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Crises Pose Major Challenges for Reproductive Health Care
Every year armed conflicts and natural disasters kill hundreds of thousands of people and inflict great suffering. Armed conflicts tear societies apart and disrupt people’s lives, often for years. Natural disasters devastate whole regions without warning, as the December 2004 Asian tsunami, the August 2005 New Orleans hurricane, and the October 2005 Pakistan earthquake have demonstrated. Health care systems, often struggling to meet people’s needs in the best of times, can be quickly overwhelmed by the added burden of injury and infectious diseases. At the same time, health systems themselves may be crippled by disaster or conflict. As a result, many people’s reproductive health needs including safe motherhood, protection from and response to sexual and gender-based violence, prevention and treatment of HIV/AIDS and other sexually transmitted infections (STIs), family planning, and adolescent reproductive health—are often neglected. Unless concerted attention, effort, and resources can be mobilized, meeting people’s immediate needs becomes impossible, and many lives are put at risk.
As of mid-2005 some 45 countries, predominantly in Africa and Asia, faced crises related to armed conflicts or natural disasters (123).Today, nearly 40 million people have fled their homes as a result of conflicts and now are living as refugees outside their countries or, more often, as displaced people within their own countries. Natural disasters affect millions more (see 'Millions Need Care in Crisis'). Although the United Nations (UN) formally distinguishes refugees from internally displaced persons (IDPs), according to whether or not they have crossed an international border (106), in general, this report uses the term “refugees” to include all people displaced by crises, whether internationally or within their own country. Whatever their status, people who have been uprooted by armed conflicts or natural disasters have similar needs for protection, food, shelter, and health care, including reproductive health care.No international treaty defines responsibility for the protection of people displaced within their own country, however, as is the case for international refugees (20, 106). There is a common perception of refugees as people crowded into camps with few amenities. In reality, people living in refugee camps are usually better off than refugees who are dispersed within local communities. Food,water, and basic health care are more likely to be available in camps (18, 55).Where refugees are dispersed, their status and needs are unknown, and it is more difficult for relief agencies to meet their emergency needs (53). Out of sight of international relief agencies, these people must depend on existing local services for health care and other needs.
Conventionally, in a crisis situation, humanitarian and relief workers have focused on providing basic emergency services such as food,water, shelter, security, and primary health care, with a focus on controlling infectious diseases (16).These are priorities in a major emergency because many lives are at risk. Reproductive health care is also a serious public health issue in crises.More attention to reproductive health care, and to providing it immediately—particularly emergency obstetric care—saves lives in refugee settings (7, 121). Increasingly, international relief agencies are making reproductive health care a key emergency service. National and community reproductive health care organizations and providers, too, can become better prepared and able to respond—particularly to the needs of refugees living outside camps or beyond the reach of relief agencies. This issue of Population Reports is intended to help national and community reproductive health care providers respond to crisis situations and to collaborate with international relief agencies. (For more on the steps that health care providers can take to prepare for crises and tools they can use, see 'Reproductive Health Care Providers Can Help'.) This issue also discusses how relief agencies can address the reproductive health needs of refugees as part of emergency care. Through cooperation and collaboration, international relief agencies and national and local reproductive health programs can help people survive an emergency, sustain their health, and rebuild their lives. Range of Reproductive Health Care Needed in Crises According to the United Nations High Commissioner for Refugees (UNHCR), meeting a range of reproductive health needs is crucial in a crisis situation. These needs include: safe motherhood, protection from and response to sexual and gender-based violence, prevention and treatment of STIs including HIV/AIDS, family planning, and adolescent reproductive health (63, 93).
