Meeting the Reproductive Health Needs of Conflict-affected Women by Global Health Council

RESEARCH REPORT 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. Often in these emergencies, women face increased risks to their personal health and safety, bearing the brunt of violence and burden of disease. During this time, many if not all of the human rights of these women are affected by their experience of displacement. The Universal Declaration of Human Rights (UDHR) lists at least four human rights that are particularly relevant to displaced women1

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Article 3: Everyone has the right to life, liberty and security of person; Article 5: No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment; Article 7: All are equal before the law and are entitled without any discrimination to equal protection of the law. All are entitled to equal protection against any discrimination in violation of this Declaration and against any incitement to such discrimination; and Article 25: (1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. (2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.

In conflict situations, certain human rights frequently face the threat of violation – among these is a woman’s right to reproductive health. Although reproductive health care is not explicitly stated in the UDHR, 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. The rights of women are also included in other international agreements, such as the:

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International Covenant on Civil and Political Rights (ICCPR) International Covenant on Economic, Social and Cultural Rights (ICESCR) Convention for the Elimination of all forms of Discrimination Against Women (CEDAW)

Currently, more than 15 million people are refugees and another 26 million people are displaced within their own countries.2 An estimated 50 to 75 percent of individuals displaced by conflict are women and girls.3, 4 Of these women, 25 percent are of reproductive age and one in five is likely to be pregnant.3 Providing displaced women with access to reproductive health services is crucial to their survival; obtaining access to reproductive health services that acknowledge their specific needs is often difficult. The availability of services is often dependent upon whether a woman has crossed an international border and whether that country has signed on to relevant international agreements or conventions. This brief will: 1) identify the international legal basis for reproductive rights; 2) explore the major reproductive health concerns of women affected by forced migration; 3) enumerate obstacles in providing service to women affected by forced migration and ways in which these barriers are amplified according to a woman’s displaced status; and 4) recommend how to provide comprehensive reproductive health care services to this unique population.

Women and Conflict In many areas throughout the world, women are often the most disadvantaged members of society. They are increasingly vulnerable to violence and exploitation, both in the home and in the community. Their economic options may be limited if they are not given adequate educational opportunities or the social and financial capital they need to insure their livelihoods. Their social standing in their communities before conflict often leaves them dependent on men for security and support.5 Armed conflict has a devastating effect on the lives of women, exacerbating the impact of the disease burden, poverty and insecurity on their families. In the midst of conflict, women are often tasked with ensuring the health, safety and economic security of their families – a task for which they are often ill-prepared.5, 6 During times of conflict, women may experience:5, 7

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Loss of family and community ties Increase in female-headed households Increase in care giving burden Limited access to food and shelter Disruption in health and social services Lack of security Increased psychological trauma and physical abuse

The addition of these pressures in a conflict setting often increases women’s vulnerability, as many of the social networks that were used to provide support prior to conflict are disrupted or disbanded and women are required to take on new roles. The sexual violence that has become a part of warfare often places women at increased risk of unintended or poorly spaced pregnancies, unsafe abortions, sexually transmitted infections (STIs), forced engagement in commercial sex, and gender-based violence (GBV).5 The increased insecurity of war often places women at risk of injury and violence as they flee conflict or when attempting to locate resources for survival.6 The destruction of public infrastructure places at risk the basic needs of women, making them more susceptible to diseases associated with poor environmental and living conditions (malnutrition, water-borne illness, over crowding in camps, GBV, etc.).5, 6, 7 Finally, the breakdown of the public health infrastructure leads to increases in maternal and infant mortality as women are unable to seek or receive services from health facilities, such as antenatal care, postpartum care, or immunizations.7 However, it is important to note that while women are categorized as vulnerable during conflict, their victim status does not fully capture the strength and resilience that they demonstrate in the midst of crisis. The courage and

resilience of women during conflict situations is demonstrated in their ability to cope with the stress and trauma associated with conflict and by their capacity to take on new roles to ensure their survival and that of their families.6

Who are Conflict-affected Women? Refugee is the term commonly used to describe individuals displaced by conflict. However, this term defines only a specific segment of the displaced population – those displaced outside of their home country. In many cases, the types of reproductive health care services available to displaced women are dependent on whether she is externally or internally displaced. Refugee Women. The 1951 Refugee Convention, which established the United Nations High Commissioner for Refugees (UNHCR), and the subsequent 1967 Protocol define a refugee as an individual “owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country.”8 With the creation of the UNHCR, the focus of the international community shifted from all individuals displaced by war to those individuals who can be legally categorized as refugees. The UNHCR and the Conventions that comprise its mandate did not make provisions for individuals who are affected by other forms of disruption but remained in their country of origin. Internally Displaced Women. Internally displaced persons (IDP) are defined as, “persons or groups of persons who have been forced to leave or flee their homes or places of habitual residence as a result of armed conflict, internal strife, systematic violation of human rights or natural or man-made disasters, and who have not crossed an internationally recognized State border.”9 Internally displaced persons do not leave their country for various reasons, including geographic constraints, safety, economic insecurity and concerns about their rights to return. While the legal definition of a refugee and an internally displaced person might appear similar, the crossing of an international border has tremendous implications for the types of protections, rights and services that these individuals receive.

