RAISE-ing the Bar: Transforming Sexual and Reproductive Health and Rights in Humanitarian Settings
“Every population, including those affected by crises, includes pregnant women,” said Sara Casey, DrPH, Director of Reproductive Health Access, Information, and Services in Emergencies (RAISE) Initiative. “And we know that 15% of pregnant women will experience a life-threatening complication that requires clinical emergency care.”
In 2006, Columbia University’s Heilbrunn Department of Population and Family Health (PopFam) and MSI Reproductive Choices developed the RAISE Initiative to transform the way sexual and reproductive health (SRH) is addressed in humanitarian settings. In honor of PopFam’s 50th Anniversary, we sat down with Drs. Sara Casey and Jessica Kakesa, MD, a Health technical advisor for the International Rescue Committee (IRC) — a RAISE partner — to talk about their work supporting SRH efforts in conflict-ridden countries.
Tell us about how you got involved with RAISE.
“I came to PopFam for my MPH and started working with Therese McGinn, DrPH, who focused on sexual and reproductive health,” Dr. Casey said. “I came back when RAISE, led by Dr. McGinn, started. And I worked on the program from the beginning. When Therese retired a few years ago, I became the director.”
Dr. Casey explained, “It was exciting to have the opportunity to do something that could really change the field and maybe finally get sexual and reproductive health and rights on the agenda.
“When we started working with our partners to advance safe abortion care, no major international humanitarian NGOs publicly said they provided abortions or even had a policy on abortion,” she continued, pointing to a debate article, Why Don’t Humanitarian Organizations Provide Safe Abortion Services?, that led to a response from Médecins Sans Frontières, the first time an international humanitarian NGO publicly acknowledged providing safe abortion care.
“I got involved with RAISE in 2007 in DRC,” added Dr. Kakesa. “Back then, I was working with another NGO. When I saw the opportunity for a reproductive health manager position, I felt like this was a calling for me.”
How has RAISE helped partners since the program launched?
“I work for IRC, which has partnered with RAISE, and they had a big primary healthcare program,” Dr. Kakesa explained. “IRC used to say SRH was part of the larger program, but we could still find gaps around reproductive health that a focus on Emergency Obstetric and Newborn Care (EmONC) would help to fill.”
With support from RAISE, IRC improved contraceptive services and post-abortion care. “At the time, only a medical doctor could offer these types of services,” said Dr. Kakesa. “Can you imagine in remote places where you only have one doctor for 250,000 people? So we developed a skills-based approach that expanded the number of providers. We used checklists to assess new providers’ skills and tailored resources for them appropriately.”
“When we started working with IRC and other partners, few had staff with SRH skills,” Dr. Casey added. “Our work together focused on expanding SRH expertise at organizational and country level, including Ministry of Health providers. The partners then promoted some of these staff to be regional SRH technical advisors – which is what Dr. Kakesa became after starting at the local level.”
What are the challenges of providing SRH services in humanitarian settings?
“The humanitarian community is very male dominated,” Dr. Casey said. “We’ve had to argue for years that sexual and reproductive health services save lives, that women die when you don’t prioritize EmONC or contraception.”
“The other thing I find extremely frustrating –– and it’s the same everywhere I work –– is that reproductive health is stigmatized. We have to tiptoe. People are afraid to talk about it, even though we know that unintended pregnancies and unsafe abortion are widespread problems, particularly in places where contraception is lacking, and abortion is highly restricted. It feels like we are constantly refighting the same battles.”
“Reproductive health always has to compete with other priorities,” added Dr. Kakesa. “When the time comes to choose where to focus resources, you’re back to square one, and again you need to argue for SRH.”
Drs. Casey and Kakesa cited the example of COVID-19, during which the humanitarian community deprioritized reproductive health to focus on the pandemic. “We still needed these services,” Dr. Kakesa said. “Women were still pregnant. People still had sex.”
How have PopFam’s resources, global network, and approach helped shape your work?
“One thing I’ve appreciated is that we’ve always had a lot of flexibility and independence to do the work we needed to do,” Dr. Casey explained. “We’ve never been asked to tone down or to not do certain work in certain places. I’ve felt that our department chair had our backs.”
