Health in Emergencies Issue 10, Jun 2001
Challenges to reproductive health in emergencies
by Wilma Doedens WHO and Kate Burns, UNHCR
What is the challenge?
Implementing comprehensive reproductive health (RH) care for a population is never a simple matter, but emergencies and displacement pose special challenges for delivering this kind of care. Refugees and internally displaced persons (IDPs) have the same reproductive health needs as non-displaced people. However, the factors that forced them to flee also render them extremely vulnerable to reproductive as well as to other health problems. Forcibly displaced persons have left behind the support of traditional values, extended families and familiar ways of life.They have often lost their loved ones, their possessions, their livelihoods, their social status and even their human dignity. The changes wrought by displacement - a lack of traditional support and role models, different cultural pressures to reproduce lost members of the community and changing roles and identities of men and women along with their roles in society - are major barriers to implementing adequate reproductive health programmes. In emergencies, mortality and morbidity from reproductive causes may increase, life transitions such as the one from adolescence to adulthood are made more difficult, and important aspects of RH programmes, such as the integration of men are major challenges.
WHO is a member of and provides technical support to the Inter-Agency Working Group for Reproductive Health in Refugee Situations (IAWG). This group was established in 1994 under the co-ordination of UNHCR and includes approximately 30 UN agencies, NGOs, academic and donor institutions. The IAWG developed the Minimum Initial Service Package (MISP), which incorporates all necessary elements to provide basic reproductive health services during the first phase of an emergency, with the aim of reducing mortality. A person or organisation to coordinate the reproductive health response and planning for comprehensive reproductive health service provision, as soon as the situation stabilises, are part of the package.
The MISP and other reproductive health measures to be taken in the emergency and the post-emergency phase are described in "Reproductive Health in Refugee Situations, an Inter-Agency Field Manual" produced by the IAWG (see page 2). The medical supplies needed to implement these measures are assembled in the "Reproductive Health Kit for Emergencies", developed by the IAWG and assembled and stockpiled by UNFPA. The IAWG meets twice a year and continues to address RH problems in emergencies.
This year, WHO has produced a guide for programme managers: "Reproductive Health during Conflict and Displacement", which is complementary to the IAWG field manual.
An example: Sexual and gender-based violence
At every stage of a conflict, women and adolescent girls and boys are vulnerable to sexual and gender-based violence. Rape and other forms of violent assault are often used as weapons of war. Women and girls are forced to offer sex in exchange for food, shelter or protection. Emergency contraception and other medical and psychological care are rarely available. Sexual and gender-based violence has a disastrous effect on people’s physical and mental health. Some of the psychical effects include unwanted pregnancies, unsafe and complicated abortions, HIV/AIDS and other sexually transmitted infections(STIs), sexual dysfunction and injuries. Psychological ill effects can include anxiety, post-traumatic stress disorder (PTSD), depression, and suicide. This may lead to impaired social and community health, such as lack of women’s income, interrupted education of adolescents, infanticide, and delayed community reconciliation and reconstruction.
The challenge to effectively prevent and respond to sexual and gender-based violence is in employing a multi-sectoral approach, involving protection, security, community and health sectors.
While it is not proven, it seems likely that the incidence of sexual and gender-based violence, specifically rape, may increase in the early phases of an emergency, particularly during flight. However, the grouping of people in refugee or IDP camps also offers an opportunity for prevention and community education. Preventive measures such as careful design and layout of camps (i.e. adequate lighting, security patrols, and the planning the location of basic services and facilities in such a way that this does not expose women to attack) can reduce the risk of sexual and gender-based violence.
Other ways to prevent sexual and gender-based violence and to reduce the negative health impact this has on individual survivors include information campaigns (taking into account cultural sensitivities, ethics and the medico-legal circumstances in the host-country), along with ensuring easily accessible, private and confidential health services for survivors.
There are a number of tools available to help meet the challenges of sexual and gender-based violence in emergency situations. General guidance is available through the UNHCR’s "Sexual Violence against Refugees - Guidelines on Prevention and Response" which provides useful advise on camp planning and education and information campaigns. Specific programme guidance is provided in the inter-agency field manual and the WHO guide for programme managers (in preparation).
Furthermore, WHO, in collaboration with the IAWG, is developing a guide for the "Clinical Management of Post-Rape Survivors", which outlines best practices for managing the health implications of rape. The protocol details essential components of post-rape medical care such as:
- Forensic evidence collection;
- STI evaluation and treatment;
- Pregnancy risk evaluation and prevention;
- Crisis intervention;
- Care of injuries;
- Referral to other services:
- The needs of special groups, such as children and pregnant women.
Many agencies working in the field implement only one element of a reproductive health programme; very few deliver comprehensive reproductive health services, integrated into primary health care. Effective reproductive health programmes safeguard basic human rights of displaced people - such as the right to life and health, the freedom to marry and determine the number, timing and spacing of children, and the right to liberty and security of the person, including freedom from sexual violence and coercion.
What is reproductive health?
Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity, in all matters related 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 capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the rights of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.
International Conference on Population and Development -Cairo 1994; Programme of Action, para 7.2
An inter-agency effort
Providing comprehensive and high-quality reproductive health services requires a multi-sectoral, integrated approach. Protection, health, nutrition, education and community service personnel all have a part to play in planning and delivering reproductive health services.
The Inter-Agency Field Manual on Reproductive Health in Refugee Situations, which is the result of a collaborative effort of many UN agencies, governmental and non-governmental organisations and refugees themselves, is intended for use in refugee situations. It may also be of use in refugee-like situations, such as situation with internally displaced persons or returnee-affected areas.
The Manual includes chapters on safe motherhood, sexual and gender-based violence, sexually transmitted diseases including HIV/AIDS, family planning, reproductive health of young people and surveillance and monitoring. The information contained in the Manual is based on the normative, technical guidance of WHO.
The Manual is available online at:
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