International Legal Basis for Reproductive Rights The right to reproductive health care for all displaced women is rooted in international law.10, 11

• Human rights law is outlined in the Universal Declaration of Human Rights and other internationally recognized human rights documents.

• Humanitarian law outlines the rules of war and the rules aimed at protecting the victims of armed conflict. • Refugee law is composed of the Convention on the Status of Refugees and its Protocol and several treaties that define responsibilities for the provision of services for individuals legally defined as refugees.

Conventions prohibit, among other things, violence to life and person and outrages upon personal dignity, which have been interpreted to include rape committed by government military and non-military personnel and opposition military personnel.16

Protecting the Right to Reproductive Health Human Rights Law. The three main documents that specify the right to reproductive health are:

• International Covenant on Economic, Social and Cultural Rights (ICESCR)*

• Convention for the Elimination of all forms of Discrimination Against Women (CEDAW or the Women’s Convention)* • International Convention on the Elimination of all Forms of Racial Discrimination (CERD)*1 The right to the “highest attainable standard of mental and physical health” is protected by Article 12 of ICESCR.12 Although that provision does not contain the phrase “reproductive health,” the Committee on Economic, Social and Cultural Rights, which monitors compliance with the ICESCR, issued a general comment interpreting Article 12(2) to create a right to maternal, child and reproductive health, including sexual and reproductive health services, resources, and education.11 CEDAW defines the right to reproductive health more strongly than any other international instrument.13, 14Article 12.1 of the Convention requires state parties to “take all appropriate measures to eliminate discrimination against women in the field of health care … to ensure [equal] access to health services, including those relating to family planning.” CEDAW also requires state parties to provide “appropriate services” to women before, during, and after pregnancy (Article 12.2) and to ensure general access to educational information on family planning (Article 10).15

*ICESCR has 149 state signatories; CEDAW has 177 state signatories; and CERD has 169 state signatories.

Externally Displaced Women ! Camp Rules (when applicable) ! National Laws of Host Country ! Regional Arrangements ! Cartagena Declaration (1984) ! The Conventions on Refugee Problems in Africa (1969) ! International Law ! Refugee Law ! Human Rights Law ! United Nations High Commissioner for Refugees (UNHCR) Internally Displaced Women ! National Law ! International Law ! Human Rights Law ! Humanitarian Law (in the case of war) For some externally displaced women, refugee camp rules offer the possibility of protection, though it is often unclear who makes these rules, which may be described as “traditional, cultural rules,” and how well they are followed. For example, in Kenya’s Dadaab camp for Somali refugees, refugees have set up a court that resolves disputes within the camp under sharia rather than local or national law. A second level of protection is available under the national law of the host country. The Refugee Convention and its 1967 Protocol guarantees refugees the right to protection under the national laws of the host country, in many cases to the same extent those laws protect the country’s own citizens. A third option for some refugees is the availability of regional arrangements that offer protection. Two notable regional arrangements are the Cartagena Declaration on Refugees (1984) that covers Central American refugees and the Conventions on Refugee Problems in Africa, adopted by the Organization of African Unity (now the African Union) in 1969. Both agreements go beyond the Refugee Convention’s definition of refugees by covering people threatened by

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Article 5 of the Racial Discrimination Convention requires state parties to “undertake to prohibit and to eliminate racial discrimination in all its forms and to guarantee [to] … (e)(iv) the right to public health, medical care, social security and social services.” The right to reproductive health is also dependent on the realization of several other closely related rights. Extremely high rates of maternal mortality violate the right to life as expressed in Article 6 of the International Covenant on Civil and Political Rights (ICCPR) and Article 3 of the Universal Declaration of Human Rights.14 These documents also articulate rape as a violation of the right of refugee women to freedom from torture and degrading treatment (Article 5 of the UDHR and Article 7 of the ICCPR). In cases of war, the Geneva

While international law provides legal protections for all women to obtain reproductive health care, the ability of displaced women to access the complaint mechanisms of the human rights conventions depends on whether their state is a party to those instruments.

