Women and Girls Critically Underserved in the Rohingya Humanitarian Response

The Interagency Working Group on Reproductive Health in Crisis (IAWG) calls on the international community to ensure that the sexual and reproductive health (SRH) and protection needs of Rohingya women and girls displaced in Bangladesh are fully met. Without urgent action, maternal and newborn deaths, sexual violence and other lifethreatening disabilities and illnesses will rise. The IAWG applauds the existing efforts of the Bangladesh government and local and international NGOs and urges the donor and relief community to continue to work closely with the Bangladesh government and local partners to strengthen and scale up coverage of the Minimum Initial Service Package (MISP) for Reproductive Health – a set of priority interventions designed to save lives and avert preventable injuries, illness and suffering, particularly among women and girls, at the onset of a crisis. We also urge all actors to invest in transitioning from this minimum initial set of services to comprehensive SRH and protection services as soon as possible.

Overview

Since renewed violence began in Northern Rakhine State, Myanmar on Aug. 25, more than 688,000 Rohingya have fled to Bangladesh, joining an estimated 200,000 Rohingya refugees residing there prior to this latest escalation of violence. According to a rapid needs assessment from the Inter-Sector Coordination Group, 60 percent of new arrivals are women and girls, including a high number of pregnant (3%) and lactating women (7%). This influx has created an urgent need to rapidly scaleup health and protection services to support an already vulnerable population, fleeing horrific human rights abuses.
The Bangladesh government, together with international partners, is providing temporary sanctuary for the Rohingya refugees, but is facing an uphill task in responding to the massive scale of the crisis. The response needs urgent strengthening and an increase in services to meet the sexual and reproductive health (SRH) needs of women and girls. This includes clinical, psychosocial and other support for survivors of sexual violence, as well as unhindered access to basic sexual and reproductive care such as a full range of contraception methods, menstrual regulation, safe delivery, and emergency obstetric and newborn care for those who need them.

Key Concerns

Lack of Access to Comprehensive Post-Rape Care: Rape has been a prominent and devastating feature of the Burmese military’s campaign against the Rohingya and multiple reports from survivors suggest that sexual violence is widespread.
NGOs, the UN Secretary General’s Special Representative for Sexual Violence in Conflict and journalists have also provided evidence for widespread and sometimes systematic use of rape, especially gang rape, by Myanmar’s military against Rohingya in Rakhine State. Despite the acute need, post-rape care, including access to safe abortion and emergency contraception, is inadequate in the camps. Services are rarely comprehensive, of inconsistent quality, and unavailable 24 hours/day, 7days/week (24/7) in all locations.
Gender-based violence (GBV): The crisis in Myanmar and the displacement into Bangladesh has further exacerbated already existing gender inequalities in Rohingya communities and increased the incidence of domestic and other violence against women and girls now living in poor conditions in underserved refugee camps, especially sexual violence. IAWG members have heard accounts of forced prostitution, trafficking, and sexual violence within the camps, including child marriage, intimate partner violence, and sexual exploitation and abuse.
Sexual and reproductive health services: Displaced Rohingya women and girls have limited access to critical and life-saving SRH services in Bangladesh. Further, these same women and girls were denied access to adequate sexual and reproductive healthcare when in Myanmar and knowledge and understanding of services is low.

• Emergency obstetric and newborn care (EMONC)
Home deliveries – often in unsafe and unhygienic conditions – are common, and for the majority of residents, lifesaving EMONC is not available 24/7. Transportation is a major issue and ambulances are scarce. This is further exacerbated by restricted movement into and out of the camps. UNFPA estimates that only 22% of expected deliveries occur in a health facility.

• Voluntary Contraception There are currently policy barriers for Rohingya’s to access the full spectrum of contraception: for example, refugees are required to provide proof of a permanent address to access highly effective, long-acting reversible methods.
Access is also limited by restrictions that bar key frontline health personnel (nurses, midwives) from providing a complete range of contraceptive methods. Furthermore, few health facilities providing services to Rohingyas are fully equipped to provide the full range of contraceptives. For example, stock-outs of injectible contraceptives, a discreet method that many Rohingya women prefer, have been reported.

