Assessment of Reproductive Health for IDPs
Angola, February 15-28, 2001
Reproductive Health
Angola falls under the category of a chronic emergency, yet even the most basic minimum standards for reproductive health (RH) services are not being met. Even the many NGOs and UN agencies that signed on to the Inter-Agency Field Manual for Reproductive Health in Emergency Situations 7 are not coming close to meeting the minimum standards they committed to by signing on to this document. This is due not so much to a lack of interest or concern, but a lack of resources. And in some cases this is due to the pervading attitude of international health agencies that reproductive health services fall outside of emergency life saving interventions.
Although comprehensive reproductive health services are virtually non-existent, there are efforts to increase services in some locations. UNFPA is supporting the national reproductive health program in four provinces, and NGOs augment the government services in certain provinces. The government is also launching a national AIDS campaign. However, a representative from the Ministry of Health with whom we met is aware that many Angolans, including IDPs, do not have access to the most basic of reproductive health services, including antenatal care and contraceptives. Many provinces do not even have adequate emergency obstetric services, or people live too far away from the only existing services. In many areas, there is a great distance between communities and health facilities.
Although the needs are great in both the IDP and local communities, we were told that IDPs did have special needs and considerations. In the four provinces that we visited, health workers said that awareness of reproductive health issues is lower among IDPs than in the local communities. We were also told that IDPs often wait too long to access services. The reasons for this are unclear. We did hear complaints that IDPs were not treated well at certain health facilities, and that they lack faith in the health system. We also heard that some health workers demand payment from patients as a way to supplement meager salaries, and that IDPs are less likely to be able to pay for the services. At some hospital maternities we visited, the IDPs were sleeping on the floor because they did not have sheets to put on the mattresses.
Refugees International (RI) conducted an assessment of UNHCR's response to IDPs in Angola in April 2001. Although RI found that UNHCR had made great progress in service provision to the IDPs, one key recommendation to UNHCR was specifically ". to establish reproductive health, family planning and HIV/AIDS prevention programs." for IDPs in Angola. 8
Specific findings from each of the provinces we visited
will be discussed in more detail below, but the following are some
general findings and observations that were applicable to each setting.
Please note that this assessment was limited to Luanda and four
provincial capitals and only 30% of the population is accessible.
Health conditions in the more rural and inaccessible areas of Angola
are believed to be much worse.
Safe Motherhood
Angola has one of the highest maternal mortality ratios in the world, estimated at 1,500 per 100,000 compared to bordering Namibia at 370 per 100,000 and Canada at 5 per 100,000.9 This should not be surprising, since fertility rates are high, use of family planning is low, ante-natal care is not widely available, and many women do not have access to emergency obstetric services. UNFPA-Angola produced a report in June 1999 titled The Demographic Profile and the Reproductive Health of the IDPs. The findings of this report are based on interviews with 1,422 IDPs in Huila, Benguela, Malanje and Zaire provinces. 10 This study reports that the average number of children per woman interviewed was 8.6. The infant mortality rate is 172 per 1,000 in Angola, whereas in Canada, for instance, it is 5.5 per 1,000. 11
Ante-natal care is offered in some health posts and health centers, but we were told that many women do not go for pre-natal care. This could be due to a lack of awareness of its importance, or because it was not widely available or accessible to many women. The majority of women deliver at home, and some NGOs are training traditional birth attendants (TBAs) to identify potential risks and refer women to the maternity center or hospital. However, many women in Angola do not have access to emergency obstetric services and this certainly contributes to the extremely high national maternal mortality ratio. We were told that those with delivery or post-partum complications usually arrive at the hospital too late to be saved.
Because many IDP women do not live near a provincial hospital, transportation is a huge problem. In Kuito, we were told that the roads leading to the provincial capital have only been opened since March (due to security issues), and that IDP have had no real access to health services, including emergency obstetric services. Even when roads are opened, they are generally poorly maintained and dangerous. Bridges are often dilapidated or destroyed. There is also the risk of robbery, harassment and violence when traveling by road. There are few private vehicles and no public transportation system. Informal transportation systems are unreliable or nonexistent.
Unsafe abortion may also contribute to the high maternal mortality and morbidity in Angola. According to the UNFPA study, 19% of the female respondents reported that they knew of cases of unwanted pregnancy and that in ¾ of those cases, the women tried to end their unwanted pregnancies.
The majority of IDP deliveries are at home
with a TBA. "Home" for an IDP
may be a tent shared with another
family or a straw hut with a dirt floor and some deliveries take
place under a tree or in a classroom or some other structure within
the camp. We heard consistently that women go too late to the hospital
when obstetric complications arise - a sign of very low awareness/education
of women and poorly trained TBAs. Hospitals
generally have very limited equipment, few trained staff and poor
sanitary conditions that lead to high rates of life-threatening
postpartum infections. Some IDP women in
the hospital maternities must sleep on the floor because they have
no sheets to put on the mattresses and they often go without food
because there are no family members to bring them meals. We were
told by health facility and hospital staff that many IDP
women are so malnourished they cannot breastfeed. These women may,
however, just need better education and support for breastfeeding.
