(January 2013) Worldwide, nearly 43 million people were considered forcibly displaced due to conflict and persecution in late 2011 (the most recent global estimate); half of these refugees, internally displaced people, and asylum seekers were women and girls.1
During such humanitarian crises, the reproductive health needs of women and girls do not disappear. Displacement can actually increase the need for reproductive health services since access, information, and supplies are greatly disrupted. The lack of family planning services and lifesaving interventions (including obstetric care) results in increased unplanned pregnancies and unsafe abortions, and in women and girls dying or being permanently disabled from rape or complicated deliveries.
Women who are cut off from a regular source of reproductive health services and contraceptives, and who live in conditions hostile to pregnancy and childbearing, are more likely to turn to unsafe abortion when facing an unplanned pregnancy. The United Nations Population Fund (UNFPA) estimates that 25 percent to 50 percent of maternal deaths in refugee settings are due to complications of unsafe abortion.2
In some places, ongoing conflicts have destroyed what little health services were available and have left millions of women and girls without access to essential reproductive health care. In eastern Burma, for example, decades of conflict have led to a limited health system that has very few trained health professionals and an insufficient and inconsistent amount of medications and supplies, leading to high rates of maternal mortality and unsafe abortion.3
Brutal conflict in the Democratic Republic of the Congo has displaced 1.5 million people and destroyed the health care infrastructure. Sexual violence is widespread. Women facing complications during pregnancy and birth have no access to emergency obstetric care; and hospitals lack adequate sterile surgical supplies, anesthetics, and IV fluid.4
Although the evidence demonstrates the need to include reproductive health services in a humanitarian response, a number of barriers have prevented relief agencies and organizations from integrating such services into traditional programs.
A Growing Response
Since 1993, when an editorial in The Lancet denounced the absence of reproductive health services for those who are displaced from their homes, a number of organizations and groups have begun to advocate for the inclusion of reproductive health in humanitarian responses. The Women's Refugee Commission, Interagency Working Group on Reproductive Health in Crisis (IAWG), the Reproductive Health Response in Crisis Consortium, and the RAISE Initiative, have pushed for increased political and financial support for the reproductive health and rights of people affected by conflict and natural disasters, which was a declaration made at the 1994 International Conference on Population and Development.
In 1996, the IAWG developed the Minimal Initial Service Package (MISP) for Reproductive Health in the first Interagency Field Manual for Reproductive Health in Emergencies.5 The MISP is a coordinated set of high-priority activities designed to prevent and manage the consequences of sexual violence, to reduce HIV transmission, to prevent maternal and newborn death and disease, and to plan for comprehensive reproductive health services.
In 2010, the IAWG released a statement on family planning for women and girls as a lifesaving intervention in humanitarian settings. The document outlines the need for comprehensive reproductive health care to be integrated into humanitarian responses and supply systems, even though funding for family planning in humanitarian settings is limited.
In July 2012, the IAWG Steering Committee sent an open letter to the organizers of the London Summit on Family Planning, urging donors to close the reproductive health funding gap between stable development settings and conflict settings; to provide long-term funding for family planning programs and innovative service delivery mechanisms; to include crisis-affected populations in the Family Planning Summit objectives and in health advocacy messages; to offer an appropriate contraceptive method mix to those who are displaced; and to provide each woman and adolescent girl the opportunity to decide if, when, and how many children she wants without coercion or discrimination.6
Gaps and Challenges Remain
In 2004, the IAWG conducted a global review of reproductive health in crisis-affected populations that identified both substantial progress and also remaining gaps in services, institutional capacity, policies, and funding.7 Reproductive health services in stable refugee settings increased and were generally well established and consistent with the Interagency Field Manual for Reproductive Health in Emergencies. The review also showed that not all reproductive health services were offered equally: Almost nonexistent were services that offer family planning methods beyond pills and condoms; that treat sexually transmitted infections; or that address gender-based violence, obstetric complications, and adolescent health.
The review also highlighted the lack of data available to guide program implementation and the need to improve cross-agency collaboration to prevent the duplication of efforts and to fill program gaps. Janet Meyers, deputy director for Health Policy and Practice at the International Medical Corps (and former senior adviser for Health in Emergencies at CARE USA), commented on the availability of data: "The RAISE initiative focused a lot on data collection during the past few years, on population-based surveys, health facility assessments, and service delivery data. Other organizations that are providing sexual and reproductive health in humanitarian settings have also begun to work towards better data collection and sharing of information, coordination of activities, and addressing gaps in this field, especially through the IAWG." Preliminary results from the next global review will be available in late 2013.