“At IRC, we’ve been able to take PopFam’s model for RAISE and replicate it in other areas, so we can provide similar processes and support to more people in other countries,” said Dr. Kakesa. “We know that women will use SRH services when they are made available from trained providers. In some remote areas, we’re seeing over 60% of women choose long-acting reversible contraceptive methods. These communities rarely had access to such options, which are important since access to providers was so limited.”
What PopFam accomplishments are you most proud of?
“What I love seeing most is that many of our alumni are leaders in the field of sexual and reproductive health and rights and serve in humanitarian settings,” Dr. Casey explained. “We’re really one of the very few programs that has this focus.”
Dr. Kakesa added, “I see that there are SRH champions all over the place. Wherever we are, we take it to heart, the work is a priority, and we do whatever it takes to advocate for SRH.”
“Even now, I run into people we worked with in DRC and other countries who gained all of these skills, and find they are still using them in their own countries or elsewhere,” Dr. Casey said. “Now they’re the ones leading the fight and promoting SRHR.”
What are the most pressing challenges in sexual and reproductive health, and how do you think the field will change over the next 50 years?
“The biggest challenge is the complexity of working in humanitarian settings,” Dr. Kakesa said. “You have outbreaks, conflicts, shifting priorities. You have climate shocks and reductions in funding. And at the same time, you have to somehow keep these vital services up and running.”
She spoke about the need to create a resilient system that elevates SRH as a priority, “one where SRH is considered as important as immunization, for example.”
As for the future? “In 50 years, I’m seeing opportunities for things like localization of decision-making, because that would be a more effective approach,” she explained, “and bringing services closer to the population, especially community-based services, including self-care and contraception.”
“I remember my mentor complaining 20 years ago that she couldn’t believe we were fighting the same SRH battles we fought 20 years before,” added Dr. Casey. “And now, I feel the same way. But I’m hopeful that we, as a global society, can come together and break down the stigmas attached to sexual and reproductive health.”
Interested in learning more about RAISE?
Watch our webinar, which brings together RAISE partners to discuss their work revolutionizing the landscape for contraception and comprehensive abortion care (CAC) in humanitarian settings: Catalyzing Change for Contraception and Comprehensive Abortion in Fragile Settings
Publications (+ indicates PopFam students at the time, *PopFam alum)
S E Casey, A Ngarmbatedjimal, T Varelis+, A Diarra+, T Kodjimadje, M Abdelaziz, V Djerambete, Y Miangotar, S Tamira, A Ndingayande, K Vourbane, R Madjigoto, S Luketa, VdP Allambademel. (2024) Sexual and reproductive health of Sudanese refugee girls in Chad: mixed methods study with perspectives from 12-19 year old girls, parents, and health workers. BMC Public Health 24, 3217. https://doi.org/10.1186/s12889-024-20581-y
S E Casey, G P Isa, E I Mazambi, M M Giuffrida+, M J Kulkarni+ & S M Perera (2021). Community perceptions of the impact of war on unintended pregnancy and induced abortion in Protection of Civilian sites in Juba, South Sudan, Global Public Health, DOI: 10.1080/17441692.2021.1959939 https://doi.org/10.1080/17441692.2021.1959939
S E Casey, M C Gallagher*, E F Dumas, J Kakesa, J M Katsongo, J B Muselemu (2019). Meeting the demand of women affected by ongoing crisis: increasing contraceptive prevalence in North and South Kivu, Democratic Republic of the Congo. PLoS ONE 14(7): e0219990. https://doi.org/10.1371/journal.pone.0219990
S E Casey, M C Gallagher*, J Kakesa, A Kalyanpur*, J-B Muselemu, R V Rafanoharana, N Spilotros*. (2020) Contraceptive use among adolescent and young women in North and South Kivu, Democratic Republic of the Congo: A cross-sectional population-based survey. PLoS Medicine 17 (3): e1003086. https://doi.org/10.1371/journal.pmed.1003086
S E Casey, V J Steven+, J Deitch+, E F Dumas, M C Gallagher*, S Martinez+, C N Morris*, R V Rafanoharana, E Wheeler* (2019). “You must first save her life”: Community perceptions towards induced abortion and post abortion care in North and South Kivu, Democratic Republic of the Congo. Sexual and Reproductive Health Matters, 27:1. https://doi.org/10.1080/09688080.2019.1571309.
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