The Office of the United Nations High Commissioner for Refugees (UNHCR) International protection of displaced persons is the primary goal of the UNHCR’s work. It does this by ensuring respect for a refugee’s basic human rights and ensuring that no person is returned involuntarily to a country where he or she has reason to fear persecution – a process known as refoulement.8 The UNHCR assists refugees with many services (e.g., protection, food, shelter, health care and legal assistance) throughout the displacement and integration process, and works with governments and NGOs to provide these services.11, 10 The UNHCR has become increasingly involved in the protections of IDPs who have been displaced as a result of armed conflict, though there is no legal mandate to address these needs.9 Even thought the UNHCR does not have a separate policy on reproductive health, it does have guidelines and procedures that address the specific reproductive health concerns of women in conflict situations.11 generalized violence.17 The fourth level of security is international law, which provides a strong basis for protection of refugees under both human rights law and refugee law. The final, less formalized, layer of protection is UNHCR and its implementing NGO partners. There are limited sources of legal protection for internally displaced women. Since internally displaced persons have not left their home country, they are entitled to the same rights afforded other people in their country. However, given the situation of internally displaced women – disruption of usual services, being forcibly displaced with few resources, perhaps being seen as combatants – the governments that are supposed to protect them and provide services are often unable or unwilling to do so.18 In terms of applying international human rights law, internally displaced women have the same protection of their reproductive health rights as refugee women. To the extent that displacement is caused or affected by war, humanitarian law (the Geneva Conventions) is also a source of protection for internally displaced women. The fact that there is no mandate and no separate legal status to assist IDPs reflects the uncertainty of their situation.19

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Addressing Major Reproductive Health Concerns for Conflict-affected 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. The ICPD established reproductive health as a human right and extended this right to conflict-affected populations.20 Participants called for an increase in attention given to the reproductive health needs of all displaced women and acknowledged that conflict-afflicted women were a unique population and that their reproductive health concerns warranted special attention.

From the ICPD meeting, two groups were formed to champion this call: The Reproductive Health Response in Conflict Consortium and the Inter-Agency Working Group (IAWG) on Reproductive Health in Refugee Situations. The Reproductive Health Response in Conflict Consortium (RHRC) is a seven member group: American Refugee Committee, CARE, Columbia University, International Rescue Committee, JSI Research and Training Institute, Marie Stopes International, and the Women’s Refugee Commission. The aim of the Consortium is to increase the availability of quality and voluntary reproductive health services to all individuals affected by conflict.21 The largest group, the IAWG on Reproductive Health, was formed by the UNHCR, UNFPA, WHO and more than 50 governmental and nongovernmental organizations. One of the group’s first activities was to design a field manual that could be used to implement reproductive health services in conflict situations, which calls for a minimal service package to be implemented in the first stages of relief and for the provision of services in six core areas: safe motherhood, GBV, STIs, family planning, reproductive needs of adolescents, and other reproductive heath concerns.22 In the emergency phase, relief programs in conflict situations place greater attention on meeting the immediate needs of the population, such as providing food, water and sanitation services, and shelter.23, 24 Focus is placed on managing the infectious disease outbreaks that lead to increase mortality and morbidity in conflict settings, such as diarrhea, measles, respiratory illness, and malaria.24 During the emergency phase, reproductive health services are limited to providing emergency obstetric care, as comprehensive reproductive health services are seen as a long-term priority of the primary health system rather than a short-term emergency response.23,24 Incorporating the reproductive health needs of displaced women at the beginning of the crisis is critical to ensuring the overall health and wellbeing of this population, and lays the groundwork for sustaining and improving reproductive health services throughout the duration of relief management.

Providing Emergency Reproductive Health Care To integrate reproductive health care into the initial stages of emergency response, the Minimum Initial Service Package (MISP) was created.22 The package is comprised of 12 kits that include essential supplies and list activities that are to be implemented on the onset of a crisis by trained staff. The package is based on five objectives: 22

• IDENTIFY an organization(s) to facilitate the coordination and implementation of the MISP

• PREVENT and respond to sexual violence • REDUCE HIV transmission • PREVENT excess neonatal and maternal morbidity and mortality

• PLAN for comprehensive reproductive health services to be integrated into primary health care Even though the MISP is the standard approach used by the SPHERE Humanitarian Charter and Minimum Standards in Disaster Response**2and its use been advocated by **The SPHERE charter and standards have been generated by national and international humanitarian NGOs, UN agencies, and academic institutions. The standards provide guidelines for disaster assistance in five key areas: water supply and sanitation, nutrition, food aid, shelter and health services.

several NGOs and UN agencies, uptake has been slow and sporadic for various reasons. " A 2004 study of the MISP delivery for Sudanese refugees in Chad found limited awareness and understanding of the MISP, and that budget concerns and supply shortages were barriers to program implementation.25 For example, less than 23 percent of the field staff from nine organizations providing services for the refugees had heard of the MISP; only 6 percent could accurately define all of its objectives and activities, and were aware that the MISP is a SPHERE standard.25 " Another evaluation of the MISP found that the recommended services were either not regularly available or were not provided when needed. The study found that the most commonly implemented parts of the MISP were: components of safe motherhood, family planning and condom distribution; among the components least likely to be available were those related to GBV, emergency obstetric services, STI HIV/AIDS prevention programs (other than condom distribution), and services geared towards youth.26

Minimum Initial Service Package (MISP) for Reproductive Health in Crisis Situations22 Objective 1: Identify Agency/Persons to Facilitate Coordination & Implementation • RH coordinator in place under health coordination team • RH focal person in place in camps • RH kits available & used

Objective 5 Plan for Comprehensive RH Services, Integrated Into Primary Health Care • Obtain baseline info & M&E • Identify sites for future delivery of comprehensive RH • Assess staff & identify training protocols • Create procurement channels

Objective 3 Reduce Transmission of HIV/STI • Ensure that universal precautions are enforced • Provide free condoms • Ensure safe blood transfusion

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Objective: 4 Prevent Excess Maternal & Neonatal Mortality & Morbidity • Create a referral system for essential obstetric care that is available at all times • Distribute midwife delivery kits for clean and safe deliveries at health facilities • Distribute clean delivery kits to visibly pregnant women & birth attendants for home deliveries.

