The 2018 Inter-agency field manual on reproductive health in humanitarian settings: revising the global standards

Abstract Since the 1990s, the Inter-agency field manual on reproductive health in humanitarian settings (IAFM) has provided authoritative guidance on reproductive health service provision during different phases of complex humanitarian emergencies. In 2018, the Inter-Agency Working Group on Reproductive Health in Crises will release a new edition of this global resource. In this article, we describe the collaborative and inter-sectoral revision process and highlight major changes in the 2018 IAFM. Key revisions to the manual include repositioning unintended pregnancy prevention within and explicitly incorporating safe abortion care into the Minimum Initial Service Package (MISP) chapter, which outlines a set of priority activities to be implemented at the outset of a humanitarian crisis; stronger guidance on the transition from the MISP to comprehensive sexual and reproductive health services; and the addition of a logistics chapter. In addition, the IAFM now places greater and more consistent emphasis on human rights principles and obligations, gender-based violence, and the linkages between maternal and newborn health, and incorporates a diverse range of field examples. We conclude this article with an outline of plans for releasing the 2018 IAFM and facilitating uptake by those working in refugee, crisis, conflict, and emergency settings.


Setting the context
In 2015, the United Nations High Commissioner for Refugees (UNHCR) estimated that the global forcibly displaced population exceeded 65 million for the first time in history. 1 This included over 21 million refugees, 40 million internally displaced persons, and more than 3 million asylum seekers. 1 Of those needing humanitarian assistance, approximately one in four are women and girls of reproductive age. 2 The global community began prioritising the sexual and reproductive health needs of refugee and displaced populations in the mid-1990s. In 1995, more than 50 governments, UN agencies, and non-governmental organisations (NGOs) committed themselves to strengthening reproductive health services for refugee populations and subsequently formed the Inter-Agency Working Group on Reproductive Health in Crises (IAWG).* One of the first activities of the new organisation was to develop guidelines for providing reproductive health services in refugee settings. After extensive field-testing of a beta version, in 1999 IAWGaffiliated agencies released Reproductive health in refugee situations: an inter-agency field manual. 3 Importantly, the manual outlined a set of minimum reproductive health interventions, known as the MISP, to be put in place at the outset of a humanitarian crisis. The manual also served as a tool to: facilitate discussion and decision-making in the planning, implementation, monitoring, and evaluation of comprehensive reproductive health interventions; guide sexual and reproductive health officers, programme managers, and service providers in introducing and/or strengthening evidence-based interventions; advocate for a multi-sectoral approach to meeting the comprehensive needs of affected populations; and foster coordination among partners. 3 In 2010, IAWG released a new edition of the manual. Reflecting the relevance of the document for a broad array of refugee, crisis, conflict, and emergency settings, IAWG agencies retitled the manual the Inter-agency field manual on reproductive health in humanitarian settings (IAFM). 4 In addition to technical updates, the 2010 IAFM reframed safe motherhood as maternal and newborn health, included standalone chapters on adolescent reproductive health, HIV, and sexually transmitted infections, and introduced a new chapter on comprehensive abortion care. Available in print and online versions, the multi-modal resource also linked users to detailed clinical guidelines issued by normative bodies.
In 2016, IAWG embarked on a 24-month process to revise the IAFM. In this article, we describe the frameworks and principles that undergird the 2018 version of the manual. We then highlight major changes to the new edition. We conclude with a discussion of IAWG's plans to disseminate information about the changes and facilitate adoption of the manual by humanitarian agencies and field staff.