Despite increased attention, donor funding for reproductive health in humanitarian settings has been limited. Researchers from the RAISE Initiative, the London School of Hygiene and Tropical Medicine, and King's College London investigated disbursements of development aid for reproductive health activities in 18 conflict-affected countries between 2003 and 2006. They found that only 2 percent of the $21 billion in reproductive health aid worldwide was allocated to conflict-affected countries, even though these countries have worse reproductive health indicators than their stable counterparts.8
Priorities for the Future
Conflicts will likely continue to increase the number of refugees and other displaced people across the globe. In November 2011, UNHCR and the Women's Refugee Commission undertook a multicountry baseline study to document refugees' knowledge of family planning and their beliefs and practices, and the state of service provision in select refugee settings in Djibouti, Jordan, Kenya, Malaysia, and Uganda.9 The study revealed that:
- Contraceptive use was lower in refugee camps than in more-stable environments surrounding the refugee camps.
- Access to information and services was particularly difficult for adolescents.
- Emergency contraception was available only in the context of care following rape.
- The poor quality of services limited the willingness of women to use the services.
- The women faced limited availability of long-term and permanent methods.
From the research described above and the statement released in 2010 by the IAWG, researchers and advocates have identified the following steps to meet the growing need:
- Governments should respect the reproductive rights of all crisis-affected populations by ensuring, with the humanitarian community, the provision of reproductive health services in their settings to all those in need, including adolescent girls.
- Donors should prioritize comprehensive reproductive health programs when implementing fundraising strategies during the first three months to six months of an emergency.
- Donors need to evaluate all proposals for activities to ensure that the Minimum Initial Service Package is integrated into multiple sectors responding to the emergency, specifically the site-planning, community services, water and sanitation, and health sectors.
- Implementing agencies, including government and nongovernmental organizations, should prioritize reproductive health as one of the key health services included in the planning, coordination, funding, implementation, and monitoring and evaluation of activities in response to an emergency, whether caused by a conflict or by natural disaster.10
- Implementing agencies should integrate universal access to reproductive health into their own goals and commitments by including it in their policies, needs assessments, action plans, and funding, as well as increasing their investment in reproductive health supplies and in training staff to provide quality services. This means not only offering basic family planning services but also providing emergency obstetric care and services to address gender-based violence, including rape.
- Nongovernmental organizations should call upon governments and policymakers to recognize and address the reproductive health needs of women and girls in crisis settings as a necessary component of achieving the Millennium Development Goals, especially that of improving maternal health (MDG 5).
- Nongovernmental organizations and donors should ensure more sustained funding sources to address the various needs brought on by a humanitarian crisis and should provide continued support as countries move from addressing an emergency and resuming ongoing development.11
Providing health services during a conflict or natural disaster is a challenging task, and the humanitarian field has made significant progress since the early 1990s. Despite the progress, many relief programs still omit reproductive health care as part of their strategy.
Mia Foreman is a policy analyst in International Programs at the Population Reference Bureau.
- United Nations High Commissioner for Refugees (UNHCR), Global Trends 2011: A Year of Crisis (June 2012), accessed on July 2, 2012.
- CARE International, Women’s Lives, Women’s Voices: Empowering Women to Ensure Family Planning Coverage, Quality, and Equity (Geneva: Care International, 2012); and UN Fund for Population Activities, "Working to Empower Women: Women and Armed Conflict," accessed on Oct. 2, 2012.
- Margaret Hobstetter et al., Separated by Borders, United in Need: An Assessment of Reproductive Health on the Thailand-Burma Border (Cambridge, MA: Ibis Reproductive Health, 2012), accessed on Oct. 16, 2012.
- RAISE Initiative, "Country Profiles: Burma and Democratic Republic of the Congo," accessed on Oct. 3, 2012.
- Interagency Working Group on Reproductive Health in Crisis, Interagency Field Manual on Reproductive Health in Humanitarian Settings: 2010 Revision for Field Review, accessed on Oct. 3, 2012.
- International Medical Corps UK, An Open Letter to Organisers of the London Summit on Family Planning 11 July 2012, accessed on Sept. 7, 2012.
- UNHCR, Inter-Agency Global Evaluation of Reproductive Health Services for Refugees and Internally Displaced Persons (New York: United Nations, 2004).
- Preeti Patel et al., "Tracking Official Development Assistance for Reproductive Health in Conflict-Affected Countries," PLOS Medicine 6, no. 6 (2009).
- Women's Refugee Commission and UNHCR, Refocusing Family Planning in Refugee Settings: Findings and Recommendations From a Multi-Country Baseline Study (New York and Geneva: United Nations, 2011), accessed on Oct. 16, 2012.
- RAISE, RAISE Factsheet: Minimum Initial Service Package, accessed on July 2, 2012.
- Marlou den Hollander, "The Blind Spot of the Millennium Development Goals," Forced Migration Review 34, no. 1 (2010): 58-59.