Goal Reduce mortality, morbidity, and disability in crisis-affected populations

Objective 2: Prevent Sexual Violence and Assist Survivors • Ensure that a protection system is in place for displaced populations, especially women and girls • Provide medical services & psychosocial support available for survivors

Despite difficulty in getting the MISP implemented, reproductive health advocates have had relative success in having some of the priorities outlined in the Reproductive Health in Refugee Situations field manual to be given priority in relief programs: safe motherhood, GBV, STIs and HIV/AIDS, family planning. Safe Motherhood. Complications from pregnancy and childbirth are the leading causes of death and injury of women of reproductive age in developing countries.27 While the exact maternal mortality ratio for refugee or internally displaced women is unknown, conflict places pregnant women at increased risk of mortality and morbidity as they are often 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 an increase trauma and injury.28 The impact of war has significant outcomes on maternal mortality. Of the 169 countries included in the UN 2005 maternal mortality index, half of the countries with highest maternal mortality were in the midst of conflict or emerging from conflict (see table). Furthermore, 60 percent of the countries with the highest maternal mortality ratio, the bottom ten, were conflict-affected countries. Making motherhood safer is a global challenge, but is

of particular concern for women affected by conflict. Safe motherhood activities should be geared towards preventing neonatal and maternal morbidity and mortality.22 The WHO defines the four pillars of safe motherhood as: family planning, antenatal care, clean/safe delivery, and essential obstetric care.30 In refugee situations, the same principles of safe motherhood apply and there is a need to increase the provision of services offered so as not to completely overwhelm local resources of the host country.22 In camp situations, the primary goal should be to use host country services rather than establishing â&#x20AC;&#x153;new refugee specific facilitiesâ&#x20AC;? that are not long-term solutions and will often be disposed of as attempts are made to integrate refugees into host county societies.31 Key services include: ! Providing displaced women with access to family planning services that can reduce the occurrence of unintended pregnancy during displacement. ! Promoting the same antenatal care services for displaced women as for women who have not been displaced: assessment of maternal heath, screening for and management of complications, prevention of disease, and the establishment of a delivery plan.22 ! Ensuring displaced women have access to safe and clean deliveries. To this end, the MISP has created clean delivery kits for the use of mothers and traditional birth attendants, as well as another kit that is to be used by midwives.22 The majority of maternal deaths are the result of not receiving timely assistance from a skilled and equipped provider.

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Maternal Mortality in Conflict-affected Countries29

Ranking Country Maternal Mortality Ratio* 169 Sierra Leone 2100 168 Afghanistan 1800 166 Chad 1500 165 Somalia 1400 164 Angola 1400 162 Liberia 1200 159 Guinea-Bissau 1100 158 Democratic Republic of the Congo 1100 157 Burundi 1100 154 Central African Republic 980 150 Guinea 910 14 7 Nepal 830 146 Mauritania 820 144 Cote d'Ivoire 810 142 Ethiopia 720 *The maternal mortality ratio is defined as the number of maternal deaths (from any cause related to pregnancy that occurs during pregnancy or within 42 days of pregnancy termination) in a specific period of time per 100,000 live births that occur within the same time period.

In conﬂict situations, the IAWG ﬁeld manual calls for safe motherhood services to:22, 31 Identify skilled health workers (those that are able to identify and either treat or refer obstetric complications) Provide additional training and supervision for health workers, as needed Recognize community beliefs and practices relating to pregnancy, delivery, and postpartum care for mother and infant Ensure that all individuals are aware of where to obtain antenatal care services and how to recognize early warning signs for complications Secure the availability of the all supplies needed for antenatal care Providing women in conflict situations with timely access to essential obstetric services is a key component of the safe motherhood package.22 During the initial stage of disaster management, the MISP calls for a referral system to be established with a local health facility that has the capacity to perform essential obstetric care. Focusing on postpartum care is also an important aspect of safe motherhood services. In addition to providing services to ensure the survival of the infant, services need to be provided to protect the mother’s health and wellbeing. Support should be given to encourage breastfeeding to limit risks of infection to the newborn.22 Research on safe motherhood in conflict settings reveals that maternal deaths may be higher during the acute phase of an emergency, but that, as the situation stabilizes, maternal outcomes also stabilize.32 Surprisingly, refugee maternal mortality and morbidity outcomes may be better than that of the maternal outcomes of the host country and the country of origin.24, 32 The explanation of the improvement in maternal outcomes has been linked to the increase in quantity and quality of services offered in the host country and country of origin during the time of conflict.24, 32

