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Introduction: Reproductive Healthcare according to the WorldHealth Organisation (WHO), should allow people to have an enjoyable and safesex life and the autonomy to decide if, how often and when they wish toreproduce. KL1 (1) This means that men and women should know aboutand be able to access a method of fertility regulation of their choosing thatis safe, affordable and effective.

Women should be able to have safepregnancies and childbirth with accessibility to healthcare services to equipthe parents with the highest chance of having a healthy baby. (1,2) Thequality of this healthcare is compromised in conflict affected areas and according to the EU definition, these are “Areas in a state of armed conflict, fragilepost-conflict areas, as well as areas witnessing weak or non-existinggovernance and security, such as failed states, and widespread and systematicviolations of international law, including human rights abuses.” (3, p5)KL2 IW3 Accordingto 2014 statistics from a review in The Obstetrics and Gynecologist Journal,1.5 billion people are residing in areas affected by conflict.KL4 IW5  (4)Many people affected byconflict are displaced from their homes and 70% of these are women and childrenKL6 IW7 . (4,5)Women of areproducing age account for 20% and 1 in 5 of these are pregnant.KL8  (3)Aprediction in the review stated that 15% of women, pregnant and displaced,experience hemorrhage, sepsis, obstructed labour, eclampsia and other life-threateningcomplications. (4) KL9 Oftendue to these, Maternal mortality is exponential in these areas with 8 of the 10countries that have the highest rates being countries currently or recentlyaffected by conflict.

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KL10 (4,6)Theseareas are also affected by an increased spread of sexually transmittedinfections, cases of gender-based violence and due to poor family planningavailability, an increase in the practice of unsafe abortions. (4) Conflict KL11 affects many areas of women’s reproductivehealth. Three areas affected that have enormous implications on women’swellbeing are as follows.  Gender Based violenceGenderbased violence KL12 isclassified as an act of harming performed intently because of gender. Sexualassault is used as a method of warfare.Women are usually the targets for these rapes which inflict physical,psychological and social suffering.

It is used as a means to humiliate theother party, by destroying the social assets that these women hold in theirsociety. (7) In communities, an act of Gender-based violence such as rape canbe massively stigmatized. (7) KL13 Thisrestricts women’s health-seeking behaviour and prevents them seeking out theappropriate physical and psychological Healthcare. (4) Anexample of this occurred in Rwanda where the Hutu warriors raped many of theTutsi women in an act of Gender-based violence.

This was in order to claim landthat these Tutsi women owned as they were now bearing Hutu children. (7)  Antenatal CareConflictputs strain on Antenatal Services KL14 thatmay already be of poor availability in these mainly developing regions;affecting the care of the mother and newborn. (4) In a studyin the post-conflict area of Northern Uganda and Burundi, participants identifiedthe main issues with antenatal care being sparse availability of services, pooraccessibility to services present and under-developed neonatal units that wereresulting in neonate disabilities and deaths.KL15  (9)This was a result of closure of health services, damage to facilities,displacement of medical staff and of health-seeking women to areas further awayfrom services. (9)  Sexually transmitted infectionsSexuallytransmitted infections and HKL16 IVprevalence increases during conflict. This is because of displacement duringconflict, which can be to areas where HIV or another STI is more prevalent. (10)Conflictcan also limit accessibility to HIV and STI services due to a decrease in thenumber of services (because of damage to facilities or decreased healthcareworkers) or poorer accessibilityKL17 . (11)As aforementioned, conflict also increases the cases of sexual violence whichcan exacerbate the transmission of STIs and HIV.

(12) Finally,conflict can also increase the number of young women beginning sexual interactions,which often occurs to increase the population number, replace lost children or earnmoney for their families. (4) Withoutthe relevant Family Planning, women trying to earn money for their family mayexperience KL18 IW19 unwantedpregnancy and undertake unsafe abortions. (13)   Method:          A search of peer-reviewed literature wasundertaken to identify relevant studies regarding the approaches to providingreproductive healthcare to women in post-conflict areas to support the project.

