FACT SHEET Meeting the Reproductive Health Needs of Conflict-affected Women Throughout the last century, as complex humanitarian emergencies around the world gained international attention; concern for the welfare of the individuals affected by these situations has also increased. Frequently in these emergencies, women and children face increased risks to their health and safety, bearing the brunt of the burden of disease. Providing these women with access to reproductive health services is crucial to their survival, yet the ability to access reproductive health services that acknowledge the specific needs of displaced women is frequently difficult. » Currently, more than 15 million people are refugees and another 26 million people are displaced within their own countries.1 » It is estimated that between 50 and 75 percent of individuals displaced by conflict are women and girls.2, 3 Of these women, 25 percent are of reproductive age and one in five is likely to be pregnant.3
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In conflict situations, certain human rights frequently face the threat of violation – among these is the right to reproductive health. Although reproductive health care is not explicitly stated in the Universal Declaration of Human Rights, public health advocates assert that reproductive health care is in fact a human right, as it is critical to the overall health and wellbeing of all displaced women. Prior to the 1990s, little information was known about the reproductive health situation of displaced women. With the release of Refugee Women and Reproductive Health Care: Reassessing Priorities and the International Conference on Population and Development (ICPD) in Cairo in 1994, the reproductive health concerns of displaced women gained international attention. Participants called for an increase in the level of attention given to the reproductive health needs of displaced women and acknowledged that conflict-afflicted women were a unique population and that their reproductive health concerns warranted special attention.4 Throughout the past decade, certain key issues have been deemed crucial to meeting the reproductive health needs of conflict-affected women: safe motherhood, gender-based violence (GBV), sexually transmitted infections (STIs) and HIV/AIDS and family planning.5 Safe Motherhood » Making motherhood safer is a critical concern for all displaced women. » Of the 169 countries included in the United Nations 2005 maternal mortality index, half of the countries with highest maternal mortality were in the midst of or emerging from conflict.6 » Conflict places pregnant women at increased risk of mortality and morbidity, as they may be without the medical services that they once relied upon. The breakdown of social structure may place them at heightened risk for malnutrition and infectious diseases, and as a result of the ongoing fighting, they may experience a higher levels of trauma and injury.7 » Research shows that while maternal deaths may be higher during the acute phase of an emergency, maternal health outcomes stabilize as the situation stabilizes.8 Gender-based Violence » Programs to provide awareness and reduce the incidence of GBV have received the least attention among the reproductive health services for conflict-affected women.5 » Women are increasingly vulnerable to GBV during armed conflict, as many of the social orders that were in place to protect them are disrupted.9 » In conflict situations, women frequently suffer from both physical and structural forms of GBV (sexual bartering, domestic violence, sexual assault, and the harmful design of camps). » Sexual violence increases women’s morbidity and mortality, as they may face unwanted pregnancies, increased risk of STIs and HIV/AIDS, unsafe abortions, psychological trauma and mental health concerns, serious injury and homicide.10 » Although data on refugee women is incomplete, a report of Burundian refugees reported that between 22 and 17 percent of females age 12-49 years reported having experienced some form of sexual violence since becoming a refugee.11, 12
Sexually Transmitted Infections » During conflict, women are at increased risk of contracting STIs due to an increase in GBV, gender inequity, engagement in commercial sex work and survival sex, poverty, and lack of condoms.5, 11 » While displaced women are believed to have higher prevalence rates of HIV/ AIDS because of their high risk of coerced sex, it is a misperception that the HIV prevalence among refugees is always higher than of the surrounding local host country populations. 11, 13 » HIV surveillance data from 20 refugee camps in Eastern Africa in 2002, reported that in three out of four countries the refugee populations had a lower HIV-prevalence rate than the surrounding community in the host country.14
Family Planning » Family planning is a culturally sensitive issue and there is debate as to how to best provide these services and what type of services should be provided.11 » While family planning services have become more widely available, access to comprehensive services varies by location and the nongovernmental organizations (NGOs) providing the services.5 » From the earliest stages of an emergency, organizations should be able to respond to displaced women’s demands for contraception.5 » The change in fertility for displaced women in response to conflict is complex, and while research has attempted to identify a universal pattern, each population and situation is different and fertility responses have varied.11 One of the most critical problems is that internally displaced women are not guaranteed the same rights and privileges of externally displaced women, refugees.15 All displaced women, regardless of whether they are a refugee or an internally displaced person, should have access to comprehensive reproductive health care. This is not only a human right, but it is the only way that the international community can guarantee the dignity of these women. Greater attention should be made to eliminating barriers to reproductive health care for displaced women. Current guidelines, field manuals and programs provide some direction, but these approaches need to be evaluated to ensure how well they meet the reproductive health needs of conflict-affected women. Specific recommendations include: » United Nations High Commissioner for Refugees should require that all NGOs that work with this population provide comprehensive health care or access to these services through referrals. » A guarantee of funding, minimally at the current level, for reproductive health services is needed to sustain sufficient human resources and health care materials. » Research is also needed to examine the before and after conflict levels of health in both displaced and host communities. » Collaboration between reproductive health and other disaster relief providers is needed to better integrate services and provide increased protection of women in camp settings. » Programs need to acknowledge women’s autonomy and the role that certain cultural traditions may place in women gaining access to reproductive health care. **An expanded version of this document can be found on our website http://www.globalhealth.org/publications/** References 1. UNHCR. 2008 Global trends: refugees, asylum seekers, returnees, internally displaced and stateless persons. 2009. 2. Cottingham C, et al. Sexual and reproductive health in conflict areas: the imperative to address violence against women. BJOG 2008;115:301-303. 3. UNFPA. Assisting in Emergencies. In; 2009. 4. UN ICPD. Reproductive rights and reproductive health. In: Programme of action of the United Nations ICPD; 1994. 5. IAWG Reproductive Health in refugee situations: An Interagency Field Manual. Geneva: UNHCR; 1999. 6. World Health Organization, UNICEF, UNFPA, World Bank. Maternal mortality in 2005; 2007. 7. UNFPA. Women are the Fabric: Reproductive Health for Communities in Crisis. New York: UNFPA; 2006. 8. O’Heir J. Pregnancy and Childbirth Care Following Conflict and Displacement.J Midwifery Womens Health 2004;49(supplemnet):14-18.
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9. Vann B. Gender-Based Violence: Emerging Issues in Programs Serving Displaced Populations. Arlington; 2002. 10. Hynes M, et al .Sexual Violence against Refugee Women. Journal of Women’s Health and Gender-Based Medicine 2000;9(8):819-823. 11. McGinn T, et al. Reproductive Health for Conflict-affected People. London: Humanitarian Policy Group; 2004 April 2004. 12. Nduna S, Goodyear L. Pain Too Deep for Tears. International Rescue Committee; 1997. 13. Hankins C, et al. Transmission and prevention of HIV and Sexually Transmitted Infections in War Settings.AIDS 2002;16:2245–2252. 14. Spiegel PB. HIV/AIDS Among Conflict-affected and Displaced Populations: Dispelling Myths and Taking Action. Disasters 2004;28(3):322-339. 15. Hakamines N,et al. Providing Reproductive Health Care to Internally Displaced Persons. Reproductive Health Matters 2008;16(31):33-43.
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