Gender-based Violence. According to the UNHCR the term gender-based violence “is used to distinguish common violence from violence that targets individuals or groups of

Sexual violence Intimate partner or spouse abuse Sex trafficking Forced prostitution Sexual exploitation Sexual harassment Harmful traditional practices Emotional and psychological abuse Socioeconomic violence Political violence/exclusion

According to reproductive heath advocates, programs to provide awareness and reduce the incidence of genderbased violence (GBV) have received the least attention when providing reproductive health care for conflictaffected women. Although violence against women during conflict is not a new phenomenon, women are increasingly vulnerable to GBV during armed conflict, as many of the social orders that were in place to protect them are disrupted.35 Sexual and gender-based violence is most prevalent in environments where there is a general lack of respect for human rights and has been defined as a violation of an individual’s human rights. 5, 35 A report by IRC of Burundian Refugees in Tanzania reported that between 17 and 22 percent of females age 12-49 years reported having experienced some form of sexual violence since becoming a refugee.10, 37 In refugee or IDP camp settings, conflict-affected women frequently suffer from both physical and structural forms of gender-based violence. Sexual assault and rape are widespread in forced migration contexts. Rape is increasingly recognized by the international community as a weapon or tactic of war, often being used as an “instrument of torture or ethnic domination.”38 A study undertaken by Save the Children reported that 94 percent of displaced families surveyed in Sierra Leone had experienced some form of sexual assaults.39

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For example, a study that examined maternal health outcomes of Afghan refugees in Pakistan found that the women had MMR of 291 per 100,000 live births compared to 820 per 100,000 in Afghanistan.33 When maternal deaths did occur, the majority of these women faced multiple barriers in accessing health care, even those living in stable camps with established health systems. Most women in the study died in route to the health center or at the facility.33 Eliminating barriers to access health care, such as encouraging individuals to utilize health facilities for labor and delivery, increasing the number of trained health workers to assist in deliveries, and educating families on the warning signs for possible complications, are key to reducing maternal mortality in conflict situations. 32, 33

individuals on the basis of their gender….It includes acts that inflict physical, mental or sexual harm or suffering, threat of such acts, coercion and other deprivations of liberty.”34 Forms of gender-based violence include: 35, 36

Displaced women are particularly subject to sexual coercion because they are often dependent on various male authorities to ensure their most basic survival needs are met.40 In such situations, it is common that women and girls will use sexual bartering to get food and access to other necessary goods and services.16 Often times, sexual bartering becomes women’s only source of leverage in their interactions with male refugees who are designated heads of household or with NGO workers and camp security. Domestic violence also occurs frequently in refugee and IDP camps, not only between intimate partners but also between unmarried or widowed women and extended family members. 16 Although many displaced women already faced domestic violence before being forced to flee, the special pressures and uncertainties of displacement combined with the loss of status for displaced men often result in increased abuse.38 A study on intimate partner violence in East Timor, found that 24.8 percent of women had reported an incident of violence within

their home in the past year during the 1999 conflict.41 Sexual violence increases women’s morbidity and mortality, as they may face unwanted pregnancies and an increased risk of STIs and HIV/AIDS, unsafe abortions, psychological trauma and mental health concerns, serious injury and homicide.36 Displaced women who are survivors of rape continue to suffer these health problems long after the initial trauma.38 As a result of sexual violence being officially recognized as a tool of war, there has been an increase in services provided to these women and in attention given to the enforcement of human rights in conflict settings.35 Sexually Transmitted Infections. During complex humanitarian emergencies, women are at increased risk of contracting STIs due to a variety of factors, including an increase in GBV, gender inequity, engagement in commercial sexual activity, poverty, and lack of condoms.10, 22 The need to provide focused testing and treatment for displaced women during conflict is another component of comprehensive reproductive health care. Most of the literature on STIs

Prevention and Service Activities Targeting GBV 28, 35, 42 Prevention of GBV Community and Social Services

• Raise community awareness about GBV • Engage men in GBV reduction activities • Raise community awareness on human

Medical Services

• Educate medical staff on signs of GBV • Establish medical infrastructure that is

rights and protections • Educate survivors on where to go to get assistance • Promote changing national and traditional laws that negatively impact women’s health

properly equipped to deal with GBV

Response to GBV

• Establish a referral system that engages community resources, medical services, and legal services

• Provide community education on GBV • Provide victim rights awareness • Engage in outreach to identify survivors • Provide a safe space for survivors • Provide counseling for survivors and families • Advocacy and assistance for survivors • Engage in outreach to identify survivors • Examine survivors, treat injuries and mental trauma • Prevent STIs, unwanted pregnancy • Document medical evidence for legal proceedings • Provide follow-up care • Referrals • Establish specialized counseling services for children and extremely traumatized women

Safety and Security

• Establish shelter and camp design that •

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• • • • Legal System

acknowledges gender and security Equal distribution of resources that acknowledge female heads of households Advocate for community policing Ensure an appropriate number of properly trained security staff Educate NGO staff and security staff Establish enforcement standards for NGO staff and security members

