Upholding sensitization as a pillar of sexual and reproductive health and rights' implementation among youths in ongoing conflict zone in Eastern DR Congo

¹Youth Alliance for Reproductive Health, Goma, Democratic Republic of the Congo, ²Schoolof Allied Sciences, Department of Public Health, Kampala International University Western Campus, Ishaka-Bushenyi, Uganda, ³Provincial Hospital of Nord-Kivu, Department of Obstetrics and Gynecology, Goma, Democratic Republic of the Congo, ⁴Heal Africa Hospital, Department of Obstetrics and Gynecology, Goma, Democratic Republic of the Congo, ⁵Youth 2 Youth, Bamenda, Cameroon

^&Corresponding author
Simon Binezero Mambo, Youth Alliance for Reproductive Health, Goma, Democratic Republic of the Congo

Commentary    

Armed conflicts are known to incite health challenges. The Democratic Republic of Congo (DRC) has experienced decades of violence related to armed conflicts for more than 25 years and this has been worsened in the eastern part of the country [1]. Long-lasting and protracted conflicts, in particular, have consequences not only for the war-wounded but also for the health of entire communities. Resurgent confrontations in North Kivu have led to extensive population displacement estimated at 1.2 million and 650,000 internally displaced persons (IDPs), respectively [2]. Over the years, global and humanitarian health actors have developed health policies and guidelines to improve the delivery of health services in emergencies or humanitarian crises. Despite these advancements, the international health response in conflict-affected settings still faces gaps and challenges [3]. In addition to a deprived health system due to crises in low- and middle-income countries (LMICs), poverty, gender-based violence, abuse, forced marriages and cultural norms further hinder adolescents´ access to Sexual and Reproductive Health and Rights (SRHR) services. In response to these challenges, World Health Organization (WHO) is working with other governmental and non-governmental organizations to ensure that health care services are available, accessible, acceptable, and equitable for diverse youth sub-populations in LMICs [4].

In the eastern regions of DRC, nearly two decades of conflict and instability have contributed to a weakened health system, unable to adequately respond to health needs. Since 2021, Ipas under the program Makoki Ya Mwasi have collaborated with youth led-organizations to support the Congolese Ministry of Health (MOH) to provide good quality sexual and reproductive health services and information and safe abortion in legal framework in North and South Kivu. Technical assistance to the MOH included capacity building and supportive supervision of health workers, provision of necessary equipment and supplies, and community mobilisation activities. Conflicts have a damaging impact on health and health-related infrastructure and lead to shortages in medicines, medical supplies, health personnel, and financial resources [5] and in addition to that, it renders more difficult for health workers to access populations in need and for these populations to access health services. Poor health outcomes in terms of a high maternal mortality ratio of 846 maternal deaths per 100,000 live births and low modern contraceptive prevalence of 7.5% can be explained by the effect of the crisis in the region of Eastern DRC [6]. A study conducted in North-Kivu and South-Kivu by the DRC government and health survey in 2014 found that 18.0% and 20.7% of adolescents were childbearing [9]. Furthermore, pregnancy outside of marriage was found to be related to stigma among girl-mother in the Eastern DRC [7,8]. Structural barriers such as a restrictive legal environment, limited medical resources, and highcosts inhibit access to safe abortion in the Democratic Republic of the Congo (DRC); these barriers are exacerbated by two decades of conflict. All the above findings are supporting what was found in Masisi, North Kivu, where it was mentioned that adolescent women were less likely than adult women to access contraceptive services and other studies of a nationwide level with Sexual and Reproductive Health (SRH) services limitation among adolescents in DRC.

Since access to health services is vital for ensuring SRH and the well-being of adolescents, training and sensitization are required in the community among public authorities, health workers, community leaders, and adolescents to implement the applicability of SRHR services without stigma among adolescents. The DRC government with donors and implementing partners continue to expand the implementation of SRH programming within the country in terms of policies and frameworks despite the lack of up taking of SRH services among youth in poor health system due to army conflict. To achieve this gap, a community-based health system (CBHS) approach can be applied in this conflicted area in terms of sensitization. Therefore, this short commentary is highlighting the need for increasing sensitization as a pillar of SRHR implementation in the Eastern DRC.