Family Planning
The same UNFPA study showed that 81% of the women interviewed had no knowledge of any method to prevent pregnancy, and only 2.2% of the women were using a contraceptive method. During our visit, each facility that offered family planning complained of frequent stock-outs of contraceptives. The Angolan Ministry of Public Health, with the assistance of UNFPA, is supplying the country with contraceptives. However, lack of resources and the difficulty of transporting supplies to many of the provinces are barriers to consistent and reliable stocks. Supplies are also stolen for private use or resale in the market.
Depo Provera is the most favored form of contraceptive but there were stock-outs of Depo in every facility we visited. We were told that when the rare shipment of Depo arrives, word spreads fast and the supply is expended almost immediately. During our visit, one of the few health facilities that actually had contraceptives available was a facility supported by Medecins sans Frontieres (MSF). MSF obtained the contraceptives on their own, so they are not dependent on the government/UNFPA supply. But all contraceptives have to be imported which raises costs considerably. Agencies face logistical challenges in distribution and the obstacle of corruption when clearing supplies through customs.
Numerous barriers to family planning access exist. Often family planning services are only available in the provincial capital, which again makes access difficult. Family planning counseling may be offered in a health post or health center, but then a woman may have to go elsewhere to actually obtain the contraceptives.
Lack of awareness is also a barrier to family planning services. While 81% of the IDP women interviewed in the UNFPA study had no knowledge of any method to prevent a pregnancy, 32.8% of the women also said that they were interested to know a way to prevent pregnancy. This information demonstrates a significant need for education and awareness building.
STDs/HIV/AIDS
Lack of supplies and essential drugs prohibits the provision of quality HIV prevention and sexually transmitted disease (STD) services. HIVs are believed to be extremely common in Angola and yet not a single health facility that we visited had a supply of STD drugs. Diagnoses are based on symptoms and/or physical examinations only. Persons with STDs must go to the market or a private pharmacy for drugs, and it can be quite expensive. We were also told that people rely on traditional methods of treatment that can be dangerous, causing miscarriage and/or infertility. UNFPA staff commented that because STDs are so common, some people consider what are obvious symptoms of an STD to be normal bodily functions that they cope with rather than seek treatment.
The percentage of Angolans with HIV/AIDS between the ages of 15-45 is estimated to be 2.1%. 12 Due to the lack of testing and difficulty in gathering statistics, however, the reality is assumed to be higher and rising swiftly. Considering that HIV/AIDS is now the leading cause of death in Africa and that Zambia, bordering Angola to the east, has one of the highest known prevalence rates in Africa, there is potential here for an HIV explosion, if it has not already happened.
Voluntary counseling and testing for HIV is non-existent outside of Luanda. Blood for transfusions at the provincial hospitals is tested for HIV, but hospital staff complained of a shortage of HIV test kits. One expatriate doctor expressed concern at the increase in HIV she is seeing at a provincial hospital among the blood tested for transfusions. NGOs and the Angolan government are initiating HIV prevention activities and information campaigns, but condoms are not always available.
Sexual and Gender-Based Violence
| There are men that batter. They really
pound you. Men, when they beat women, it's as if they were
pounding corn to make flour. - Young woman in Lobito, UNFPA video Nkulimbwa ("The Forgotten") |
According to the UNFPA study, 30% of the
women respondents were victims of physical violence, and of those
30%, 70% had been abused by their husband or partner. 21% of the
interviewees knew of women forced to have sex against their will,
and 12% of IDP respondents know of men forced
to have sex against their will. We were consistently told that cases
of SGBV skyrocket whenever there is an influx
of the military or close proximity of IDPs
to a military base. Angola does not have any specific laws protecting
women from physical or sexual violence. Greater attention is now
being paid to this issue, however, with the creation three years
ago of the Ministry of Family and the Promotion of Women (MINFAMU).
Data from MINFAMU and the Angolan Women's
Association (OMA) show that between 1997
and 1999, of the 3,550 reported cases of violence against women
in Luanda 60% were domestic violence and 30% were attributed to
sexual violence by a stranger or acquaintance. While these statistics
are not specific to the IDP population, they
do indicate that violence is a significant problem in general.
7. WHO, UNFPA, UNHCR. Reproductive Health in Refugee Situations - An Inter-Agency Field Manual, 1999.
8. Refugees International, Angola: UNHCR Succeeds in Helping Internally Displaced, April 2001.
9. WHO and UNICEF. Revised 1990 Estimates of Maternal Mortality: A New Approach by WHO and UNICEF, April 1996.
10. The findings of this report were presented at the Reproductive Health Response in Conflict Consortium's Conference 2000 - Findings on Reproductive Health of Refugees and Displaced Populations, December 2000. The presentation abstract is available here.
11. This figure is taken from the 2000 World Population Data Sheet of the State of the World's Children 2001, UNICEF.
12. ibid.
