Health system resilience during COVID-19 understanding SRH service adaptation in North Kivu.

BACKGROUND: There is often collateral damage to health systems during epidemics, affecting women and girls the most, with reduced access to non-outbreak related services, particularly in humanitarian settings. This rapid case study examines sexual and reproductive health (SRH) services in the Democratic Republic of the Congo when the COVID-19 hit, towards the end of an Ebola Virus Disease (EVD) outbreak, and in a context of protracted insecurity. METHODS: This study draws on quantitative analysis of routine data from four health zones, a document review of policies and protocols, and 13 key-informant interviews with staff from the Ministry of Public Health, United Nations agencies, international and national non-governmental organizations, and civil society organizations. RESULTS: Utilization of SRH services decreased initially but recovered by August 2020. Significant fluctuations remained across areas, due to the end of free care once Ebola funding ceased, insecurity, number of COVID-19 cases, and funding levels. The response to COVID-19 was top-down, focused on infection and prevention control measures, with a lack of funding, technical expertise and overall momentum that characterized the EVD response. Communities and civil society did not play an active role for the planning of the COVID-19 response. While health zone and facility staff showed resilience, developing adaptations to maintain SRH provision, these adaptations were short-lived and inconsistent without external support and funding. CONCLUSION: The EVD outbreak was an opportunity for health system strengthening that was not sustained during COVID-19. This had consequences for access to SRH services, with limited-resources available and deprioritization of SRH.

Women and girls often face increased challenges to accessing healthcare during epidemics on top of pre-existing health disparities. There is emerging evidence that COVID-19 has had negative impacts on the health of women and girls in sub-Saharan Africa due to diverted funding, reduced services, negative socioeconomic impacts, and increased or new barriers to access. In the DRC, COVID-19 hit shortly after the end of an Ebola epidemic within a context of protracted insecurity. This study used mixed methods and drew upon 13 interviews to examine the effects of COVID-19 on SRH services in North Kivu and how the health system did or did not adapt to ensure continued access and utilization of SRH services. There was limited prioritization of SRH during COVID-19. Although the government issued policies on how to adapt SRH services, these were developed centrally, without much guidance on how to operationalize these policies in different contexts. Consequently, healthcare providers and civil society actors developed their own ways to continue activities at local levels, not necessarily in a systematic way. There was limited longer-term strengthening of the health system that could adapt to the subsequent COVID-19 pandemic aside from increased capacity of healthcare providers to manage infection prevention and control measures. However, this was hampered by the lack of personal protective equipment that received no external support. Therefore, donors need to consider how resources can be leveraged to support sustained strengthening of the health system to be able to adapt to shocks even when resources are limited.

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.

Contraceptive use among adolescent and young women in North and South Kivu, Democratic Republic of the Congo: A cross-sectional population-based survey.

BACKGROUND: Adolescent girls in humanitarian settings are especially vulnerable as their support systems are often disrupted. More than 20 years of violence in the Democratic Republic of the Congo (DRC) has weakened the health system, resulting in poor sexual and reproductive health (SRH) outcomes for women. Little evidence on adolescent contraceptive use in humanitarian settings is available. CARE, International Rescue Committee (IRC), and Save the Children, in collaboration with the Reproductive Health Access, Information and Services in Emergencies (RAISE) Initiative, Columbia University, have supported the Ministry of Health (MOH) since 2011 to provide good quality contraceptive services in public health facilities in conflict-affected North and South Kivu. In this study, we analyzed contraceptive use among sexually active young women aged 15-24 in the health zones served by the partners' programs. METHODS AND FINDINGS: The partners conducted cross-sectional population-based surveys in program areas of North and South Kivu using two-stage cluster sampling in six health zones in July-August 2016 and 2017. Twenty-five clusters were selected in each health zone, 22 households in each cluster, and one woman of reproductive age (15-49 years) was randomly selected in each household. This manuscript presents results from a secondary data analysis for 1,022 women aged 15-24 who reported ever having sex: 326 adolescents (15-19 years) and 696 young women (20-24 years), 31.7% (95% confidence interval [CI] 29.5-34.1), of whom were displaced at least once in the previous five years. Contraceptive knowledge was high, with over 90% of both groups able to name at least one modern contraceptive method. Despite this high knowledge, unmet need for contraception was also high: 31.7% (95%CI 27.9-35.7) among 15-19-year-olds and 40.1% (95% CI 37.1-43.1, p = 0.001) among 20-24-year-olds. Current modern contraceptive use (16.5%, 95% CI 14.7-18.4) was similar in both age groups, the majority of whom received their method from a supported health facility. Among current users, more than half of 15-19-year-olds were using a long-acting reversible contraceptive (LARC; 51.7%, 95% CI 41.1-61.9) compared to 36.5% of 20-24-year-olds (95% CI 29.6-43.9, p = 0.02). Age, younger age of sexual debut, having some secondary education, being unmarried, and having begun childbearing were associated with modern contraceptive use. The main limitations of our study are related to insecurity in three health zones that prevented access to some villages, reducing the representativeness of our data, and our defining sexually active women as those who have ever had sex. CONCLUSIONS: In this study, to our knowledge one of the first to measure contraceptive prevalence among adolescents in a humanitarian setting, we observed that adolescent and young women will use modern contraception, including long-acting methods. Meaningful engagement of adolescent and young women would likely contribute to even better outcomes. Creating an enabling environment by addressing gender and social norms, however, is key to reducing stigma and meeting the demand for contraception of young women. As we continue to build such supportive environments, we can see that they will use effective contraception when contraceptive services, including short- and long-acting methods, are available, even in protracted crisis settings.

Meeting the demand of women affected by ongoing crisis: Increasing contraceptive prevalence in North and South Kivu, Democratic Republic of the Congo.

CONTEXT: Over 20 years of conflict in the DRC, North and South Kivu have experienced cycles of stability and conflict, resulting in a compromised health system and poor sexual and reproductive health outcomes. Modern contraceptive use is low (7.5%) and maternal mortality is high (846 deaths per 100,000 live births). Program partners have supported the Ministry of Health (MOH) in North and South Kivu to provide good quality contraceptive services in public health facilities since 2011. METHODS: Cross-sectional population-based surveys were conducted in the program areas using a two-stage cluster sampling design to ensure representation in each of six rural health zones. Using MOH population estimates for villages in the catchment areas of supported health facilities, 25 clusters in each zone were selected using probability proportional to size. Within each cluster, 22 households were systematically selected, and one woman of reproductive age (15-49 years) was randomly selected from all eligible women in each household. RESULTS: Modern contraceptive prevalence among women in union ranged from 8.4% to 26.7% in the six health zones; current use of long-acting or permanent method (LAPM) ranged from 2.5% to 19.8%. The majority of women (58.9% to 90.2%) reported receiving their current method for the first time at a health facility supported by the program partners. Over half of women in four health zones reported wanting to continue their method for five years or longer. CONCLUSION: Current modern contraceptive use and LAPM use were high in these six health zones compared to DRC Demographic and Health Survey data nationally and provincially. These results were accomplished across all six health zones despite their varied socio-demographic characteristics and different experiences of conflict and displacement. These findings demonstrate that women in these conflict-affected areas want contraception and will choose to use it when good quality services are available to them.