J R Soc Med 2005;98:400-403
doi:10.1258/jrsm.98.9.400
© 2005 Royal Society of Medicine
Impact of the Tsunami on reproductive health
M Carballo
M Hernandez
K Schneider
E Welle
International Centre for Migration and Health, Route du Nant d'Avril,
CH-1214 Vernier (Ge), Switzerland
Correspondence to: Dr Manuel Carballo, Executive Director, ICMH
E-mail:
mcarballo{at}icmh.ch
 |
INTRODUCTION
|
|---|
In the past ten years, increasing attention has been paid to
the
consequences of man-made disasters (conflicts) for reproductive
health—in
terms of pregnancy outcomes, sexual violence and sexually
transmitted
infections
1,2—but
far
less to the consequences of natural disasters such as floods,
landslides
and earthquakes. Despite the many obvious differences
between natural and
man-made disasters there are similarities
in the way they affect people. In
any disaster, one public-health
imperative is to understand and respond to the
reproductive
health needs of women and girls, men and boys, and lessons should
be
learned from the effects of the Tsunami that struck Indian Ocean
countries
on 26 December 2004.
The concept typically covers pregnancy and motherhood, gynaecological care,
child spacing and family planning, sexually transmitted infections and
HIV/AIDS, and adolescent reproductive health. Other issues that merit
consideration in the wake of disasters are vulnerability, gender violence and
poor access to care.
|
FEMALE VULNERABILITY
|
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For various reasons, women were at much greater risk of death
in the
Tsunami than other people. The ratio of female to male
deaths was 3:1 and in
some communities only women are reported
to have been
killed.
3 Surviving
women may also have become more
vulnerable than other survivors to a range of
social and economic
threats, and most of those who survived have been thrust
into
unemployment and poverty. Unlike men in these countries, many
were
unaccustomed to swimming or to being in the water other
than to bathe. Also,
the clothes they wore and their culturally
prescribed long hair became
entangled in tree branches and other
debris. In some coastal communities,
moreover, there are stories
of women running back to the beach to search for
missing children
when the first wave receded, only to be caught by the second
wave
when it struck. The vulnerability of women who survived is also
an issue
of concern in relation to sexual violence and rape,
and with respect to their
economic livelihoods. Everywhere in
the region people have been thrust back or
further into poverty
and for women this may be more problematic than for men.
Even
in the special camps, the safety of women will remain fragile.
|
PREGNANCY
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About 150 000 women in the countries hardest hit by the
Tsunami—namely,
Indonesia, Thailand, Sri Lanka, India and the
Maldives—would
have been pregnant at the time of the
disaster,
4 with 50
000
in the third trimester. In India alone, 8300 women in the Tsunami
region
are estimated to have been pregnant, about 1380 of whom
would have been in the
last three months of
pregnancy.
5 In Sri
Lanka
in February 2005, 5000 births were anticipated in the Tsunami-affected
population
and in Aceh the number of pregnant displaced women was
6000.
6 Even under
normal circumstances a substantial proportion of
these women could be expected
to experience complications and
require emergency obstetric care. In the
countries where maternal
and neonatal health was a major challenge even before
the Tsunami,
the likelihood of pregnancy and delivery complications is higher.
Maternal
deaths in the SE Asia region accounted for one-third of all
reported
maternal deaths worldwide, and over three million children
in the region did
not live to see their fifth birthday, dying
from preventable
causes.
7
It can be assumed that most of the estimated 40 000 pregnant women who
survived the Tsunami are now living in displaced persons' camps, with host
families, or in makeshift shelters. In the case of Indonesia a total of 133
318 women of reproductive age were displaced and of these some 11 350 were
pregnant (374 deliveries between 3 January and 22 March in Banda Aceh
Besar.5
Forcible displacement imposes an especially heavy psychosocial and physical
load on pregnant
women.2,8-10
Spontaneous and induced abortion became more likely with their hazard to
maternal life; also, babies are more likely to be born preterm or
small-for-gestational
age.11-13
The breakdown in healthcare services and the confusion that typically
surrounds forced displacement also reduces the chances of perinatal risk
factors being identified and responded to
promptly.14
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HEALTHCARE
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The poverty of some of the communities affected by the Tsunami
meant that
their access to good-quality care was always precarious,
and maternal and
infant mortality rates were already high. As
a result of the Tsunami, coverage
by health services in certain
locations is now even less secure. In Sri Lanka,
for example,
100 medical personnel were killed and 4 out of 8 maternity
clinics
on the east coast were destroyed or prevented from
functioning.