Sexual and reproductive health and rights among youth and the role of sensitization as a pillar of SRHR implementation in Eastern DRC: the unmet need for contraceptives is estimated to be approximately 222 million women worldwide, resulting in unintended pregnancies, unsafe abortions, and elevated maternal mortality and morbidity. The DRC has a prevalence of 8% of modern contraceptive use with an unmet need for contraception of 28% among unmarried women aged 15-49 years but, in the North-Kivu with the intermittent armed conflict that has impacted the use in terms of inability to obtain SRH care [9]. Other studies done in the eastern region of DRC found that contraceptive use among adolescents was low, with a prevalence of 16.5% [9]. This finding was supporting the previous studies done in the same region where 18.0% to 20.7% of adolescents were childbearing [9] and that adolescent girls were less likely than adult women to access contraceptive services. Although present in few health facilities in the region, SRH services access still have barriers from the community members, impacting significantly the unequal gender norms and influencing women´s individual SRH choices. This finding indicates a need for a community-based health system (CBHS) approach to sensitize the different members of the community in the region for the implementation and the use of SRH services in this part of the country to reach the 2030 target of access to sexual, reproductive health and rights services. Sensitizing the community by involving the public authorities, health workers, community leaders, and adolescents in "speaking for" and supporting SRHR of adolescents in the communities can increase the uptake of SRH services among the youth in this conflict region of DRC. Studies done in different countries found that community leaders can facilitate the success of SRH interventions, especially when the promoted health behaviours deviate from traditional norms in Kenya and Ghana in Malawi and Zambia [10]. In the eastern region the DRC with the armed conflict´s impact on the health system, linking community members to health services by publicizing SRH information, addressing socio-cultural barriers to contraceptive use, actively voicing the support for SRH services during SRH campaigns, community events, and town halls will help in implementing SRHR among youth in a conflict region. A study in eastern DRC recommended for community engagement and discussion regarding discriminatory beliefs towards women who induce abortions, sensitization is critical to break down normative behaviors that impede access to life-saving medical care. While the recent progress in integrating the Maputo Protocol into Congolese law was a necessary step towards reducing legal obstacles to obtaining safe abortion, decriminalizing abortion alone is insufficient to reduce unsafe abortion. Interventions must prioritize addressing abortion stigma and engage communities to shift social norms to be less discriminatory towards young women who induce abortion [8]. Easy translation of standard operating procedures that are complemented by practical tools and materials in sexual reproductive health services for youth and its importance should be made available for the community and in the different health facility levels to increase the effectiveness of SRH services access among youth in this region of DRC.

Steps for scale-up of SRHR services or programmes among youth in Eastern DRC: here we provide some steps which can be put in place in this conflict-affected region to improve SRH implementation among youth: the DRC Government must ensure that sensitization efforts are embedded in the implementation of national frameworks for quality health services in SRH for adolescents and young people. Health care workers should emphasize commitments and obligations with SRH services and empower young people by increasing their awareness and choice of SRH services; dedicated adolescent- and youth-friendly spaces with visible prompts, such as posters outlining SRH services highlighting obligations and responsibilities of the community; sensitization that targets all cadres that form part of SRH service, including non-clinical staff such as security agents, administrative and religious leaders; sensitization around the value of providing different SRH services to women with particular attention placed on youth; integration of SRH services in essential packages and facilitation of intergenerational dialogues breaks down barriers, and builds greater understanding of SRH services among youth and improve confidentiality and privacy key drivers for young people to access SRH services, especially those related to abortion, which is highly stigmatized; debriefing opportunities should be provided for psychosocial support among affected youth and help young clients feel more comfortable and confident in asking for information and seeking services without feeling discriminated against, stigmatized or judged; standard tools and materials that are adolescent and youth-friendly must be provided to support the integration of SRH services in the post-conflict region and to ensure SRH services that are non-judgmental and free from stigma. Meaningful youth and adolescents´ engagement as full partners in the design, implementation, monitoring and evaluation of SRH programs and increase client satisfaction, and their likelihood to return and recommend the service to their friend; the government, donors and humanitarian and development organizations should effectively address the sexual and reproductive health risks for adolescents in crisis situations by scaling up services in emergencies and investing in adolescent sexual and reproductive health from the onset of an emergency.

Conclusion     

The eastern part of DRC is living in a situation of armed conflict with an impact on the health system which renders SRH services difficult to access among youth. This has an impact on the health status of the cadres of the future of this country and in achieving the Sustainable Development Goal 3. Sensitization of the community based on the comprehensive sexuality education approach has the potential to impact positively the integration of SRH services in this post-conflict region. The government and non-governmental organizations should work in collaboration to uphold sensitization as a pillar of SRH services among youth in Eastern DRC and ensure the provision of SRH information and services are central to an effective humanitarian response and to fulfilling the fundamental human rights and humanitarian law obligations, thus reduce maternal mortality, mitigate vulnerability to unwanted pregnancy, and improve health and development outcomes for young people.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All authors contributed equally, read and approved the final manuscript.

Acknowledgments     

The authors are thankful to Ipas-DR Congo for supporting youth-led organisations through the Makoki Ya mwasi programme to increase access to sexual and reproductive health information and services especialy promoting women´s rights in Eastern-DR Congo and Dr Franck K. Sikakulya for his intellectual contributions to the manuscript.

References