• Raise awareness of GBV as a tactic of war • Train legal personnel to respond sensitively to victims

• Ensure presence of security (after dark and in high risk areas outside of camp if needed) • Create an appropriate trained, competent security force • Provide protection for victims of GBV • Identify a private location for individuals to report GBV

• Require courts to have the capacity and willingness to prosecute cases • Provide education on protecting human rights

and displaced women has focused on the spread of HIV/ AIDS and less on other STIs, like chlamydia, gonorrhea, or syphilis. Recent data issues surrounding the spread of STIs, HIV and AIDS are complex and further research in needed to examine the impact of war on the spread of the disease. ! One study of Rwandan women in camps located in Tanzania found that more than 50 percent of women visiting antenatal care centers needed to be treated for some form of STI.7, 43 ! One study of a refugee population in Guinea found that while women where just as likely as men to have knowledge of STIs and their symptoms, women were less likely to seek treatment (78 to 46 percent respectively). 44 While displaced women are believed to have higher prevalence rates of HIV and AIDS because of their high risk of coerced sex, it is a misperception that the HIV prevalence among refugees is always higher than that among their surrounding local host country populations. 10, 45 In fact, new epidemiologic data suggests that the opposite is more likely. ! When examining the HIV surveillance data for 20 refugee camps in Eastern Africa in 2002, UNHCR 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.46 ! Another study examined the impact of wide spread rape on HIV transmission rate and found that even in countries in which assailants had HIV prevalence rates that were eight times the that of the countryâ&#x20AC;&#x2122;s population rate, wide spread rape increased the overall country prevalence rate by less than one percent (.023). 47 Prevention measures are needed to avert the spread of STIs in conflict situations. This would include: 1) establishment of universal precaution measures at health facilities (including safe blood transfusions), 2) providing health education on preventing of all STIs, 3) providing treatment and management for all STIs, and 4) providing access to free condoms.28, 22

Even in nonconflict settings, family planning is a culturally sensitive issue and there is debate as to how to best

! A study of refugees in Guinea found that current contraceptive use in refugee camps was higher than in country of origin (25 percent vs. 4 percent). Even though both men and women reported a high approval of family planning (80 percent) this did not correspond to current usage nor did it increase intra-couple communication about family planning practices (44 percent reported never having discussed).50 ! For Cambodian refugees residing in Thailand, one study found that 82 percent expressed a desire to stop or delay childbearing, but only 12 percent reported using a modern form of contraception.51 ! A study of barriers to use among Cambodia refugees found that 61 percent of women reported side effects and 24 percent cited lack of information as reasons for not using family planning. Women also noted limited knowledge of modern contraception.51 ! A study of Somali refugees found that religious and cultural factors played a crucial role in determining contraception choices.52 The study noted that it is important to educate not only the displaced population, but also the health workers providing service to improve utilization and quality of care.52 In addition to the cultural concerns regarding family planning for conflict-affected women, there are program implementation concerns for providers on the ground. While the UNHCR encourages NGOs to provide comprehensive reproductive health services, it does not require them to provide family planning services.11 In many camp settings, nongovernmental organizations administer care, but they may be unable or unwilling to provide family planning services to women because of political pressure or religious concerns. Programs are also plagued by poor supply chain management, resulting in frequent commodities stock-outs and are hampered by a limited number of adequately trained staff that can work with family planning programs.25, 53

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Family Planning. The change in fertility for displaced women in response to conflict is complex, and while research has attempted to identify a universal pattern, fertility responses have varied by population and situation. Some communities note an increase in fertility in response to calls for nationalism, pressure to repopulate communities, yearning to rebuild families and loss of health systems that provided contraception measures. Other communities report a decline in fertility in response to economic uncertainty, marital separation, social instability and loss of health services to ensure safe pregnancy outcomes.10, 48

provide these services, what type of services should be provided and by whom.22 Family planning programs have become more widely available for displaced women, though access to comprehensive services varies by location and the NGOs providing the services. However, from the earliest stages of an emergency, organizations should be able to respond to displaced womenâ&#x20AC;&#x2122;s demands for contraception.22 The IAWG field manual suggests that one of the first activities for family planning programs is to conduct a needs assessment that will identify the knowledge, attitudes and practices on site. 22,49 These include:

Gap in Access to Reproductive Health Services are unable to provide all health services.11 for Displaced Women Lack of coordination between actors providing reproductive services and the variety of locations where services are provided are two barriers to providing care to displaced women. Who Provides Services? The degree to which reproductive health services are available is contingent on the living situation of the displaced woman.54 For refugees, who have been resettled in host countries, the availability of reproductive services is often dependent on the types of services that the host government offers their citizens and whether or not there is a UN presence in country. In refugee camp situations, UN agencies and their implementing NGO partners often assist national governments with providing reproductive health services. Technically, internally displaced women are to receive services from their home governments; however, because of their precarious relationship with the state, they are often unable to access care. As a result, in some cases, with the consent of their home governments, UN agencies are able to provide services to internally displaced women.

