The provision of reproductive health services for refugees has attracted an increasing amount of interest and controversy over the last two years. Whilst at bureaucratic and research level the issue has attracted minimal attention for years, it is now being vigorously debated in international circles among NGOs, environmentalists, donor agencies and academics. Reproductive health also became a major item on the agenda at the two recent UN conferences on women in Cairo and Beijing. In this article, Louisiana Lush examines the nature of this new emphasis on reproductive health for refugees, whilst Sara Davidson provides an overview of the key elements of reproductive health care and the issues surrounding their delivery in refugee situations.
Until recently, the issue of reproductive health has not been seriously or comprehensively addressed by agencies working with refugees or others displaced and living under emergency conditions. Services have tended to concentrate on prenatal and postnatal care and safe delivery, whilst family planning and birth spacing, interventions to deal with sexually transmitted diseases, and awareness of the problems of sexual violence have been limited.
This situation has arisen from a complex set of interactions: sometimes refugees themselves object to the provision of reproductive health care for cultural reasons or because they interpret it as a cynical manoeuvre to limit their population; in other cases, for whatever reason, the host country does not provide adequate reproductive health care to its own population, let alone to refugee communities; and some NGOs working in emergency situations are themselves wary of providing reproductive health care since not only may its provision be highly controversial but the agency may also experience practical constraints such as lack of resources, trained staff and logistical capacity.
In 1993 The Lancet published an editorial lamenting the neglect of family planning services for refugee women and claiming that in refugee settings, `there are virtually no data on fertility, abortion or desired family size'. It concluded that the `family planning needs of refugees have been totally ignored'. In 1994, the subject received increased attention through the wide acceptance of the importance of reproductive health at the International Conference on Population Development (ICPD) held in Cairo in September. Here, for the first time at such a forum, the issue of reproductive health care for refugees was explicitly highlighted and taken into account in the final document and Plan of Action.
The ICPD defined reproductive health as:
`a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capacity to reproduce and the freedom to decide if, when and how often to do so.'
The most important outcome of the Cair conference, however, was that `reproductive health', while perhaps previously being a politically correct way of saying `family planning', has come to represent the incorporation of an understanding of the rights of the individual, and in particular of women, into the provision of family planning and related services. At the recent UN Women's Conference in Beijing, this was taken one step further: while there were some problems in getting national delegations to agree to some of the issues already discussed at Cairo, the emphasis was on placing reproductive health within a context of reproductive rights and within the overall framework of human rights.
As such, the goals of any reproductive health programme must be the empowerment and enhancement of the capacity of both women and men, and not the limitation of population size for economic considerations or for reasons of resource maintenance. `Family planning' must be part of an integrated package of services which do not relate simply to technical interventions to control the size of families or limit the overall population, but to services which enhance the dignity and self-determination of women, men, adolescents and families. The principles of `empowerment' and `participation' must therefore inform all stages of the planning, design and delivery of `family planning' and other sexual health projects, to promote effective reproductive health and enable refugees to move from being passive recipients of care to active participants in such health programmes.
Women's health needs are put into focus by UNHCR's Guidelines on the protection of refugee women. A section discussing women's access to appropriate health care points out that: `existing health services too often overlook female-specific needs. For example, gynaecological services are frequently inadequate as are child spacing services. Basic needs such as adequate cloth and washing facilities for menstruating women are overlooked. Serious problems such as infections and cervical cancer, and harmful practices such as female circumcision, go all but undetected. Counselling regarding sexually transmitted diseases is generally inadequate for both women and men. Few if any programmes focus on the needs of adolescent girls, even though early marriages and pregnancies are a reported cause of poor health. Access to family planning information and devices is limited in most refugee camps even where it is available to women and men in the host country'.
Reproductive health care for refugees is characterised as including five key elements:
1.provision of safe motherhood services;
2.prevention of sexual violence, and provision of support to victims;
3.provision of family planning and contraceptive services;
4.provision of abortion-related services;
5.prevention and treatment of sexually transmitted diseases.
Few emergency relief agencies have the capacity to implement all five essential components of reproductive health in refugee situations. Effective programmes therefore require coordination by agencies to ensure all areas are covered. The five elements of RHC are briefly discussed below and explored in more detail in subsequent articles.
1. Provision of safe motherhood services It is not hard to understand the emphasis given in refugee camps to mother and child health programmes (MCH) that focus on the survival and improved health of pregnant women and children, for this is where the most dramatic and easily identifiable health need exists, especially during a camp's initial emergency phase. In developing countries, where most of the world's refugees are situated, women of childbearing age (1845) comprise 20% of the population and 25% of this group are expectant mothers. Poor food, poor shelter, poor health, physical hardship, bereavement and trauma are likely to have preceded and followed displacement, and forced migration will have increased exhaustion. In one, Karen IDP (internally displaced persons) camp on the Burma/Thai border, it was reported in 1994 that 80% of women gave birth with the assistance of untrained birth attendants; 10% of all infants died during delivery or before the age of one; 50% died before their fifth birthday of causes that included miscarriage, birth injuries, malnutrition and infections1.
