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      Not a luxury: a call to maintain sexual and reproductive health in humanitarian and fragile settings during the COVID-19 pandemic

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          Abstract

          About 1·8 billion people live in fragile contexts worldwide, 1 including 168 million individuals in need of humanitarian assistance. Approximately a quarter of those in fragile contexts are women and girls of reproductive age. 2 Experience from past epidemics in these settings has showed that discontinuing health-care services deemed unrelated to the epidemic response resulted in more deaths than did the epidemic itself. 3 Issues related to sexual and reproductive health are among the leading causes of mortality and morbidity among women of childbearing age, with countries affected by fragility and crisis accounting for 61% of maternal deaths worldwide. 4 Poor health outcomes will surge from the absence or disruption of lifesaving services, including emergency obstetric and newborn care, contraception to prevent unwanted pregnancies, and the management of abortion complications. Gender-based violence and sexual exploitation and abuse might increase during outbreaks because of confinement, increased exposure to perpetrators at home, economic precarity, and reduced access to protection services. The care for children and others confined at home further reduces women's ability to properly care for themselves. 5 In the context of the pandemic preparedness and response, members of the Inter-Agency Working Group for Reproductive Health in Crises have issued various field guidance documents on sexual and reproductive health and coronavirus disease 2019 (COVID-19). Building on the overarching need for humanitarian actors to coordinate and plan to ensure that sexual and reproductive health is integrated into the pandemic preparedness and response, 6 there are four prongs on how to mitigate the impact of COVID-19 on mortality and morbidity due to sexual and reproductive health conditions in crisis and in fragile settings. First, with the understanding that the risks of adverse outcomes from medical complications outweigh the potential risks of COVID-19 transmission at health facilities, the availability of all crucial services and supplies as defined by the Minimum Initial Services Package for sexual and reproductive health should continue. 6 These services include intrapartum care for all births and emergency obstetric and newborn care (caesarean sections should only be performed when medically indicated as a COVID-19 positive status is not an indication for a caesarean section 7 ), post-abortion care, safe abortion care to the full extent of the law, contraception, clinical care for rape survivors, and prevention and treatment for HIV and other sexually transmitted infections. Early and exclusive breastfeeding and skin-to-skin contact for neonates should be promoted, and mother and neonate should not be separated unless one or both are critically ill in cases of suspected or confirmed COVID-19 infections. 7 Second, comprehensive sexual and reproductive health services should continue as long as the system is not overstretched with COVID-19 case management. For relevant consultations and follow-up, remote approaches should be considered where feasible (eg, telephone, digital applications, text messaging). In addition to the Minimum Initial Service Package, these comprehensive services—ie, all antenatal care, postnatal care, newborn care, breastfeeding support, and cervical cancer screening, as well as care for individuals experiencing intimate partner violence—should remain available to all individuals who need them, including adolescents. Third, clear, consistent, and updated public health information crafted with representatives of the targeted audiences should reach the community and health-care workers. This information should reaffirm that medical complications outweigh the potential risk of transmission at health facilities and that community members should continue to seek and receive care during childbirth and for all other essential sexual and reproductive health needs or emergencies resulting from other diseases, trauma, or violence. The community should understand that any changes in routine services are for patients' benefit to ensure support to the COVID-19 response, avert undue exposure to the risk of contracting the virus in a health facility during the outbreak, or both. However, the coordination and planning to re-establish such comprehensive services should occur as soon as the situation stabilises. Fourth, COVID-19 infection prevention and control precautions, including hand hygiene, physical distancing, and respiratory etiquette should apply to patients (and accompanying family members if their presence is necessary). Additionally, staff should be protected with adequate personal protective equipment. Facilities also need to establish a patient flow that incorporates triage before entrance into the facility, and an isolation area and separate consultation room for suspected or confirmed cases. To minimise preventable deaths, crucial health-care services, including sexual and reproductive health services, should remain accessible during public health emergencies, even when resources from already fragile health systems are often redirected for outbreak response. The COVID-19 pandemic will magnify the risks inherent to resource reshuffling at the expense of other services; however, sexual and reproductive health cannot be viewed as a luxury. 8 On March 31, 2020, the United Nations Secretary-General highlighted in relation to COVID-19 that “we are only as strong as the weakest health system in our interconnected world”. 9 To echo this statement, we have offered guidance on sexual and reproductive health and COVID-19, and we call on health authorities to prioritise these lifesaving services in humanitarian and fragile settings. Such interventions should be considered as indispensable components of health services that do not strain, but strengthen health systems during COVID-19 preparedness and response efforts. The collective health of women, girls, and the wider community depends on these services.

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          Most cited references2

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          Health-Care Access during the Ebola Virus Epidemic in Liberia.

          The Ebola virus disease (EVD) epidemic, which began in West Africa in December 2013, claimed more than 11,000 lives, with more than 4,800 of these deaths occurring in Liberia. The epidemic had an additional effect of paralyzing the health-care systems in affected countries, which led to even greater mortality and morbidity. Little is known about the impact that the epidemic had on the provision of basic health care. During the period from March to May 2015, we undertook a nationwide, community-based survey to learn more about health-care access during the EVD epidemic in Liberia. A cluster sampling strategy was used to administer a structured in-person survey to heads of households located within the catchment areas surrounding all 21 government hospitals in Liberia. A total of 543 heads of household from all 15 counties in Liberia participated in the study; more than half (67%) of urban respondents and 46% of rural respondents stated that it was very difficult or impossible to access health care during the epidemic. In urban areas, only 20-30% of patients seeking care during the epidemic received care, and in rural areas, only 70-80% of those seeking care were able to access it. Patients requiring prenatal and obstetric care and emergency services had the most difficulty accessing care. The results of this survey support the observation that basic health care was extremely difficult to access during the EVD epidemic in Liberia. Our results underscore the critical need to support essential health-care services during humanitarian crises to minimize preventable morbidity and mortality.
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            Is Open Access

            Self care interventions could advance sexual and reproductive health in humanitarian settings

            Forcibly displaced people often lack access to adequate sexual and reproductive health services. Carmen Logie and colleagues examine the role of self care interventions in filling the gap
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              Author and article information

              Contributors
              Journal
              Lancet Glob Health
              Lancet Glob Health
              The Lancet. Global Health
              The Author(s). Published by Elsevier Ltd.
              2214-109X
              21 April 2020
              21 April 2020
              Affiliations
              [a ]Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, Sydney, NSW 2007, Australia
              [b ]Faculty of Medicine, University of Geneva, Geneva, Switzerland
              [c ]Johns Hopkins Center for Humanitarian Health, Baltimore, MD, USA
              [d ]International Rescue Committee, New York, NY, USA
              [e ]Women's Refugee Commission, New York, NY, USA
              [f ]Inter-Agency Working Group on Reproductive Health in Crises, New York, NY, USA
              Article
              S2214-109X(20)30190-X
              10.1016/S2214-109X(20)30190-X
              7173831
              31958404
              cbfeab87-ccd6-4512-a861-1ed020282785
              © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license

              Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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