis on human rights principles and obligations, gender-based violence, and the linkages between maternal and newborn health, and incorporates a diverse range of field examples. We conclude this article with an outline of plans for releasing the 2018 IAFM and facilitating uptake by those working in refugee, crisis, conflict, and emergency settings.

Game on: The gamification of the pharmacy classroom.

BACKGROUND: Gamification is the use of game mechanics to promote engagement and enjoyment of problem-solving in non-game situations. Gamification has been used widely in recent years in industry and academia as a tool for training and education. OBJECTIVE: The aims of this paper are to provide an overview of gamification and digital game-based learning (DGBL), review the use of digital games in health professional education, and provide suggestions for future use in pharmacy curricula. DISCUSSION: Many examples of game-based learning in pharmacy and other health professional curricula have been published, however the body of literature on DGBL is less developed. Overall, evaluations of these techniques show that students find them engaging and enjoyable. A recent meta-analysis of studies comparing DGBL to non-game based learning in primary, secondary, post-secondary education found that DGBL significantly enhances learning. Challenges to implementing game-based learning are financial, cultural, and technological. CONCLUSION: Many areas of the pharmacy curriculum could be appropriate for digital gamification. With more students entering pharmacy school familiar with video games and game-based living the time has come for pharmacy educators to explore how these instructional technologies could benefit a new generation of pharmacy students. As serious games are developed and researched in pharmacy curricula, test scores, student confidence in knowledge and skills, and retention of knowledge and skills are all outcomes that, if published, will help advance the adoption of DGBL into the pharmacy school classroom.

Understanding the menstrual hygiene management challenges facing displaced girls and women: findings from qualitative assessments in Myanmar and Lebanon.

BACKGROUND: There is a significant gap in empirical evidence on the menstrual hygiene management (MHM) challenges faced by adolescent girls and women in emergency contexts, and on appropriate humanitarian response approaches to meet their needs in diverse emergency contexts. To begin filling the gap in the evidence, we conducted a study in two diverse contexts (Myanmar and Lebanon), exploring the MHM barriers facing girls and women, and the various relevant sectoral responses being conducted (e.g. water, sanitation and hygiene (WASH), Protection, Health, Education and Camp Management). METHODS: Two qualitative assessments were conducted: one in camps for internally displaced populations in Myanmar, and one with refugees living in informal settlements and host communities in Lebanon. Key informant interviews were conducted with emergency response staff in both sites, and focus group discussion and participatory mapping activities conducted with adolescent girls and women. RESULTS: Key findings included that there was insufficient access to safe and private facilities for MHM coupled with displacement induced shifts in menstrual practices by girls and women. Among staff, there was a narrow interpretation of what an MHM response includes, with a focus on supplies; significant interest in understanding what an improved MHM response would include and acknowledgement of limited existing MHM guidance across various sectors; and insufficient consultation with beneficiaries, related to discomfort asking about menstruation, and limited coordination between sectors. CONCLUSIONS: There is a significant need for improved guidance across all relevant sectors for improving MHM response in emergency context, along with increased evidence on effective approaches for integrating MHM into existing responses.

Progress and gaps in reproductive health services in three humanitarian settings: mixed-methods case studies.

BACKGROUND: Reproductive health (RH) care is an essential component of humanitarian response. Women and girls living in humanitarian settings often face high maternal mortality and are vulnerable to unwanted pregnancy, unsafe abortion, and sexual violence. This study explored the availability and quality of, and access barriers to RH services in three humanitarian settings in Burkina Faso, Democratic Republic of the Congo (DRC), and South Sudan. METHODS: Data collection was conducted between July and October 2013. In total, 63 purposively selected health facilities were assessed: 28 in Burkina Faso, 25 in DRC, and nine in South Sudan, and 42 providers completed a questionnaire to assess RH knowledge and attitudes. Thirty-four focus group discussions were conducted with 29 members of the host communities and 273 displaced married and unmarried women and men to understand access barriers. RESULTS: All facilities reported providing some RH services in the prior three months. Five health facilities in Burkina Faso, six in DRC, and none in South Sudan met the criteria as a family planning service delivery point. Two health facilities in Burkina Faso, one in DRC, and two in South Sudan met the criteria as an emergency obstetric and newborn care service delivery point. Across settings, three facilities in DRC adequately provided selected elements of clinical management of rape. Safe abortion was unavailable. Many providers lacked essential knowledge and skills. Focus groups revealed limited knowledge of available RH services and socio-cultural barriers to accessing them, although participants reported a remarkable increase in use of facility-based delivery services. CONCLUSION: Although RH services are being provided, the availability of good quality RH services was inconsistent across settings. Commodity management and security must be prioritized to ensure consistent availability of essential supplies. It is critical to improve the attitudes, managerial and technical capacity of providers to ensure that RH services are delivered respectfully and efficiently. In addition to ensuring systematic implementation of good quality RH services, humanitarian health actors should meaningfully engage crisis-affected communities in RH programming to increase understanding and use of this life-saving care.