The 2018 IAFM: A collaborative global effort
Consistent with previous versions of the manual, human rights principles and evidence-based policies and practices ground the IAFM. The 2018 version explicitly recognises that sexual and reproductive health and rights are central to the realisation of fundamental human rights, including the right to life, the right to health, the right to be free from torture and ill-treatment, the right to privacy, the right to education, and the prohibition of discrimination, particularly on the basis of sex and gender. In alignment with international human rights obligations and guidance from numerous human rights and political bodies, the 2018 IAFM emphasises that advancing sexual and reproductive health and rights requires that women and girls in crisis-affected settings have access to comprehensive reproductive health information and services and the ability to make informed decisions free from violence, discrimination, and coercion. 5 Sexual and reproductive health guidelines issued by normative bodies, and particularly those of the World Health Organization (WHO), provide the technical foundation for the manual. Where possible, this manual incorporates specific evidence from or examples about the application and adaptation of global sexual and reproductive health or human rights standards in humanitarian settings. Although national laws, policies, and resources in specific contexts may complicate implementation of global standards, the 2018 IAFM presents evidence-based interventions that should be offered in all settings and to all affected populations, a position consistent with broader human rights principles. The manual is intended for use in the field by a range of implementing agency staff and thus does not provide detailed clinical guidelines; users are directed to and encouraged to consult additional resources as necessary.
Since the release of the 2010 IAFM, IAWG members have conducted both formal and informal evaluations of the use of the manual and the implementation of sexual and reproductive health interventions in humanitarian settings. 6 Taken together these evaluations indicated that despite considerable progress in funding for, awareness of, and capacity to deliver sexual and reproductive health programming, significant gaps existed with respect to providing adolescent sexual and *IAWG was originally called the Inter-Agency Working Group on Reproductive Health in Refugee Situations.
reproductive health services, offering a full range of contraceptive methods and comprehensive abortion care, providing emergency obstetric and newborn care, and preventing sexual violence. These findings informed the revision process. Feedback from practitioners in the field also provided direction for the latest revision. In addition to technical updates, users of the manual working in a range of countries and settings expressed the need for simplified language, enhanced linkages between topics and chapters, and incorporation of case studies and programmatic examples to guide implementation.
The 2018 IAFM is a product of IAWG and thus the existing leadership structure of a network that includes over 2,100 members and 450 agencies governed the overall effort. 7 IAWG formally began the revision process in March 2016. IAWG sub-working groups took the lead on individual chapter revisions, providing substantive input and technical updates through consultation and a review of published sources. These sub-working groups also reached out to field staff in multiple countries, and in some cases engaged, directly with refugee and displaced populations for feedback. The 2018 IAFM Taskforce, a body comprising more than 50 individuals from 21 UN agencies, international NGOs, and academic institutions, further developed and ultimately approved the substantive changes to individual chapters and made decisions regarding overarching structural revisions. Regular conference calls and three in-person meetings allowed for robust debate, compromise, and agreement. The final step in the process involved a technical review by the WHO and sign off by the IAWG Steering Committee. Thus, the 2018 IAFM resulted from a deliberate collaborative process that included hundreds of individuals from dozens of agencies and organisations working in humanitarian settings at global, regional, and local levels. The updates to the IAFM, detailed below, represent the consensus positions of a wide cross-section of agencies working on sexual and reproductive health in the humanitarian sector.

Changes to the Minimum Initial Service Package
One of the hallmarks of the IAFM is the Minimum Initial Service Package (MISP) for Reproductive Health. 8 The MISP defines which sexual and reproductive health services are most important in preventing morbidity and mortality, while protecting the right to life with dignity, particularly among women and girls, at the onset of a humanitarian emergency (within 48 h whenever possible). All service delivery activities of the MISP need to be implemented simultaneously through coordinated actions with all relevant partners. The components of the MISP form a minimum requirement and are intended to be implemented in all circumstances.
In the 2010 IAFM, the MISP outlined a set of objectives and corresponding priority activities designed to coordinate sexual and reproductive health efforts at the outset of a crisis, prevent and manage the consequences of sexual violence, reduce HIV transmission, prevent excess maternal and newborn morbidity and mortality, and plan for comprehensive sexual and reproductive health services. 4 The manual referenced the provision of specific contraceptives in the context of responding to sexual assault and preventing maternal death and disability, as well as in a note highlighting a number of additional priorities. In the 2018 IAFM, prevention of unintended pregnancy is a standalone objective. The identified priority activities are to: (1) Ensure availability of a range of long-acting reversible and short-acting contraceptive methods (including condoms and emergency contraception) at primary healthcare facilities to meet demand; (2) Provide information, including information, education, and communication materials, and ensure contraceptive counselling that emphasises informed choice, effectiveness, and supports client privacy and confidentiality; and (3) Ensure the community is aware of the availability of contraceptives for women, adolescents, and men.
The repositioning of contraception within the MISP reflects a significant improvement and acknowledges the importance of unintended pregnancy prevention in women's health and lives. 9 In Figure 1, we provide a list of the 2010 and 2018 MISP objectives.
A second major change to the MISP chapter involves explicit references to safe abortion care. Although there is a lack of reliable data on abortion in refugee, crisis, conflict, and emergency settings, unsafe abortion is a leading cause of maternal death worldwide and the need for safe abortion care likely increases in humanitarian settings. 10 In addition to incorporating pregnancy options counselling and provision of or referral for safe abortion care into clinical care for survivors of sexual violence, provision of safe abortion care, to the full extent of the law, is now included in the MISP chapter as a standalone "other priority activity".
Finally, in addition to important technical updates and wording changes, the 2018 IAFM strengthens guidance on transitioning from the MISP to comprehensive sexual and reproductive health services. These revisions respond to a gap identified in the IAWG global evaluation. 6 The new version offers expanded content to facilitate planning for comprehensive services and focuses on health system building blocks (see Figure 1).

