Yet it is important to remind ourselves that reproductive health (RH) remains a relatively new area of attention within the humanitarian sector. Just ten years ago, there seemed to be little or no recognition of the fact that, during war and in refugee settings, women continue to have babies, sexual and gender-based violence escalates and HIV thrives.
This began to change with the International Conference on Population and Development, held in Cairo in September 1994 when for the first time refugee women were invited to speak about their RH needs on an international stage(1). The following year, at the Inter-agency Symposium on Reproductive Health in Refugee Settings in Geneva, more than 50 governments, NGOs and UN agencies committed themselves to strengthening RH services for refugees. The Inter-agency Working Group was formed, a joint memorandum of understanding was signed between UNFPA and UNHCR and consensus was achieved on a Minimum Initial Services Package for RH in emergency situations.(2)
It was also around this time that the Reproductive Health Response in Conflict Consortium (RHRC Consortium), formerly the Reproductive Health for Refugees Consortium, was formed. Founder members were CARE, the International Rescue Committee, JSI Research and Training Institute, Marie Stopes International and the Women's Commission for Refugee Women and Children. Later the American Refugee Committee and Columbia University's Heilbrunn Department for Population and Family Health joined the group. These agencies, with their complementary expertise in training, advocacy, clinical services and research, contribute diverse skills to carry out a broad agenda aimed at improving the reproductive health of refugees and displaced persons around the world in addition to garnering support from the international donor community to move from rhetoric to action.
As recognition of the importance of RH as an emergency issue has evolved since the mid-1990s, so too has understanding of the magnitude of, and need for, specific research and programming related to different RH issues. After Cairo, most of the initial emphasis was on family planning and safe motherhood. But as the HIV/AIDS crisis accelerated in Africa, where the vast majority of the world's refugees live, a new understanding of the relationship between HIV, war and displacement led to increased HIV/AIDS programming related to forced migration. At the same time, the well-documented prevalence of rape as a weapon of war - in Bosnia, Rwanda, Kosovo, Timor Leste and now DRC - has raised awareness of the increasing occurrence of all forms of gender-based violence in displacement settings, of its relationship to the spread of HIV and of the urgent need for medical treatment, psychosocial support and prevention.
Important progress has been made in all of these areas over the past decade. Recent studies have shown that at least some components of RH care are available to most refugees in non-emergency settings. The collaborative efforts of organisations, big and small, have helped to expand services in many conflict settings. The unmet need for RH care for displaced persons remains enormous but a very good start has been made. At the RHRC Consortium conference held in Brussels in October 2003, more than 150 people from 36 countries representing 70 organisations came together to share programme findings and research on conflict-affected populations around the world. Presentations highlighted new research, model programming, innovative strategies and practical tools and guidelines. The conference demonstrated how far the international community has come in recognising the rights of displaced communities to comprehensive reproductive health care while highlighting areas which need more concerted work.
Today, in comparison with ten years ago, a refugee woman has a far better chance of having a safe pregnancy and delivery, and has improved access to emergency obstetric care, information and services for prevention of STIs and HIV/AIDS and treatment and counselling for the effects of sexual and gender based violence. A war-affected adolescent has a much greater chance of getting appropriate information and access to services in order to grow up safely and in good health.
Yet, as we approach the tenth anniversary of the International Conference on Population and Development, pockets of ideological opposition to some aspects of reproductive health and rights, particularly in some donor countries, have begun to threaten field successes and add to the already daunting challenges faced by organisations working to safeguard the reproductive health of the displaced. The US government, a leader in the field and the largest supporter of RH for refugees and IDPs for many years, has, under the current administration, withdrawn or restricted the use of funding in this area for UNFPA, UNHCR, the RHRC Consortium and other partners. Small but vocal opposition groups in some other countries are lobbying their own governments to follow suit. Although other donors have tried to fill the gap, unstable funding is challenging the ability even to maintain (let alone expand) the most basic RH services for the world's 37 million displaced persons. Many programmes, even HIV/AIDS prevention, have been scaled back. Others have been cut entirely, greatly endangering the health of countless women, men and children living in already precarious situations.
As we measure and celebrate what has been achieved over the past decade, we must not forget how hard we have fought to make it even this far and how much remains to be done.
We appreciate the commitment of the editors of FMR who have provided a timely opportunity to present some of the latest developments in reproductive health in conflict settings.
Samantha Guy is Senior Advisor, Reproductive Health for Refugees Initiative at Marie Stopes International (www.mariestopes.org.uk). Email: sam.guy@mariestopes.org.uk
David del Vecchio works for UNFPA's Humanitarian Response Unit. Email: delvecchio@unfpa.org
Notes:
- See: www.un.org/popin/icpd2.htm
- MISP information is online at: www.who.int/disasters/repo/7345.doc