Sexual and reproductive health self-care in humanitarian and fragile settings: Where should we start?

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Nguyen Toan Tran, Hannah Tappis, Pierre Moon, Megan Christofield and Angela Dawson


Recent crises have accelerated global interest in self-care interventions. This debate paper aims to raise the issue of sexual and reproductive health (SRH) self-care and invites members of the global community operating in crisis-affected settings to look at potential avenues in mainstreaming SRH self-care interventions. We start by exploring self-care interventions that could align with well-established humanitarian standards, such as the Minimum Initial Service Package (MISP) for Sexual and Reproductive Health in Crises, point to the potential of digital health support for SRH self-care in crisis-affected settings, and discuss related policy, programmatic, and research considerations. These considerations underscore the importance of self-care as part of the care continuum and within a whole-system approach. Equally critical is the need for self-care in crisis-affected settings to complement other live-saving SRH interventions—it does not eliminate the need for provider-led services in health facilities. Further research on SRH self-care interventions focusing distinctively on humanitarian and fragile settings is needed to inform context-specific policies and practice guidance.


Sexual and reproductive health self-care

Self-care for sexual and reproductive health (SRH) has equipped people, especially women and girls, with skills and knowledge passed through generations to manage menstruation, fertility, pregnancy, and childbirth for themselves and care for their newborns and children. According to the World Health Organization (WHO), “Self-care is the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a health care provider”. Such self-directed health is increasingly valued as a critical asset of the healthcare ecosystem with great potential to fill SRH service gaps and bolster universal health coverage when situated within a rights-based, gender-sensitive, people-centered, and health-system integrated approach. Such interventions may save money for both users and the healthcare system through a mixed financing model that includes public and private sector financing and direct user payment. SRH self-care interventions could play a larger role in humanitarian settings, where trained health workers and adequate health infrastructure are lacking. Recent systematic reviews were published in 2019 and show the promise of self-injected contraceptives, over-the-counter oral contraceptive pills, home-based ovulation predictor kits, self-sampling for human papillomavirus, and self-testing for sexually transmitted infections. Most of the identified studies were done in high-income countries and none in humanitarian settings.

Fragile and humanitarian settings

Approximately 1.8 billion people live in fragile settings around the world, including 168 million in humanitarian contexts. Around a quarter are women and girls of reproductive age. SRH conditions are among the principal causes of death and ill-health among women of childbearing age worldwide, with 61% of maternal deaths occurring in countries experiencing fragility and crisis. While the prioritization and coverage of SRH services in humanitarian settings have expanded over the last few decades, there continue to be significant unmet needs. Funding for humanitarian assistance is limited, and variations in socio-political contexts, health system capacity, population movement, security, and humanitarian access challenge the provision and utilization of essential health services in many settings. For many fragile and crisis-affected countries, natural or human-made disasters represent an additional and unparalleled burden to already overwhelmed health systems, with significant implications for women and girls, but also men and boys. As exemplified by the coronavirus disease 2019 (COVID-19) pandemic, home confinement and travel restrictions combined with the fear of contracting the disease and the closure or limited hours of healthcare facilities and stock-outs of essential medications and equipment have delayed the uptake of and timely access to essential health services with a gendered impact on women and girls, thus rendering gender-inclusive—and age, disability, and diversity-inclusive—leadership and strategies even more relevant. Previous experience of epidemics in fragile and humanitarian settings indicates that the interruption of healthcare services considered unrelated to the epidemic response might have occasioned more deaths, including SRH-related deaths, than did the epidemic itself.

Debate rationale

Against this background, we believe that the time is ripe for programs in fragile and humanitarian settings to consider systematically implementing SRH self-care interventions. However, based on our field knowledge, programmatic models to assist decision-makers in allocating resources are lacking to guide the safe and effective implementation of SRH self-care interventions in settings with often severely disrupted health systems. This debate paper does not propose such programmatic models, nor does it offer a systematic review of existing guidance and practices on the topic—none of the systematic reviews recently published and mentioned in the introduction retrieved studies done in fragile or humanitarian settings. Instead, our debate paper aims to raise the issue among the members of the global SRH community operating in crisis-affected settings and invites them to explore together potential avenues in mainstreaming SRH self-care interventions. Consequently, the paper starts with an exploration of self-care interventions that could align with well-established humanitarian standards, touches upon the potential of digital health support for SRH self-care in crisis-affected settings, and discusses related policy, programmatic, and research considerations. Our reflection acknowledges that the programmatic implications for including self-care interventions will vary vastly depending on the setting, intervention type, where and how they are accessed, and the required links to the health system to support care.