High maternal mortality and miscarriage rates are typically causes of concern in refugee settings, and the likelihood of giving birth to underweight babies increases. Women in most refugee sites under the mandate of the UNHCR system are likely to have access to some kind of basic prenatal care, to maternity services to assist them when they give birth, to postpartum sessions to check the mother and child's progress, to supplementary feeding and oral rehydration programmes for their infants, and often to expanded programmes of immunisation and to other basic health services for their children. Provision of prenatal, delivery and postnatal care for pregnant and lactating women and programmes of MCH are essential but should not obscure the fact that programmes for refugees often fail to address other areas of reproductive health need and other sections of the community (eg adolescents, older women). Agencies risk defining women as first and foremost the mothers of newborn infants, but war and forced migration may make them rape victims or bereaved parents or widows with different, or at least additional, needs.
2. Prevention of sexual violence, and provision of support to victims The wars in Rwanda and Former Yugoslavia have dramatised the need for protection of women against the calculated use of sexual violence as a mass instrument of war. Where protection has failed, there is not only a threat to the life of the individual but a psychological effect on victim, family and witnesses, including children. Sexual violence also has other manifestations in refugee situations, however, and the UNHCR definition of sexual violence includes torture, threat, assault, domestic violence, incest, prostitution and female genital mutilation (UNHCR: Sexual Violence Against Refugees, Guidelines on Prevention and Response). The World Health Organisation and the UN Commission on Human Rights regard female genital mutilation as `a definite form of violence against women which cannot be overlooked` or be justified on the grounds of tradition, culture or social conformity'.
According to UNHCR, refugees who are at greatest risk are unaccompanied women, female heads of household, unaccompanied children, and children in foster care. Most reported cases concern male culprits and female victims, but men and boys may be victims too. The perpetrators of violence may include other refugees, security force members, civilian staff and other religious or ethnic groups. Sexual intimidation remains a constant threat throughout displacement. The fear of sexual as well as non-sexual violence by gangs within the closed-off detention centres for refugees in Hong Kong is a telling example. Poor camp layout eg a layout that requires unaccompanied women to walk long distances to collect fuel or water and poor lighting also pose threats to women in refugee centres. At one centre in Sri Lanka, women in a camp guarded by security forces preferred not to use latrines at night rather than risk walking to them in the dark.
Community leaders, female protection officers, and female field staff can help agencies plan responses that may include legal enforcement of protection measures, women only support groups and institutional support to local women's NGOs. The provision of psychosocial support requires long-term commitment and labour-intensive support that cannot be measured as easily as metric tonnes of relief goods delivered. Nevertheless, initial results from an EC study in Croatia suggest that such programmes have been effective in improving the well-being of female refugees from Bosnia2.
3. Provision of family planning and contraceptive services Displaced communities require access to a range of appropriate family planning services. Although little research has been done in this area, informal assessment and anecdotal evidence suggests that birth rates are frequently higher after migration than before, and are higher in refugee than in host communities. One example of high birth rates can be found among Afghan refugee women living in Pakistan. Without family planning the average married refugee woman could expect 13.6 births during her reproductive life while the average total fertility rate for all women in Pakistan is 6.2 children3. The reasons for increased birth rates may include: increased sexual activity through boredom, itself caused by enforced unemployment and the lack of other work or leisure opportunity; lack of contraceptives that may have been available prior to migration; rape; provision of sexual favours in return for protection, essential food or money; social pressure to replace community members killed in flight or fighting.
In talking of displaced communities, it is crucial not to overlook that the experience of displacement is an individual one, as is the experience of having children. Loss and bereavement may result in a wish to have more children. Where war continues, women may wish to marry earlier and/or bear a child as soon as possible, as has been informally reported to the author in Bosnia where some young women feel that this is the only area of their life that they can control. One researcher noted that `In Hong Kong, as in other refugee sites, one of the reasons for having a baby is that both men and women want and need something to love when they have nothing else that gives them pleasure or happiness'4. The opposite may also be the case, with women wishing to delay having children in the confines of a refugee camp where food, finances, health provision, sanitation and security may all be in short supply. A 1989 study of Central American refugees, who had lived in neighbouring Belize an average of four years, found a high level of interest in family planning. Researchers interviewed Salvadorean and Guatemalan refugees living in the town of Belmopan, as well as native Belizeans living in the same areas. More than 130 women under the age of 50 were interviewed. Over half the women in the survey indicated an interest in family planning with the highest socioeconomic group likely to have the most interest5.