15,16
In Indonesia, where only two-thirds of births were attended by trained
personnel in pre-Tsunami times, the situation may now be even worse because of
the very high loss of life among the midwives in the area. At least 1650
midwives died or are still missing, and the total complement of midwives in
the region is down by one-third. The midwives who did survive still have
difficulty in getting around because of debris; pregnant women are harder to
reach than
before.17 On the
other hand, experience elsewhere suggests that the arrival of medical relief
teams and health programmes from outside the region (national or
international) and the organization of care within camps will have improved
pregnancy-related
health18 and health
in general.
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SEXUAL VIOLENCE
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Sexual violence occurs everywhere in the world, but in situations
of chaos
and forced displacement the risk is
heightened.
19 In
Sri
Lanka after the Tsunami, a reported increase in
rape
20 led several
local
and international groups to request a refocusing of relief to
provide
more protection for
women.
17 Reports of
sexual attacks
on displaced women have also come from
Indonesia,
21 and
there
are indications that similar behaviour is emerging elsewhere
though less
assiduously reported. The implications of sexual
violence are many. Women (or
men) suffer both physical and psychosocial
damage: their integration in the
community is affected and their
ability to find work is
reduced.
22
|
CONTRACEPTION AND FAMILY PLANNING
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Patterns of contraceptive use varied considerably before the
Tsunami
(
Table 1). On the whole,
contraceptive take-up and use
rates were highest in India, Thailand and
Indonesia, where national
authorities endorsed and actively promoted family
planning.
In Thailand, for example, the contraceptive prevalence rate
in 1997
was 70% and in Indonesia in 2003 it was 57% (married
couples). The damage done
by the Tsunami has altered much of
this. In many locations, medical drugs and
contraceptive supplies
were lost and weeks if not months have gone by without
any active
replenishment of stocks or follow-up of contraceptive users.
As in
previous disasters, many relief operations have not regarded
the early
distribution of contraceptive methods as a priority.
Couples and individuals
have therefore experienced an interruption
of contraception even though their
sexual activity may be unchanged
or higher than before. Assumptions about
sexual behaviour after
disasters—that people engage in sexual activity
either
more or less frequently than beforehand—remain largely
unproven.
What is known, however, is that in many disasters
people seek emotional
support and often enter into casual sexual
relationships that are risky in
terms of both unwanted pregnancy
and sexually transmitted infections. The
tendency for women
to be forced into unwanted sexual relationships means that
the
need for emergency contraception and HIV post-exposure prophylaxis
is also
greater.
View this table:
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Table 1. Pre-Tsunami reproductive health data for affected countries [Data
source: WHO, World Health Statistics, 2005]
|
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In January 2005, a month after the disaster, UNFPA in Indonesia appealed
for more attention to be given to the demand and need for contraception. It
estimated that Banda Aceh was receiving only 16 000 units out of a requested
80 000 at a time when UNFPA believed sexual activity was increasing.
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REVERSING STERILIZATION
|
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The Tsunami not only killed women in disproportionately large
numbers but
also many
children.
23 As a
result, many surviving
adults now find themselves childless but unable to bear
further
children because they have been sterilized. In Tamil Nadu, for
example,
about 44% of the women who had already had two children had
been
sterilized by the age of 27 (the total fertility rate of
Tamil Nadu had been
effectively reduced from 3.8 in 1976 to
2.0 in
2002).
24 In the
same State, 2300 children under the age
of 18 died in the Tsunami and the
proportion of children under
12 who died was even higher. The death of
children can mean
loss of social status and self-esteem for the mother, and
also
loss of economic security in old age. In response, the government
of
India instituted measures to give women access to reversal
of tubal ligation.
189 women have so far applied for
surgery.
24
|
SEXUALLY TRANSMITTED INFECTIONS AND HIV
|
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There is a growing concern that the community disruption caused
by
disasters creates social conditions propitious for the spread
of sexually
transmitted infections and
HIV/AIDS.
4,25
Whether
this is the case in the countries affected by the Tsunami remains
to
be seen, but women are in a fragile position. The poverty
and isolation of
many women may lend itself, as it has done
elsewhere in disaster settings, to
their having to sell sex
or allow themselves to be sexually exploited.
Overcrowded living
conditions may also contribute to promiscuity and
consequent
spread of sexually transmitted infections. Other factors that
could
play a role include the arrival of military personnel,
relief and
reconstruction workers, and transport
personnel.