• Safe abortion care Although menstrual regulation with medicine (MR) is legal in Bangladesh up to 10 weeks and available at only ten health care facilities in and around the camps, service utilization remains low due to low community awareness of the method and where to access services.

• HIV/STIs Treatment and prevention of STI’s is available at selected facilities, however is limited by issues of lack of privacy and of trained service providers, particularly female providers. Access is further limited by low awareness within communities. HIV/AIDS treatment is available at the district hospital, however movement restrictions are in place and refugees can only access services if referred and escorted for service provision.
Adolescents: Adolescents girls have been neglected in the response, and adolescent boys have been almost entirely overlooked – both need urgent access to services. Gendered restrictions on mobility exacerbated by security concerns related to GBV are restricting adolescent girls’ uptake of life-saving SRH services at health facilities and participation in safe spaces and learning centers in Cox’s Bazaar. Moreover, IAWG partners on the ground are perceiving an increase in child marriage within the camps including among very young adolescent girls. Many adolescent girls are currently pregnant, hard to reach, and face additional barriers around their movements within the camp.
Recommendations We offer our full support in addressing the key concerns raised above and call on donors, implementing agencies, and the Bangladesh government to work in partnership to urgently address these needs.

Specifically, the Bangladesh Government should:

• Ensure that Rohingya are able to access lifesaving healthcare services including access to the district hospitals for management of an obstetric emergency, to treat HIV/AIDS, or to access post-rape care. Appropriate transportation and healthcare services, including EMONC, need to be made available 24/7.

• Ensure availability of the full range of short and long acting reversible contraceptive methods, including emergency contraception, and lift restrictions on access to long-acting reversible contraceptive methods.

• Facilitate a faster registration process for NGOs with specialized humanitarian SRH expertise, to ensure that additional personnel, funding, and technical assistance are available to support national government efforts.
Implementing agencies should work closely with the government and other national service providers to:

• Increase access to post-rape care, including MR and emergency contraception, and provide information to communities about the benefits of post-rape-care and how they can access it.

• Support the Bangladesh Government in its efforts to provide the full range of reversible contraceptive methods.

• Immediately integrate and implement SRH and GBV health responses, in close collaboration with GBV actors providing case management and psychosocial response services.

• Invest in safe spaces for women and girls, which are critical to improving access to information around health and other services (psychosocial support and case management), and how to access those services.

• Ensure health services are available in new sites and integrated into existing non-health services to increase access. Specifically, the number of sites that provide 24/7 EMONC and post-rape care must be increased urgently.

• Ensure adolescent-friendly SRH services are available at health facilities and community distribution points.
Targeted support and referrals for services to meet unique needs should be provided to the most marginalized and atrisk adolescents. Community mobilization and outreach strategies should be tailored to adolescents, including adolescent-specific information about what and where SRH services are available, and referrals to adolescent friendly facility-based services should be strengthened and facilitated.

• Expand self-reliance opportunities and resilience support programming for refugee women and men as well as host community members.

• Include the host community in service provision, to avoid exacerbating existing tensions between host and refugee populations.
Donors should:

• Prioritize funding to ensure the MISP is fully implemented, as per the recommendations above, and ensure supply and distribution of all essential sexual and reproductive health and menstrual hygiene management commodities.

• Support actors with capacity and experience in women’s health and protection programming in humanitarian settings to facilitate scale up of SRH and protection service delivery.

• Increase support for the government and implementing agencies to improve quality of services and adherence to international standards and national protocols, including local staff training and capacity building, supervision and mentoring.
IAWG is committed to advancing the sexual and reproductive health of people affected by conflict and natural disaster and is available to support and collaborate with partners and stakeholders in their response to this crisis.

For further information, please reach out to sarahk@iawg.net.