The contraceptives which the women and men want will be partly dictated by both their home and host community's preference, tradition and legal code, and reproductive health programmes must be guided by these too. A survey of Laotian and Cambodian refugees in Thailand during the 1980s found that contraceptive use was influenced by the cultural beliefs and teachings of the home country. Contraceptive prevalence was higher in Khao I Dang Camp, which primarily housed Kampuchean refugees from Cambodia, than in the Ban Vinai camp, which housed Hmong refugees from Laos, a country where traditional values included a large family, marriage at a young age for women, and polygyny. More than 50% of evermarried women in Khao I Dang practise contraception, compared to 24% of evermarried women in Ban Vinai. When camp residents were asked how many additional children they wanted, Khao I Dang residents said an average of 1.5, while Ban Vinai residents said 3.66. Currently, limited family planning services are available for Rwandan refugees in Tanzanian camps. Plans have been drawn up to develop a family planning programme in Benaco, through the efforts of UNHCR and UMATI, the International Planned Parenthood Federation affiliate. Population Services International is distributing 135,000 condoms per month and AIDSCAP will develop an AIDS prevention campaign. Before the political unrest that led to the migration of thousands out of Rwanda in 1994, the nationns contraceptive programme was one of the largest in sub-Saharan Africa, reaching 21%. Without family planning services the birth rate, as well as the incidence of sexually transmitted diseases, is likely to increase7.
`Cultural sensitivity' is sometimes cited as a cause for reluctance to provide family planning services by relief agencies, but agencies should beware of using cultural sensitivity to excuse absent or partial health provision for women whose social status may remain traditionally low but whose responsibilities toward family and community almost always increase during and after displacement.
4. Provision of abortion-related services Access by women to safe abortion remains a sensitive issue for religious and political leaders in refugee and non-refugee situations alike. In donor countries the issue may be crucial in deciding provision or allocation of funds. The practice in any refugee location will therefore be defined as much by legal protocol and environment as by the situation and by the individual circumstances of women. The Bangladeshi government in exile in 1971 permitted abortion for rape victims. In Hong Kong, however, the law on abortion for both host and displaced communities is similar to British law, which allows abortion if the continuation of the pregnancy would damage the mother's physical or mental health.
Access by female refugees to the best treatment available is an ethical and humanitarian imperative for medical personnel and support staff. Of the half million expectant mothers who die each year, 99% do so in developing countries and 14% of these deaths arise from complications due to septic, incomplete or unsafe abortions. This figure can be expected to rise in refugee settings where rape and violence have been a frequent occurrence, where availability and use of contraceptives are less than optimal, and where access to medical facilities is limited.
The 1995 Geneva Symposium on Reproductive Health in Refugee Situations emphasised that the 'overriding principle of humane treatment must prevail and that health care providers have a duty to provide treatment regardless of the legal status for those women having septic and/or incomplete abortions'. Such treatment should be followed by provision of counselling and family planning services.
5. Prevention and treatment of sexually transmitted diseases (STDs) AIDS spreads most rapidly in conditions of poverty, powerlessness and social instability, precisely the conditions that exist in forced migration. The spread of AIDS in most refugee situations is greatest through heterosexual transmission in conditions where rape, the breakdown of legal structure, the breakup of families, destitution and prostitution can force survivors of disaster to become victims and casualties of sexually transmitted disease. Factors such as lack of contraceptive availability, poor health awareness and poor infrastructure increase risk.
Physical and legal protection of the vulnerable, particularly women and children, is essential. Providing condoms at the earliest possible stage of an emergency prevents neither violence nor destitution but will stem the spread of STDs within displaced or host communities, and within or by military occupation or protection forces. Offering male contraceptives to communities where large numbers of women have been widowed or raped calls for considerable tact and sensitivity by aid agencies and emphasises the need for involvement by female representatives of the local community in programme planning.
`Good health is too big a subject to be left only to doctors' (Handbook for Emergencies, UNHCR, 1982). Good reproductive health needs aid administrators, donors, and policy makers who are proactive in assuring women, men and their children of access to sexual health projects, in ensuring that protection and health care programmes target women on the basis of their need, and not even by default of their age, creed, marital or social status, and in recognising `the crucial role played by women in disasterprone communities' and ensuring that this role is `supported, not diminished, by our aid programmes' (Code of Conduct for the JRC/RCM and NGOs in Disaster Relief).
Sara Davidson is Refugee Initiatives Manager, Marie Stopes International.
Louisiana Lush is a Research Fellow at the Centre for Population Studies, London School of Hygiene and Tropical Medicine.
1.Wulf D, Refugee women and reproductive health care: reassessing the priorities, Women's Commission for Refugee Women and Children/International Rescue Committee, New York, June 1994.
2.Agger I, `Evaluation of psychosocial field action: a pilot study', Marie Stopes International.
3.Wulf D, ibid.
4.6October 24, 1996 ibid.
5.Moss N, Stone M C, Smith J B, 'Fertility among Central American refugees and immigrants in Belize', Human Organisation, 52 (2), 1993, pp 18693.
6.Chongvatan N, Wongboosin K, `Family planning programmes and contraceptive practice in Khao I Dang and Ban Vinai Refugee Camps', Chulalongkorn University, 1989.
7.Wondergem P, Brady B, `AIDS/STD programme for Rwandan refugees in Tanzania: health system and community assessment, Benaco Camp, Ngara District, Tanzanian, Arlington, John Snow Inc., AIDSCAP, 1994.
October 1996