Addition of a logistics chapter
The supply chain is a critical component of successful sexual and reproductive health service delivery. Without sexual and reproductive health medicines and other supplies, health workers cannot provide effective services. When humanitarian emergencies occur, organisations involved in the response must quickly identify or establish functioning, agile supply chains to meet the needs of the affected population, whether in cities or in remote rural areas. Humanitarian response agencies also have a responsibility to contribute to building and maintaining strong, flexible, sustainable supply chains in all settings in which they work; doing so is consistent with the concepts of availability and geographic accessibility present within the human rights corpus. Recognising the importance of these issues, the 2018 IAFM includes a chapter dedicated to logistics. The chapter maps the key stakeholders and processes that are essential to effective sexual and reproductive health supply chains; provides recommendations on transitioning from emergency to ongoing supply chains; outlines key steps including forecasting, Figure 1. Objectives of the Minimum Initial Service Package procurement, transportation, and last-mile distribution; and identifies staff roles and responsibilities for effective supply chain management. The inclusion of this chapter responds directly to feedback from users in the field.

Changes in emphasis and language
The 2018 IAFM places greater and more consistent emphasis on human rights obligations and principles, gender-based violence, and the linkages between maternal and newborn health. The introduction and the revised chapter on "fundamental principles" engage more fully with the human rights underpinnings of the manual and situate the recommendations within broader international guidelines. The revised chapter on gender-based violence not only provides robust and updated technical information regarding service delivery, but also includes an expanded focus on a broader array of types of gender-based violence encountered in humanitarian settings. This includes exploration of the relationship among the substantive topics of sexual violence, domestic and intimate partner violence, female genital cutting, and early marriage and sexual and reproductive health. The third edition lays out a survivor-centred, rights-based approach to these issues in humanitarian settings that pays specific attention to adolescents and lesbian, gay, bisexual, transgender, queer, intersex, and asexual populations. The new version of the manual also places greater emphasis on quality care for mothers and newborns on the day of birth and contains more information about newborn health. 11 This includes expanded content related to emergency obstetric and newborn care, essential newborn care, and care for small and sick newborns. Finally, the 2018 version of the manual uses "sexual and reproductive health" in place of reproductive health, reflecting better the scope of the manual and expanded understanding of the field of sexual health.

Inclusion of programmatic examples: highlighting successes and challenges
In response to expressed needs from the field, the 2018 IAFM includes a series of programmatic examples showcasing the implementation of sexual and reproductive health programming in different humanitarian settings. These examples involve numerous implementing agencies in different countries and regions operating during different phases of an emergency. Case studies also explore a range of challenges that are routinely experienced by those in the field.
Next steps for the 2018 IAFM IAWG will officially release the third edition in early 2018. At that time, humanitarian stakeholders will have access to both print and electronic versions of the English version of the manual. Supplementary materials, including detailed clinical guidelines, decision aids, and templates will be available online. Arabic, French, and Spanish translations of the manual will become available in late 2018.
In the year following the release, members of the 2018 IAFM Taskforce will work with their own organisations and professional networks to ensure adoption of the new version of the manual. IAWG members will undertake a series of efforts to implement the new guidelines and will continue to work with local, regional, and global stakeholders to facilitate monitoring and evaluation of implementation. The new edition of the IAFM and associated dissemination efforts represent significant steps to improving sexual and reproductive health in humanitarian settings.