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In many cases UNHCR works with NGOs that are already providing other types of relief services. Since many of these NGOs have other sources of funding, it is difficult for UNHCR to mandate that these NGOs provide all comprehensive reproductive health services. As a result, “the level of sexual and reproductive health care that refugees and internally displaced persons receive depends to a large extent on the policies of these agencies and organizations.”11 Given that each organization is allowed to determine which services it will and will not provide, women in conflict areas often lack access to all reproductive health services.

The situation is further complicated in that some NGOs object to the provision of all reproductive health services.11 For example, one faith-based organization’s policy is to not provide access to emergency contraception, nor does it refer women to other clinics where this service is offered.11, 55 The UNHCR’s Guidelines on the Protection of Refugee Women state that women who have been victimized by sexual violence should have access to emergency contraception (where legal and once fully and carefully explained) “regardless of the individual beliefs of the counselors, medical staff or other involved persons.”56 Thus, the organization’s policy is a breach, not only, of the spirit of the UNHCR’s Guidelines on the Protection of Refugee Women but also to CEDAW’s recommendation that health providers refer patients to locations where services are being provided when they

Camp Settings. Discrimination against and degradation of displaced women in camps takes the form of sexual and structural violence, as the ways in which camps and relief services are set up negatively affect women’s health. Gender bias can be observed in the various systems that give structure to the camps, including camp security, camp administration, health care, and housing. The level of security varies from camp to camp. Often, camps for internally displaced persons are much less safe than camps for the externally displaced, particularly when the displacement is caused by armed conflict.19 Health systems in many camp settings fail to adequately address the needs of women in displaced populations. Organizations that attempt to provide medical care to internally displaced women are often prevented from doing so because of the inaccessibility of the camps, isolated by ongoing conflict or damaged transportation routes.16 Similarly, inaccessibility and unsafe conditions frequently prevent women from traveling to other health care facilities. In most camp settings, health care services available to displaced women focus on the needs of pregnant women.40 Although these services are critical, it is also crucial to acknowledge that women’s reproductive and general health problems are often rooted in sociocultural factors, not simply physiological difference. Where specific health programs directed at women do exist, they do not address the differential health needs and experiences for displaced women versus men.57 For example, women are disproportionately at risk for health problems related to environmental factors, as they are the ones responsible for obtaining water and disposing of household waste.18 Although preventive programming would go far toward improving the health of women and their families, programs in camps continue to focus on treatment of disease rather than prevention.18 Camp housing and logistical systems frequently ignore women’s needs. Unaccompanied women are often sheltered with strangers, making them more vulnerable to sexual coercion. Camp latrines are often placed far from the shelters in unlit, isolated areas where women are more subject to attacks. For example, in refugee camps in Pakistan, Afghan women wait until dark to visit the latrines because of the combination of traditional cultural rules and the location of the latrines, thereby increasing their chances of being attacked at night and harming their renal systems because of lack of water intake throughout the day.16

Conclusions and Recommendations Meeting the needs of conflict-affected women is complex; more attention is needed to determine how best to deliver

services. One of the most critical problems is that internally displaced women are not guaranteed the rights and privileges of externally displaced women. All displaced women, regardless of whether or not 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.

! The second obstacle to care is determining which services should be provided for displaced women, when those services should be provided, who should be providing them in conflict settings, and who should be making the decision. The voices of displaced women should be included in the process when these decisions are being made. 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. Though promising, the approaches currently available have been used in a limited manner, largely due to lack of resources.

! Third, there needs to be more of an ongoing effort to strengthen respect for the human rights that are already recognized in national laws, international human rights documents, and other consensus documents that benefit the reproductive health needs of conflict-affected women. In particular, efforts to support women’s civil and political rights (such as the right to decide the number and spacing of children) and economic and social rights (the availability of contraceptives and safe and affordable health services) will improve the health status of women everywhere.

! Specific recommendations include: ! The international community should codify the existing UNHCR’s Guiding Principles on Internal Displacement to address directly the pressing needs of

References

10. McGinn T, Casey S. Reproductive Health for Conflict-affected People. London: Humanitarian Policy Group; 2004 April 2004. 11. Girard F, Waldman W. Ensuring the Reproductive Rights of Refugees and Internally Displaced Persons: Legal and Policy Issues. International Family Planning Perspectives 2000;26(4):167-173. 12. UN. International Covenant on Economic, Social and Cultural Rights. 1966. 13. UN. Convention on the Elimination of All Forms of Discrimination against Women; 1979. 14. Bogecho D. Putting It to Good Use: The International Covenant on Civil and Political Rights and Women’s Right to Reproductive Health. Southern California Review of Law and Women’s Studies 2004(13):229-240. 15. Purdin S, McGinn T, Miller A. Reproductive health among forced migrants—an issue of human rights. Lancet 2004. 16. Kelley N. Report on the International Consultation of Refugee Women. International Journal on Refugee Law 1989(1).

