Since 2009, Northeast Nigerian communities have faced a violent insurgency led by fundamentalist extremists, including the militant terrorist group Boko Haram and associated fractured groups. An estimated 1.7 million women and girls of reproductive age have been displaced, and two-thirds of health facilities have been destroyed. There is a critical need for sexual and reproductive health (SRH) services, including contraceptive services, for people affected by the conflict.
Globally, studies have shown that conflict-affected and forcibly displaced women and girls face increased risks of maternal morbidity, mortality, and gender-based violence (GBV); higher risks of sexually transmitted infections (STIs); greater risks of unintended pregnancy; and heightened risks of unsafe abortion and its associated complications. Therefore, contraceptive services, including long-acting reversible contraceptives (LARCs), and post-abortion care (PAC) are included in internationally accepted minimum standards for humanitarian health responses. As a crisis stabilizes, the response should transition from the provision of basic, lifesaving SRH services to the provision of comprehensive SRH services for all affected women, men, and adolescents.
One of the areas most seriously affected by the insurgency in Northeast Nigeria is Borno State. In June 2019, the Women’s Refugee Commission (WRC) conducted a case study of contraceptive service delivery in Maiduguri and Jere Local Government Areas (LGAs) in Borno State. While multiple reports have documented the SRH needs of women and girls in Northeast Nigeria since the onset of the crisis, this case study is the first to focus specifically on contraceptive service delivery and PAC in this region. It documents the important work that humanitarian actors, the government of Nigeria, and other stakeholders are undertaking to provide contraceptive services to internally displaced persons (IDPs) and host communities. It highlights challenges, documents how some of these challenges were addressed, and presents recommendations.
The case study employed mixed methods, including key informant interviews (KIIs) with the United Nations Population Fund (UNFPA) and nongovernmental organization (NGO) health and SRH program managers; health facility assessments, including SRH knowledge and attitudes surveys with service providers; focus group discussions (FGDs) with IDPs and community members; and a review of service delivery data from UNFPA and partner implementing agencies. Due to the security situation, WRC was unable to visit sites or conduct interviews outside of Maiduguri and Jere LGAs. The situation in the broader Borno State may vary significantly.
A global evaluation by the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) published in 2014 found that the provision of sexual and reproductive health (SRH) services, including contraception, in humanitarian settings was weak, and pointed to a cross-cutting need for more systematic research and a robust program evaluation. This study is the second of three such case studies undertaken by WRC as part of a global landscaping to help fill that evidence gap by documenting contraceptive service delivery in humanitarian settings.
The global landscaping also comes after an important update to the Minimum Initial Service Package (MISP) for Reproductive Health in Crises, which added preventing unintended pregnancy as an objective. In addition, the importance of family planning in humanitarian settings has been elevated through key global moments, such as the Family Planning Summit in 2017.
The locations for the global landscaping were selected based on a set of criteria that included diversity of settings (geographic, type of crisis, phase of crisis) and the existence of family programming and partners. Northeast Nigeria was selected due to the geographic location (West Africa); existence of camp and host community settings; internally displaced population; protracted crisis due to long-term conflict; and WRC’s ongoing partnership with Nigerian government health agencies.