24,26
Also,
with the large numbers of injuries, HIV-contaminated blood may
have been
used
inadvertently
27 in
settings where there were
insufficient facilities for testing and too little
time to wait
for supplies from elsewhere. Exacerbating factors are the poor
general
awareness of HIV/AIDS and the fact that condom distribution
to
displaced people has not been given high priority in most
of the
countries.
26
Much will depend on the prevalence of these diseases before the Tsunami. In
the case of Indonesia, Sri Lanka and the Maldives the prevalence of HIV/AIDS
was low, but both Thailand and Tamil Nadu (India) had relatively high rates.
In Phuket, 5% of migrant women and 9.5% of fishermen had been previously
estimated to be
HIV-infected26 and
in Tamil Nadu 8% of injecting drug users and 9% of female sex workers had been
reported to be
HIV-infected.28
|
MISP AND REPRODUCTIVE HEALTH KITS
|
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One of the challenges to effective protection of reproductive
health in
disasters has been defining what to do, when and with
what level of priority.
The concept of a Minimum Initial Service
Package emerged in 1995 through the
medium of an Interagency
Symposium on Reproductive Health in Emergency
Situations. The
MISP and the Emergency Reproductive Health Kit (which was
created
a year later by an Interagency Working Group on Reproductive
Health in
Refugee Situations and then taken up by UNFPA) were
designed to address the
most pressing reproductive health needs
of women and men in disaster settings.
The MISP focuses on how
to prevent and manage the consequences of sexual and
gender-based
violence, how to reduce transmission of HIV through universal
precautions
and condoms, and how to facilitate clean and safe deliveries.
UN and other agencies also collaborated on the development of a series of
reproductive health kits that have now been effectively used in man-made
disasters (Bosnia, Albania, Macedonia, Sierra Leone, Liberia, and Congo).
Their value in terms of concept, product and process has been confirmed most
recently in the Tsunami, and hospitals and clinics as well as
displaced-persons facilities were able to replace lost equipment and/or
benefit from new materials. The kits are made up of twelve subsets that
include: field administration of reproductive health; male and female condoms;
clean delivery; rape treatment; oral and injectable contraception; treatment
of sexually transmitted infections; clinical delivery; intrauterine devices;
management of miscarriage and complications of abortion; suture of tears
(vaginal and cervical) and vaginal examination; vacuum extraction delivery;
referral level kits; and blood transfusion
kits.29
|
HYGIENE KITS
|
|---|
Experience in other recent disasters (man-made and natural)
has highlighted
the special biosocial needs of women and girls
with respect to personal
hygiene. Forced displacement typically
involves losing access to the personal
hygiene supplies women
need, and to address this UNFPA has experimented with
packages
that can be made up with locally procured materials that include
sanitary
pads, soap and towels. In the context of the Tsunami many local
UNFPA
offices developed hygiene kits that included additional
materials that women
said were essential to being able to function
with dignity. In Indonesia,
where many women had lost everything,
the kits included long-sleeved blouses
or shirts, head scarves,
material that could be used as sarongs, underwear,
and prayer
mats as well as the basic hygiene ingredients. A similar evolution
of
these kits took place in Thailand and Sri Lanka and also in
the Maldives,
where a special mother/baby kit was developed.
The introduction of hygiene
kits is widely recognized as having
been an important boost to the morale of
women. By 24 June,
UNFPA had distributed over 250 000 of these
kits.
22
|
CONCLUSIONS
|
|---|
The Tsunami affected reproductive health in many ways. It caused
sex-specific
death on a scale that has devastated families and family life.
In
doing so it placed many people in a new type of vulnerability
that will
require highly creative policies and strategies to
overcome. It also
devastated many of the healthcare services
that are essential to sound
antenatal care and delivery, killing
large numbers of midwives in Indonesia
and medical personnel
in other countries, and destroying vital physical
infrastructures.
In disrupting so many families and communities and causing one of the
greatest displacements of people ever seen, the Tsunami also created
conditions that are likely to bring new threats and challenges to women and
girls. Securing their health will have to include protection as well as
good-quality healthcare.
Many relief organizations failed, as in previous disasters, to give
adequate priority to reproductive health. The various complements are vital to
individual, family and public health, and their neglect will only set back the
health reconstruction effort, especially in populations where the reproductive
health indicators were cause for concern even before the Tsunami.
|
Acknowledgments
|
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We thank the participants of the ICMH Tsunami Expert Review
Committee
meeting that took place in Male, Maldives, 22-24 April
and the Taiwan
International Health Operations Center and others
for their support of this
project.
|
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INTRODUCTION
FEMALE VULNERABILITY
