Sexual and reproductive services are important for women in all settings. In humanitarian emergencies where even existing services may be disrupted or unavailable, particularly to those who have been displaced, the provision of reproductive health services may mean the difference between life and death. Without emergency obstetric care, pregnancy and childbirth complications quickly become life-threatening. At the same time the lack of contraceptive protection – often at a time of intensified sexual and gender based violence – can lead to sharp increases in HIV and other sexually transmitted infections, unplanned and unwanted pregnancies and, ultimately, unsafe abortions.
In contrast to when I first wrote about this for FMR back in 2004, I am pleased to say that reproductive health in humanitarian settings is now firmly on the global agenda. We have seen significant progress made through service delivery initiatives like RAISE and advocacy efforts which have led to policies and guidance to encourage service provision on the ground.
These efforts most recently include:
- the IASC/WHO Global Health Cluster’s guidance to include sexual and reproductive health in 2009
- the revision in 2010 of the Field Manual on Reproductive Health in Humanitarian Settings coordinated by the Inter-agency Working Group on Reproductive Health in Crises
- the 2011 updated version of the Minimum Initial Service Package for reproductive health in crisis situations
- the extension of the 2011 edition of the Sphere Handbook (the principal resource for virtually all humanitarian agencies in the field) to include a dedicated section on sexual and reproductive health.
So, more guidance than ever now exists. We should know what we should be doing. But has this momentum resulted in meaningful change on the ground? According to a study reviewing funding patterns for reproductive health in conflict-affected countries between 2003 and 2009, the answer is yes – but unequally so. During this period, funds allocated to comprehensive reproductive health increased by 176% in 18 sampled countries; this was largely attributable to funding for HIV/AIDS activities which increased by 280% during the period. Unfortunately, other important components of sexual and reproductive health remain relatively neglected. Family planning services experienced a decline in Overseas Development Aid between 2003 and 2007 but encouragingly funding for these services increased in 2008 and 2009.
Safe or unsafe abortion
This suggests that, despite the progress being made, serious gaps remain in meeting reproductive health needs in humanitarian and conflict settings. One of the most critical gaps is the lack of provision for safe abortion services. Unsafe abortion remains a major global public health concern and a human rights imperative. It also remains a controversial issue that the international community continues to dance around. Left out of the improved global health policies and guidance for crisis situations listed above, access to safe abortion services remains near to impossible for the majority of women caught up in humanitarian emergencies. Without clear guidance, clinics in emergency settings are not usually prepared to provide this type of care and health-care professionals are often unsure of when international humanitarian law and organisational policies allow for the provision of safe abortion services.
The consequences of our inaction over safe abortion services are devastating. Feeling they have nowhere left to turn, women risk their lives by resorting to unsafe abortions and go to great lengths to hide them. One study of maternal mortality amongst refugees in ten countries found maternal deaths from childbirth or abortion to be as high as 78%. However the limited amount of information on causes of maternal mortality in humanitarian settings makes it difficult to estimate the real level of damage unsafe abortions are having.
The World Health Organization (WHO) has taken steps to address this through its safe abortion guidance which was updated in 2012. The revised guidelines make important headway in trying to prevent unsafe abortion in order to reduce maternal mortality and do refer to refugees and emergency settings. But the potential for implementation of these recommendations has yet to be realised.
One of the best ways to reduce unsafe abortion, of course, is to help prevent unplanned pregnancies through family planning services. The reproductive health rights of refugees and displaced persons must be respected but here again we are still seeing gaps. A study conducted by UNHCR and the Women’s Refugee Commission in 2011 found that contraceptive use is generally lower in refugee settings than in surrounding settlements and awareness of family planning methods is low. There are many contributing factors but whilst organisations may support some family planning services, there seems to be a prevailing attitude that there is no demand for longer-term methods or that the subject is too sensitive. Results from a study carried out in northern Uganda in 2007-2010 demonstrate how at odds with reality this belief is. Recording a marked rise in modern contraceptive use (from 7.1% to 22.6%) and an increase of long-acting and permanent methods (from 1.2% to 9.8%), the study showed that when comprehensive family planning services are made readily available and accessible among conflict-affected populations, women will choose to use them.
In these challenging settings, logistics and supply chains continue to be major constraints for service delivery, as does the critical shortage of clinical expertise. And historically the shortage of health-care professionals has hindered women’s access to long-term or permanent methods of contraception and emergency obstetric care.
Here there are signs of improvement, thanks to the implementation of initiatives like task-sharing. Put simply, task-sharing is the enabling of mid- and lower-level health-care professionals like midwives, health officers and lay health workers to perform procedures that were previously restricted to provision by higher-level health workers only. Many countries, for example, continue to limit the provision of tubal ligation to doctors and contraceptive injections to nurses, despite ample evidence that clinical officers and lay health workers respectively can be safe and effective at these tasks given appropriate training. At the end of 2012, WHO published task-sharing guidelines for maternal and new-born health care.
A beacon of light for the future, these guidelines recommend that a much wider range of different health worker cadres be trained to provide family-planning and safe-delivery services to overcome shortages of health workers and improve access to these life-saving services. Again, like the new WHO safe abortion guidelines, we need to see these applied in humanitarian settings where the shortage of higher health worker cadres such as doctors is especially acute.
More to achieve
Progress is undoubtedly being made but we need to be braver, and all the more demanding for reproductive health in humanitarian settings. We must continue to advocate for policy change but, crucially, we must make sure that policy change makes it from paper to people. We should be extending critical advances found in guidelines, and building capacity for their implementation.
And, finally, we need to stop prioritising components that we, or indeed the donor community, feel most comfortable with and make sure that all areas of sexual and reproductive health are provided for from the onset of any emergency.
The needs and importance of sexual and reproductive health have been recognised. The momentum for change has picked up speed. Now is our chance to make comprehensive sexual and reproductive health in emergencies a reality.
Samantha Guy was one of the guest editors for the 2004 issue of FMR ‘Reproductive health for displaced people: investing in the future’ www.fmreview.org/reproductive-health From 2007 for several years, Marie Stopes International, with the Columbia University Mailman School of Public Health, provided funding for FMR on an annual basis.
 The Reproductive Health Access, Information and Services in Emergencies (RAISE) Initiative set up in 2006 by the Columbia University Mailman School of Public Health and Marie Stopes International to improve the way reproductive health is addressed from the outset of an emergency. www.raiseinitiative.org See regular articles about the outcomes of the RAISE Initiative in FMRs 27-30 and 32-35. See www.fmreview.org/issues
 Health Cluster Guide: a practical guide for country-level implementation of the Health Cluster. IASC Global Health Cluster, World Health Organization, 2009 www.who.int/hac/global_health_cluster/guide/en/index.html
 Inter-agency Field Manual on Reproductive Health in Humanitarian Settings. Inter-agency Working Group (IAWG) on Reproductive Health in Crises, 2010 www.who.int/reproductivehealth/publications/emergencies/field_manual/en/index.html
 Tracking Official Development Assistance for Reproductive Health in Conflict-Affected Countries: 2003 to 2006. www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000090, and updated at www.mariestopes.org/sites/default/files/RH-tracking-study-February-2011.pdf
 WHO. Safe abortion: technical and policy guidance for health systems – 2nd ed. Geneva; World Health Organization, 2012.