Retrospective analysis of reproductive health indicators in the United Nations High Commissioner for Refugees post-emergency camps 2007-2013.

BACKGROUND: The United Nations Refugee Agency's Health Information System issues analytical reports on the current camp conditions and trends for priority reproductive health issues. The goal was to assess the status of reproductive health by analyzing seven indicators and comparing them to standards and host country estimates. METHODS: Data on seven indicators were extracted from the database during a seven-year period (2007 through 2013). A standardized country inclusion criterion was created based on the year of country implementation and the percentage of missing reports per camp and year. The unit of analysis was monthly camp reports by year within a country. To account for the lack of independence of monthly camp reports, the variance was computed using Taylor Series Linearization methods in SAS. RESULTS: Ten of the 23 eligible countries met the inclusion criterion. The mean camp maternal and neonatal mortality rates, except for two country years, were lower than the host country estimates for all countries and years. There was a significant increase in the percent of births attended by a skilled birth attendant (p < 0.0001), and 8 of 10 countries did not meet the standard of 100 % for all reporting years. The percent of births performed by Caesarian section (p < 0.001), were below the recommended minimum standard for nearly half of the countries every year. There was a significant increase in the percent of women screened for syphilis across years (p < 0.0001) and the percent of women who received post HIV exposure prophylaxis (p < 0.0001) and 10 % reached the standard for all reporting years, respectively. CONCLUSION: Comprehensive, consistent and comparable statistics on reproductive health provides an opportunity to assess progress towards indicator standards. Despite some improvements over time, this analysis confirms that most countries did not meet standards and that there were differences in reproductive health indicators between countries and across years. Consequently, the HIS periodic monitoring of key reproductive health indicators at the camp level should continue. Data should be used to improve intervention strategies.

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.

Neonatal survival interventions in humanitarian emergencies: a survey of current practices and programs.

BACKGROUND: Neonatal deaths account for over 40% of all deaths in children younger than five years of age and neonatal mortality rates are highest in areas affected by humanitarian emergencies. Of the ten countries with the highest neonatal mortality rates globally, six are currently or recently affected by a humanitarian emergency. Yet, little is known about newborn care in crisis settings. Understanding current policies and practices for the care of newborns used by humanitarian aid organizations will inform efforts to improve care in these challenging settings. METHODS: Between August 18 and September 25, 2009, 56 respondents that work in humanitarian emergencies completed a web-based survey either in English or French. A snow ball sampling technique was used to identify organizations that provide health services during humanitarian emergencies to gather information on current practices for maternal and newborn care in these settings. Information was collected about continuum-of-care services for maternal, newborn and child health, referral services, training and capacity development, health information systems, policies and guidelines, and organizational priorities. Data were entered into MS Excel and frequencies and percentages were calculated. RESULTS: The majority of responding organizations reported implementing components of neonatal and maternal health interventions. However, multiple barriers exist in providing comprehensive care, including: funding shortages (63.3%), gaps in training (51.0%) and staff shortages and turnover (44.9%). CONCLUSIONS: Neonatal care is provided by most of the responding humanitarian organizations; however, the quality, breadth and consistency of this care are limited.

A study of refugee maternal mortality in 10 countries, 2008-2010.

CONTEXT: Little is known about the prevalence of maternal mortality in refugee camps for populations displaced by conflict, or about the factors contributing to such deaths. METHODS: Maternal Death Review Reports were used to analyze maternal deaths that occurred in 2008-2010 in 25 refugee camps in 10 countries. Assessed outcomes included causes of death; delays in women seeking, reaching or receiving care; and additional aspects of case management. We conducted detailed analyses of avoidable factors that contributed to deaths in Kenya, where the majority of reported cases occurred. RESULTS: Reports were available on 108 deaths, including 68 in Kenya. In every country but Bangladesh, maternal mortality ratios were lower among refugees than among the host population. The proportion of women who had had four or more antenatal care visits was lower among refugee women who had died (33%) than among the general refugee population (79%). Seventy-eight percent of the maternal deaths followed delivery or abortion, and 56% of those deaths occurred within 24 hours. Delays in seeking and receiving care were more prevalent than delays in reaching care. In Kenya, delays in seeking or accepting care and provider failure to recognize the severity of the woman's condition were the most common avoidable contributing factors. CONCLUSIONS: Additional interventions in community outreach, service delivery and supervision are needed to improve maternal outcomes in refugee populations.

Optimising the management of vaginal discharge syndrome in Bulgaria: cost effectiveness of four clinical algorithms with risk assessment.

OBJECTIVES: To evaluate the performance and cost effectiveness of the WHO recommendations of incorporating risk-assessment scores and population prevalence of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) into vaginal discharge syndrome (VDS) algorithms. METHODS: Non-pregnant women presenting with VDS were recruited at a non-governmental sexual health clinic in Sofia, Bulgaria. NG and CT were diagnosed by PCR and vaginal infections by microscopy. Risk factors for NG/CT were identified in multivariable analysis. Four algorithms based on different combinations of behavioural factors, clinical findings and vaginal microscopy were developed. Performance of each algorithm was evaluated for detecting vaginal and cervical infections separately. Cost effectiveness was based on cost per patient treated and cost per case correctly treated. Sensitivity analysis explored the influence of NG/CT prevalence on cost effectiveness. RESULTS: 60% (252/420) of women had genital infections, with 9.5% (40/423) having NG/CT. Factors associated with NG/CT included new and multiple sexual partners in the past 3 months, symptomatic partner, childlessness and >or=10 polymorphonuclear cells per field on vaginal microscopy. For NG/CT detection, the algorithm that relied solely on behavioural risk factors was less sensitive but more specific than those that included speculum examination or microscopy but had higher correct-treatment rate and lower over-treatment rates. The cost per true case treated using a combination of risk factors, speculum examination and microscopy was euro 24.08. A halving and tripling of NG/CT prevalence would have approximately the inverse impact on the cost-effectiveness estimates. CONCLUSIONS: Management of NG/CT in Bulgaria was improved by the use of a syndromic approach that included risk scores. Approaches that did not rely on microscopy lost sensitivity but were more cost effective.