The search engine OvidSP Medline was used, followed by screening search resultsfor relevancy, depicted in figure 1below.  Results:KL20  The selection of2 papers was made based on the titles, abstracts and locationKL21 s. The papers include, one systemic review article by Bayard Robertsfrom 2008 on the Basic Package of Health Services (BPHS) and its implicationsfor sexual and reproductive health focusing on the regions in Afghanistan andSudan and a qualitative study by Natasha Howard from 2014, that discusses theperspectives of the BPHS in Afghanistan which is important since Afghanistan isa post-conflict country that has had the BPHS implemented for the longest time.(14,15) The major themes found were, quality of care;antenatal services; STIs and family planning services; gender based violenceservices and political religious and cultural limitations. (14,15)    Discussion: Sources reviewBayard Roberts systemic review articlediscusses and analyses current data from that time even though the paper mayhave been predisposed to researcher bias due to the nature of systemic reviews.(14) Natasha Howard’s qualitative study is the first of its kind asmost data on the BPHS is quantitative using the Balance score-card scoringsystem, whilst this study uses in-depth interviews and focus group discussions.

It uses a systems approach to encompass views from all health-care systemlevels and uses purposive sampling to have a diversity of opinions. A negativeis that, purposive sampling is highly subjective to researcher bias. The datain the study was analysed using the WHO health system framework, see appendix 1. However, the study onlyaddressed reproductive health as encompassing: maternal and newborn health;contraception and STI and HIV prevention treatment. (15) Gender-basedviolence was not mentioned in this study but it was outlined in Bayard’s paperthat there are no services addressing gender based violence in Afghanistan. (14) Bayard’s Paperidentifies the concerns around Gender Based violence and how the BPSH addressesit, whilst Natasha’s paper does not mention it, making it difficult to evaluatethe extent of the poor provision of these services.

(14) Bayard alsomentions Political, Religious and Cultural limitations which Natasha’s studydid not cover, making it hard to analyse their full impact. Overall, Bayarddiscusses a larger scope of topics but presents mostly negative pointssuggesting that the argument is not presented equally with no bias. (14) Thatsaid, due to the lack of acknowledgement of Gender Based Violence Services asbeing part of reproductive health, Natasha’s paper may also be bias, however, overallher paper presents equal sided results, and her methodology is thorough despiteher sampling method being subject to researcher bias. (15)  The Quality of Care provided by the BPSHBayard discussed the quality of care in thecontext of service delivery, he suggested that it was mainly general healthNGOs being contracted that did not have the skills to deliver reproductivehealth services at international standards. He suggested that specialist NGOsneeded to be contracted to overcome the controversial nature of reproductivehealth but that the BPSH did not have enough funding for this and it wascompromising the quality of care. He also outlined the detrimental effects ofthe BPSH trying to be cost-effective, with certain services being prioritizedand NGOs being contracted that cannot fulfil all the reproductive healthservices due to underestimated costs.

He outlined the difficulties ofmonitoring the contracts to correct these underestimated costs in countries ina post-conflict state. (14) On the other hand, Natasha’s studyhighlighted the effect of lack of staff on quality of care and that thequantitative data from the Balanced-Score card used to analyse quality of carewas suggested by participants to be a poor representation of the actualquality. (15)  How the BPSH addresses antenatal servicesBayard discusses antenatal services beingaddressed with regards to the large number of services the BPSH offers and bothpapers acknowledge the increased uptake of reproductive healthcare servicesafter implementing the BPSH. (14,15) Natasha’s study however alsodiscovered barriers to the uptake of antenatal services, the primary onesidentified were childcare, financial barriers and facility access. Facilityaccess had the largest impact on antenatal care but results from her studyidentified that increased ambulance and mobile outreach programs implemented bythe BPSH were addressing this problem. Additionally, the BPSH was puttingforward an initiative to train community midwives for antenatal care whenambulance services are not available.

(15) How the BPSH addresses STIs and Family PlanningIn Bayard’s paper, it stated that the number offamily planning centres had increased from the BPSH implementation. Despitethis he also discussed the lack of services specifically targeting youngpeople, the BPSH was not including a service for sexual health and familyplanning in adolescents. (14) While Natasha’s study brieflyaddressed this same issue, her results suggested that family planning uptake inthe BPSH was poor due to misconceptions about contraception and shyness causingdelayed health seeking.

