Displaced and desperate: Assessment of reproductive health for Colombia's internally displaced persons

Executive Summary
The Women's Commission for Refugee Women and Children (Women's Commission), in collaboration with Marie Stopes International (MSI), Profamilia and Columbia University's Heilbrunn Center for Population and Family Health at the Mailman School of Public Health (Columbia University), conducted an assessment of reproductive health among internally displaced persons (IDPs) in Colombia from November 11 -- 18, 2001.

Colombia was selected as a site to conduct a reproductive health needs assessment based on the Reproductive Health for Refugees (RHR) Consortium's¹ criteria for assessment missions. The criteria include identifying sites where there is a significant number of refugees or IDPs and where RHR Consortium members do not have a significant presence. Colombia was also selected for a reproductive health needs assessment since it could be integrated with a Women's Commission assessment delegation to Colombia. The purpose of the Women's Commission's delegation was to follow up on findings from a 1998 delegation to assess the conditions facing women, children and adolescents uprooted by war and violence. Findings from the 1998 and 2001 delegations are documented in the reports, A Charade of Concern: The Abandonment of Colombia's Forcibly Displaced (1999) and Unseen Millions: The Catastrophe of Internal Displacement in Colombia (2000), available on the Women's Commission website at www.womenscommission.org.

Two million Colombians have fled armed conflict and persecution, many of them have been uprooted and displaced repeatedly over the past 15 years. As the war continues to escalate, some people are displaced en masse, but the majority flee as individuals and families and do not want to acknowledge their displaced status for fear of retribution. Many of the displaced are indigenous groups uprooted from rural to urban areas and forced to flee again from one urban barrio to another in search of security and survival needs.

The assessment team found that IDPs suffer a critical lack of access to reproductive health care owing to a number of factors. Colombians' access to health care overall is faltering between national policy at the central level and services to the population at decentralized levels, leaving many Colombians, particularly IDPs, to fall through the cracks without health care. While the main role of United Nations (UN) agencies is to support local and national capacity to respond to the humanitarian crisis, the Colombian government has abdicated its responsibility to provide reproductive health services and the result is a tragic dearth of services for IDPs.

Those who are displaced in large groups, who represent less than half of all IDPs, are most likely to receive the extremely limited emergency assistance provided. This assistance, however, does not include reproductive health care. The local Planned Parenthood affiliate, Profamilia (Asociación Pro-Bienestar de la Familia Colombiana), provides most of the reproductive health services in Colombia and is just beginning to significantly increase its outreach to IDPs. However, Profamilia charges a small user fee for services, limiting IDPs' access to medicines and care. Few international organizations are supporting direct services to IDPs, despite the scale of this humanitarian emergency. Finally, lack of funds for services, medicines and transport, as well as discrimination by service providers, also prevents IDPs' access to reproductive health care.

The minimum initial services package (MISP) of reproductive health services, now considered a basic standard of care in emergency situations, is not available to IDPs in Colombia. Free services, including emergency contraception, are not available to manage and support survivors of violence. Condoms and clean delivery kits are not free and widely available to IDPs. IDP women suffering from complications of pregnancy and delivery are turned away from hospitals and life-saving emergency obstetric care.

The team learned that IDPs, particularly women, girls and adolescents, experience horrendous reproductive health problems in Colombia. Gender-based violence (GBV), including rape followed by murder, sexual servitude, forced contraception and abortions, is perpetrated by armed actors, is extensive and is largely unaddressed. In addition to GBV inflicted by armed actors, the situation is desperate for some families; the team heard of some instances of girls and boys being sexually exploited by their parents or turning to prostitution for family survival needs. The assessment team learned from IDP women that domestic violence is a major problem, exacerbated by the difficult living situation for IDPs.

The prevalence of sexually transmitted infections (STIs) among IDPs is unknown but anecdotal reports from government and UNFPA representatives suggest that it is very high. In some indigenous communities, health providers, unable to reach men for adequate treatment, have admitted pregnant women to the hospital to prevent them from becoming re-infected and to prevent mother-to-child transmission. This mobile population living among armed actors and on the whole without access to medical care is in danger of an explosion of STIs, including HIV.

The circumstances for adolescent IDPs is dire, and very little is being done to recognize their specific needs and capacities. Unable to cope with their circumstances or enticed by drug traffickers infiltrating urban barrios, many young boys turn to drugs, alcohol and stealing. Some adolescent girls seek solace and comfort from motherhood, while others would prefer to avoid or delay pregnancy, suggesting a need, currently unmet, for family planning. A recent study by Profamilia indicated that 30 percent of adolescent IDPs were already mothers or pregnant with their first child, a percentage nearly twice that of adolescents in Colombia's general population in 2000. ²

Chief Recommendations

The chief recommendations of the assessment team are as follows:

• The Colombian government should provide significantly more financial and technical support for health care, including reproductive health care, to IDPs, particularly at the local level and at referral hospitals for IDP women suffering from obstetric emergencies.

• The Ministry of Health (MOH) should collect and disseminate comprehensive information on who is doing what and where for IDPs and convene representatives of key organizations to improve the coordination of services.

• The MOH and humanitarian assistance providers should improve funding and institute data collection and monitoring mechanisms of IDP health services at major health centers and hospitals.

• The UN should scale up its efforts to promote human rights awareness and knowledge and demand for services among the IDP population.

• The UNFPA should address the MISP in Colombia by providing hospitals and health centers with the MISP kits, including safe delivery supplies, emergency contraception, condoms and essential medicines. UNFPA could also provide MISP kits to Profamilia to facilitate the MISP activities in their community outreach to IDPs.

• The MOH and humanitarian assistance actors should raise awareness about GBV, including sexual violence, by promoting community information and education about GBV and ensuring documentation and verification of incidents to identify and address these widespread human rights violations.

• The government, UN agencies and NGOs should seek to ensure that medical, legal and social services are available for IDP survivors of GBV.

• The government, UN agencies and NGOs should initiate multisectoral efforts to mobilize and support IDP adolescents and their parents. Programs should be implemented to provide health care, including reproductive health services, educational opportunities, recreational activities, income generation projects and family support groups to address household stress and domestic violence.

• Greater efforts must be made by the government, UN agencies and NGOs to conduct community outreach to educate IDPs, especially adolescents, about family planning and emergency contraception.

¹ The Reproductive Health for Refugees Consortium comprises seven organizations: American Refugee Committee, CARE International, Columbia University, International Rescue Committee, JSI Research and Training Institute, Marie Stopes International and the Women's Commission for Refugee Women and Children. The Consortium works to increase refugee and internally displaced persons' access to good quality, comprehensive reproductive health care.

² Profamilia, Salud Sexual y Reproductive en Zonas Marginadas - Situación de las Mujeres Desplazadas (Sexual and Reproductive Health in Marginal Areas - The state of Displaced Women), Profamilia Survey, Colombia, 2001.

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