The forgotten health crisis

Sexual and reproductive health problems remain the leading cause of death and disability among women, worldwide. In times of crisis, assault, violence and ill-health increase, yet all-too-often these issues are ignored. New research by PhD candidate Kristen Beek is set to improve how aid workers in crisis zones prevent sexual and gender-based violence and promote better maternal and newborn health.

26 December, 2004: a wave, releasing the same amount of energy as 23 000 Hiroshima-sized bombs, smashed the coastlines of 13 South-East Asian countries. By day's end, 150 000 people were dead or missing and millions were left homeless.

Across the world, images of flattened homes, flooded villages and tourists holed up in hotels filled the media. But what about the women, weeks away from giving birth, who were surrounded by dirt and debris and without access to care or clean water? How about the now-orphaned children who fled towards safety, but instead encountered displacement camps peppered with predators and lacking in good lighting?

"For some," explains PhD candidate in the Faculty of Health Kristen Beek, "providing food, shelter, water and basic medical care during a humanitarian crisis is adequate." For Beek, it doesn't even come close.

She says, "Sexual and reproductive health (SRH) has been a long-neglected area of humanitarian response."

The fact is gender-based violence accounts for as much death and disability among 15- to 44-year-old women as cancer, and more than malaria, motor vehicle accidents and war combined. And during conflict and after natural disasters, the incidence of sexual and gender-based violence can increase.

"It's hard to imagine the impact of not putting in place mechanisms to prevent sexual violence, or failing to provide assistance to survivors. The situations people in these settings face can be horrific."

On top of this, adds Beek, "At any given time, it's estimated that four per cent of people displaced by a disaster or conflict will be pregnant. Of these women and girls, 15 per cent will experience life-threatening complications.

"So any mechanism for protection and providing services for women and girls – and boys and men, of course, but more often than not it's women and girls – in those situations is extremely important."

That's why, in 2007, the Australian Government funded the SPRINT (Sexual and Reproductive Health Programme in Crisis and Post-Crisis Situations) Initiative.

SPRINT, managed by the International Planned Parenthood Federation in collaboration with the United Nations Population Fund and various national and international partners, aims to increase access to SRH information and services for people who have survived crises in South-East Asia and the Pacific.

"When there is a breakdown in services and social structures caused by a humanitarian emergency, women and girls are especially vulnerable. Increases in maternal and newborn deaths and ill-health; sexual violence; sexually transmitted infections; unwanted pregnancies and unsafe abortions; and the spread of HIV are all possible.

"Interventions that reduce vulnerability and increase the capacity of responders to provide services will reduce the impact of a hazard and the scale and nature of a disaster."

One of the ways SPRINT aimed to do this was through five-day, regional-level 'train the trainer' programs in Kuala Lumpur, Suva and Sydney. Here United Nations representatives, local and international NGOs, and health department staff from participating countries came together to learn about the Minimum Initial Service Package (MISP) – a set of practices for humanitarian workers detailing implementation of SRH services during an emergency.

The MISP includes five objectives – identifying a coordinator or a coordinating body, preventing sexual and gender-based violence in emergencies and providing assistance for survivors, reducing the transmission of HIV and other STIs, preventing maternal and newborn death and disability, and integrating SRH services into primary health care.

In addition to initiatives like making condoms available in crisis situations and providing pregnant women with clean delivery kits, the MISP also includes non-health practices. "Things to protect women and girls, like separation of toilets in displacement camps, good lighting – really basic things which need to be in place."

Beek, with a background in education and two master's – one in applied anthropology and development studies, the other in international public health – was a perfect fit for the PhD project.

The project, run through the UTS Centre for Midwifery, Child and Family Health, is being overseen by Beek's supervisor Senior Lecturer Angela Dawson, and co-supervisor Adjunct Professor Anna Whelan.

Says Beek, "I was brought on board to understand why people who attended these trainings did or didn't go on to use the training when they returned to their place of work.

"Through in-depth interviews with 20 SPRINT trainees, questionnaires, observation and a review of in-country-level reports, I discovered a system of factors which influenced whether they were willing and able to use the training.

She adds, "Sexual and reproductive health is a controversial topic.

"In some instances, there will be parts of the minimum package that will not be included. An example being in places where emergency contraception isn't allowed.

"In other instances, it's just not recognised by the authorities that sexual violence may occur or that women and girls need particular services.

"There are so many different reasons why people do and don't use the training. Identifying those and trying to address them should lead to optimised training transfer, which in turn should lead to the availability of better services for survivors."

Already, Beek's research has been used to revise the training curriculum for the second phase of SPRINT, and there's potential for her findings to be applied to other training packages too.

"If training isn't applied, already-scarce aid resources are wasted, and more importantly, we've lost the chance to prevent sexual and reproductive health-related disease, disability and death.

"My research can, I hope, help to make sure these services are provided to those women and girls, boys and men, who are surviving in these situations.

"We know that sexual and reproductive health is vital, not least because it's an inherent human right, but it's absolutely essential for people's physical health, and for their social and mental health as well."