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1. UN. Universal Declaration of Human Rights. 1948. 2.UNHCR. 2008 Global trends: refugees, asylum seekers, returnees, internally displaced and stateless persons. 2009. 3. UNFPA. Assisting in Emergencies; 2009. 4. Cottingham C, et al. Sexual and reproductive health in conflict areas:the imperative to address violence against women. BJOG 2008;115:301-303. 5. Levy BS, Sidel V. War and Public Helath: Oxford University Press; 2007. 6. Linsey C. Women Facing War. Geneva: International Commitee for the Red Cross; 2001. 7. Al Gasseer N, et al. Status of Women and Infants in Complex Humanitarian Emergencies. J Midwifery Womens Health 2004;49(sup 1):7-13. 8. UNHCR. Convention and Protocol Relating to the Status of Refugees. In. Geneva, Switzerland: UNHCR; 2007. 9. Global Protection Cluster Working Group. Handbook for the Protection of Internally Displaced Persons. Geneva; 2007.

internally displaced women through an agreement that is binding on states and clarifies the role of international and nongovernmental organizations through a clear mandate. UNHCR 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. Expand research better to address the reproductive needs of displaced women and the barriers that they face in gaining access to reproductive health services. In particular, there is a dearth of information related to the specific needs of internally displaced women. Research is also needed to examine the before and after conflict levels of health in both displaced and host communities. Collaboration among reproductive health and other disaster relief providers is needed to integrate services and provide increased protection of women in camp settings. Programs need to acknowledge women’s autonomy and the influence that certain cultural traditions have on women gaining access to reproductive health care. More attention needs to be placed on meeting the needs of adolescents and married women, as the attitudes of guardians and husbands may present obstacles to usage. Support needs to continue for post-conflict women, whose reproductive health services have likely been eviscerated by conflict, and add services to address the experiences faced by displaced women.

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Refugees in Tanzania: International Rescue Committee; 1997. 38. Human Rights Watch. Seeking Protection: Addressing Sexual and Domestic Violence in Tanzania’s Refugee Camps; 2000. 39. Save the Children. State of the World’s Mothers. Washington, DC: Save the Children; 2003. 40. Center for Reproductive Law and Policy. Displaced and Disregarded: Refugees and their Reproductive Rights; 2001. 41. Hynes M, et al. A Determination of the Prevalence of Genderbased Violence among Conflict-affected Populations in East Timor. Disasters 2004;28(3):294-321. 42. Norwegian Refugee Council. The Camp Management Toolkit; 2008. 43. Mayaud P, et al. STD rapid assessment in Rwandan refugee camps in Tanzania. Genitourin Med 1997;73:33-38. 44. Chen MI, et al.Reproductive health for refugees by refugees in Guinea II: sexually transmitted infections. Conflict and Health 2008;2(14). 45. Hankins C, Friedmanc SR, Zafard T, Strathdeee SA. Transmission and prevention of HIV and sexually transmitted infections in war settings: implications for current and future armed conflicts. AIDS 2002;16:2245–2252. 46. Spiegel PB. HIV/AIDS Among Conflict-affected and Displaced Populations: Dispelling Myths and Taking Action. Disasters 2004;28(3):322-339. 47. Anema A, Joffres MR, Mills E, Spiegel PB. Widespread rape does not directly appear to increase the overall HIV prevalence in conflict-affected countries: so now what? Emerging Themes in Epidemiology 2008;5(11). 48. Gagnon AJ, Merry L, Robinson C. A systematic review of refugee women’s reproductive health. Refuge: Canada’s Periodical on Refugees 2002;21(1):6-17. 49. McGinn T. Reproductive Health of War-Affected Populations: What Do We Know. International Family Planning Perspectives 2000;26(4):174-180. 50. Howard N, Kollie S, Souare Y, von Roenne A, Blankhart D, Newey C, et al. Reproductive Health Services for Refugees in Guinea I: Family Planning. Conflict and Health 2008;2(12). 51. Morrison V. Contraceptive Need Among Cambodian Refugees in Khao Phlu Camp. International Family Planning Perspectives 2000;26(4). 52. Buesseler H. Designing a Culturally Appropriate Family Planning Program for Refugees: The Somali Child Spacing Project. Contraception 2007;76(2). 53. Sonnevald E, Shaver T, Bhuyan A. Understanding Opperational Barriers to Family Planning Services in Conflict -Affected Countries: Experiences from Sierra Leone. Washington: USAID; 2008. 54. McGinn T, Purdin S. Reproductive Health and Conflict: Looking Back and Moving Ahead. Disasters 2004;28(3):235-238. 55. World Vision. World Vision Response Family Planning. In: Benjamin L, editor. Washington, DC; 2009. 56. United Nations High Commissioner for Refugees. Guidelines on the Protection of Refugee Women: UNHCR; 1991. 57. Boelaert Mea. The Relevance of a Gendered Approaches to Refugee Health. Indra D, editor. Engendering Forced Migration New York Berghahn Books 1999.

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This brief was prepared with support by the David and Lucile Packard Foundation. It was written by Lillian Benjamin and Susan Higman. 12