This discrepancy across the two papers makes itdifficult to distinguish which of these factors is having the greatest impacton family planning service uptake. (14,15) Natasha’s studyidentified that Community Health Workers leading Community Based Care seemed vitalin the provision of contraception and improving community trust. Although thiswas acknowledged to be a helpful form of care, it was also stated that theCommunity Health Workers in the BPSH program were few and their workloadimmense, discouraging people joining the team.

(15) How the BPSH addresses Gender Based ViolenceBayard discusses thelack of services addressing Gender Based Violence in the BPSH. He suggestedthat this was due to the efforts of the BPSH to be cost-effective, this wasspecifically true in Afghanistan and South Sudan, where due to costlimitations, services for Gender Based Violence were excluded. (14)In Natasha’s paper, although these services are not offered in Afghanistan, theservices were not even acknowledged as being a part of women’s reproductivehealth. This lack of acknowledgement may be due to researcher bias. This makesit challenging to understand the extent of reasons to why these services arenot being offered or adequately provisioned. (15) Political, Religiousand Cultural limitations of the BPSHAlthough not identifiedin Natasha’s results, Bayard discussed the effects of these forces on theprovision of certain services. These forces can undermine the provision ofservices such as family planning because contracts for the BPSH are oftenawarded to faith based NGOs. Despite this, he discussed what the BPSH was doingin South Sudan to eradicate this by forcing organisations to sub-contractservices they do not want to provide.

Although this sounds positive, itsimplementation in South Sudan was very recent and Bayard acknowledged thelimited evidence in South Sudan to suggest its true effectiveness. (14)  Implications for FutureResearchIt is clear across bothpapers that there is outstanding research to be done into how Gender BasedViolence is being addressed by the BPSH and how new services can beimplemented. It has also been evident from both works that there is a serviceuptake problem in the BPSH which is most considerably affecting antenatal careand there is not enough research in place as to how the barrier’s identifiedare being overcome and whether these are effective. (14,15) It isalso clear, particularly from Bayard’s research, that service provision is nottargeting the younger age groups which is effecting how the BPSH is performingat STI control and family planning uptake in adolescents. (14)Research should be undertaken to better understand the barriers to adolescentuptake to implement an approach to overcome them.   Conclusion:KL22  This paper intended toidentify the main areas in women’s reproductive health that are affected byconflict, these were: Gender Based violence; Antenatal care and STI control andFamily Planning.

It also intended to evaluate the effectiveness of an approachto providing Reproductive Healthcare to women in Post-conflict areas, for thisit identified the BPSH. This project concludes thatthe BPSH has been effective in improving the number of and access toReproductive Health Services for women in post-conflict areas, even though itis clear from the research on the BPSH that it is still not overcoming majorbarriers, social and physical, to accessing their services and is not providingall the Services that the women in post-conflict areas require. This means thatthe BPSH is more effective than not having any external approach to serviceprovision in place, however it also means that there needs to be modificationsin order to improve the service. These findings should encourage the practiceof further research into the BPSH and help guide any future development of newservices to address female reproductive health in post-conflict areas; withrespect to which aspects of the BPSH work well and where there could beimprovements.

   Reflection: I was unaware when setting my aims andobjectives that the literature I had available on my topic was limited. Despitethis, I was able to find the approach with the most literature and continueachieving my aims and objectives using the single approach. This literaturereview has improved my research skills and taught me to dissect scientificpapers in a more analytical way.

    Acknowledgements: I would like to thank my supervisor for helpingguide me through this project.  KL1Reference  KL2Fragmented,good definition but opening to sentence doesn’t make sense.  IW3done KL4 IW5done KL6Reference IW7done KL8Referencedone KL9Referencedone  KL10Referencedone  KL11Informaldone KL12Usesub headings   done  KL13Referencedone KL14Usesub headings done KL15Referenceand    done  KL16Reference and sub heading  done KL17Refererence                                done KL18Reference     done IW19 KL20Lotsof this section can go in your discussion. The result section explains theoutcome of a literature review. Eg which papers you have found and the majorthemes that were found and will be explored as part of your discussion. Criticisms of the papers definitely belong indiscussion.

 KL21done KL22whatyour findings mean, for the project and the wider context, e.g.: • did youachieve your aims and answer the big question? If not, why not? • has your worksettled uncertainty in the field, or added to it? Why? • will your findingschange your own practice? Should others do likewise

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