Q&A: 'Nothing could have prepared me for Cox's Bazar,' reproductive health expert says

UNFPA offers family planning services to Rohingya refugees at Kutapalong refugee camp in Cox’s Bazar. Photo by: Anna Dubuis / DFID / CC BY

BANGKOK — Pregnant women and new mothers are in critical need of maternal health services in Cox’s Bazar, where Rohingya fleeing violence in Myanmar have become the densest population of refugees in the world.  

Since August, more than 650,000 refugees have arrived in Bangladesh. More than half of them are women and girls, and about 10,000 women are expected to give birth in the next three months alone, according to the United Nations Population Fund. Some women are walking more than one or two hours to reach the nearest health facility. And in cases where a pregnant mother faces birth complications, a referral to a hospital is often putting both the mother and the baby in danger.

“Recently, one woman experiencing birth complications in one of the camps was referred to three different facilities before she could access lifesaving care,” Nada Hamza, UNFPA sexual and reproductive health specialist deployed to the emergency told Devex. “Her complete referral journey was over six hours.”

Despite having experience working on several humanitarian responses, “nothing could have prepared me for Cox’s Bazar,” Hamza said. “The conditions that people are living in here are really so confronting. The stories I’ve heard about the atrocities experienced by women and children will never leave me.”

UNFPA is currently supporting 20 sexual and reproductive health and rights facilities serving both refugees and host communities, while women-friendly spaces provide a safe place for women and girls to rest and receive referrals to support services, including health care, psychosocial support, and counselling.

But high rates of malnutrition put pregnant women at risk of serious health complications, while cultural norms of birthing at home rather than in a facility have complicated health care provision. Overall, access remains a top challenge in the sprawling, hilly camps, where some health centers are underutilized, and others are overstretched.

Devex spoke with Hamza about these challenges, and what UNFPA’s health care provision will look like as the response moves forward. The interview has been edited for length and clarity.  

You’ve worked on emergency responses in Sierra Leone, Yemen, Sudan, and Ethiopia. When it comes to women’s needs and the challenges of meeting them, what are some of the ways the Bangladesh response compares — or doesn’t?

The needs of women across different humanitarian and emergency settings are the same. Regardless of the context, there will always be women who need sexual and reproductive health services, particularly pregnant women and survivors of gender-based violence.

However, the scale and speed of this influx has made this humanitarian emergency a very complex situation to work in. Refugees have settled in spontaneous sites before services could be made available. The settlements are extremely overcrowded, making it difficult for health actors to establish health facilities and essential services. There is also a lack of road access to and from these sites.

It's estimated that about 10,000 women will give birth in the next three months, and many are at risk of life-threatening complications from pregnancy. How are sexual and reproductive health specialists keeping tabs on these women?

This is where our community health volunteers are so important. The volunteers help identify pregnant women, make them aware of the available services, and encourage them to seek pregnancy care. Nevertheless, the size of the community health volunteers’ network is inadequate for a crisis of this scale. We need to expand to reach more pregnant women, especially given that the population movement here is so fluid.

Encouraging women to give birth at facilities rather than in their shelters remains challenging.

What are you hearing from the women you’re aiding on why this is, and what do you think it will take to have more women seek professional health care?

UNFPA estimates that only 22 percent of deliveries among Rohingya communities happen in health facilities. We understand from pregnant women in the camps that they prefer to deliver with the support of a traditional birth attendant in their makeshifts. Some of the women we have spoken to were reluctant to use health facilities that were only a few minutes away.

The reason behind this preference could be cultural. However, a more in-depth survey during the next phase of the response is needed to better understand barriers and make services more accessible. As they appear to be trusted by the community, we are currently planning to integrate traditional birth attendants into our community health volunteers’ network. Rather than helping mothers at home, traditional birth attendants will be trained to encourage mothers to access health facilities for antenatal care and safe delivery.

Even if birthing at facilities became a more accepted cultural idea, is there even enough space for women at existing centres?

It’s not the number that is the key challenge at the moment, it’s the special distribution of services and facilities. Some health facilities are underutilized, and some are overstretched. This is where coordination is important. Partners are working hard to collaborate more efficiently, to ensure that services are provided across the camps and settlements, even in the hard-to-reach areas.

Referral of emergency obstetric complications is another key concern right now. Unfortunately, when women face birth complications, the decision to seek medical help is often delayed, and by the time they reach a health facility, it can be too late to save the mother and/or the baby.

The scarcity of available and suitable land is preventing the establishment of SRH services in some places. What do you think this will mean as the response moves forward — the establishment of more mobile clinics? Larger teams of roving SRH experts to visit these women?

Over the past several months, we have been in the acute stage of response, where partners and agencies have been focused on rapidly establishing health services in an attempt to match the speed of the influx. We are aware that distribution of health facilities is an issue. In view of this, health partners have conducted a joint mapping of all existing facilities to better understand their distribution and the range of all health services being provided, including sexual and reproductive health. This information will be used to better plan and coordinate provision of health services.  

“Midwives are the true heroes on the ground here … Supporting so many women needing care under such challenging and resource limited conditions is personally difficult for them as they are humans too.”

— Nada Hamza, UNFPA sexual and reproductive health specialist

We know that some sites are still deprived of sexual and reproductive health services, and these need to be targeted in the next phase. A combination of approaches may be used according to the needs: Mobile and static SRH clinics as well as expanding the community health volunteers’ network to encourage women to use the facilities available in their areas. We have also been using “tom tom” [auto-rickshaw] ambulances to transport pregnant mothers from the community to the health facility, and for referrals from one facility to another.

There are a number of UNFPA-supported midwives working in the camps. What role do they play?

UNFPA has deployed 60 trained midwives providing a wide range of SRH services, including antenatal care, safe deliveries, emergency obstetric care services, family planning, and clinical management of rape.

Midwives are the true heroes on the ground here. These midwives are working around the clock, stretching beyond their capacities to save mothers and babies’ lives. Supporting so many women needing care under such challenging and resource limited conditions is personally difficult for them as they are humans too and get affected by the suffering they witness. Many of them are quite young, proudly among the first cohorts of professional midwives through Bangladesh’s first official training programme. We are very proud of their commitment to serve in this crisis and we provide them with ongoing support.

Aside from lack of infrastructure and roadways to provide access, what are the other greatest challenges to women’s sexual and reproductive health care right now? Are there any issues you feel are currently falling through the cracks that need attention?

A preference for home delivery, and the inadequate distribution of sexual and reproductive health services pose a major challenge. This has a negative impact on the ability of pregnant mothers to access timely sexual and reproductive health services and emergency obstetric care.

Family planning is also an issue. UNFPA offers comprehensive and voluntary family planning as part of our humanitarian response. This includes family planning commodities and training for our deployed midwives to offer family planning services. However, efforts to improve family planning information and services for refugees need to be improved.

About the author

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    Kelli Rogers

    Kelli Rogers is a global development reporter for Devex. Based in Bangkok, she covers disaster and crisis response, innovation, women’s rights, and development trends throughout Asia. Prior to her current post, she covered leadership, careers, and the USAID implementer community from Washington, D.C. Previously, she reported on social and environmental issues from Nairobi, Kenya. Kelli holds a bachelor’s degree in journalism from the University of Missouri, and has since reported from more than 20 countries.