Safe motherhood. After the tsunami 400,000 refugees sought shelter in camps around Banda Aceh, Indonesia. An estimated 25,000 of these were pregnant women.The local health care system could do little for them, however, because the tsunami had destroyed most of the clinics and killed most of the midwives (9). In many developing countries maternal mortality is one of the leading causes of death among women of reproductive age (124). In most crisis situations about 15% of pregnant women suffer life-threatening complications of pregnancy and delivery, about the same percentage as among pregnant women in general (65, 93). But maternal complications are far riskier for women in crisis situations. The majority of refugee women are in countries where pregnancy can represent a serious health threat even in normal times (48). In crisis situations the need for emergency services to treat obstetric complications is acute, both because trauma, malnutrition, and psychological distress are widespread (38) and because many health care personnel and facilities are no longer available (18, 62). Better care could prevent most maternal deaths. A study among Afghan refugees in camps in Pakistan found that, compared with women who died of other causes, those who died of maternal causes had faced greater barriers to health care. These barriers included failure to recognize the problem, the decision of family members not to seek care, lack of emergency transport to a health facility, and not receiving good quality, timely treatment (7). Sexual and gender-based violence. Armed conflict and its aftermath unleash widespread sexual and gender-based violence—that is, acts of violence committed against females because they are female and against males because they are male (112). Sexual and gender-based violence includes sexual violence, domestic violence, emotional and psychological abuse, sex trafficking, forced prostitution, sexual exploitation, sexual harassment, harmful traditional practices (such as female genital cutting and forced marriage), and discriminatory practices. The victims are most often women and girls, although men and boys are also subject to sexual violence (121).Violence occurs during all phases of conflicts—before and during flight, in camps, and during repatriation (50, 93). In particular, rape used as a weapon of war has been documented in Algeria, Bangladesh, Bosnia and Herzegovina, Indonesia, Liberia, Rwanda, and Uganda (122). While rape and other forms of sexual and gender-based violence take place in all societies at all times, conflicts often increase the incidence.The main factors behind increased sexual and gender-based violence are loss of security, psychological trauma, ethnic tensions, and the breakdown of family and community life. Other factors include overcrowding in camps and predominantly male camp leadership who do not see preventing gender-based violence as a high priority (96, 114, 118, 122). In some instances peacemakers and humanitarian workers have been the perpetrators, exchanging food for sex by threatening to withhold food rations (71, 92). Domestic violence also wells up in many refugee settings. Men compensate for the loss of control over their lives by exerting violent control over their spouses (57, 71). In some cases, domestic violence is more common than violence by those outside the family. For instance, in a study among conflict-affected populations in East Timor, nearly half of women reported abuse by intimate partners, both during the crisis and afterwards. By comparison, 24% of women reported violence by perpetrators outside the family during the crisis; 6%, after the crisis (36). During the crisis the perpetrators outside the family were mainly militia members, soldiers, and police. After the crisis about two-thirds of perpetrators were neighbors or other community members (36). Conditions in refugee camps can expose women and girls to violence (50). In some camps women must wait in line to fetch water until late into the night, when they are vulnerable to attacks (61). Sexual attacks occur when women are doing other daily chores, too, such as collecting firewood in isolated areas, or when they have to use latrines in remote parts of the camp. Young children also are vulnerable to sexual predators when they are either separated from their families or are left unprotected in camps. (For information on how health care providers can address sexual violence in conflict situations, see 'Reducing Violence Against Women: Health Care Providers Can Help'.) HIV/AIDS and other STIs. Of the 45 major crisis zones in the world, 28 are in Africa and 12 are in Asia—the continents where HIV/AIDS is most prevalent (123). Coupled with crisis situations, HIV and other STIs can spread rapidly, especially where HIV prevalence is already high. Poverty, powerlessness, food insecurity, and displacement often make refugees more vulnerable to sexual transmission of HIV (82). For example, in Liberia the prevalence of HIV was estimated at about 8% before the civil war.The war brought widespread sexual violence, including mass rapes and abduction of women and girls to act as sex slaves for soldiers. STI screenings after the war showed that 93% of male combatants and 83% of female combatants had at least one STI. Projecting from these high STI rates, health care providers in the country now estimate that HIV prevalence is much higher than before the war (51). Family planning. In general, family planning is as much in demand during a crisis as it was beforehand (37).Yet refugees may have far less access to contraception because services and supplies have been disrupted (57).The result can be more unintended pregnancies (18, 62) and rising abortion rates (60). Also,women who rely on contraceptive methods that require continual supplies, such as pills or injectables,may have to discontinue use abruptly when they flee their communities. Many women who use IUDs or implants no longer have access to safe removal and replacement (31).
Adolescent reproductive health. Worldwide, approximately 6.6 million adolescents are displaced by armed conflict (54). In crisis situations social support networks weaken and often break down entirely (18, 48). Adolescents, especially girls, are at particular risk of forced sex and of sexual coercion in exchange for food, shelter, and protection (93, 105). In crisis situations unsafe sex and other risk-taking among youth often increase. In a refugee camp in the Republic of Congo, girls as young as 10 to 12 years old were reported to be sexually active, often with adult men (100). In a refugee camp in Kenya, a study found that despite the availability of free condoms and other reproductive health care, about 70% of young men and women had unplanned sex without condoms (84). Health Care Providers Face Unique Challenges in Crises Crises pose enormous and unique difficulties for reproductive health care providers (55, 121). Although reproductive health care in crisis situations is similar in many respects to care in more stable settings (30, 59), there are important differences. Crises disrupt services. In a crisis situation transportation and communications are often disrupted, distribution networks dissolve, and infrastructure is partly or completely destroyed (18, 48, 121).The local health care system itself may have suffered severely. Hospitals may have been looted, and medical staff may have fled or been killed (48, 74). Providers may even face armed factions that want to take control of health care facilities (3).The post-conflict period often remains unstable, as security is lacking and permanent peace appears uncertain (76, 121). Crises overwhelm health systems. When a crisis strikes, reproductive health programs often cannot accommodate the huge numbers of refugees who urgently need services (105). For example, during the Great Lakes crisis in Africa in the early 1990s, one million Rwandans fled their homes in just a few days to surrounding Zaire,Tanzania, Burundi, and Uganda, countries that had limited health services to begin with.The sheer number of people was enough to overwhelm the capacity of any agency (66). Crises come on top of existing problems. Since most conflicts occur in developing countries, where health conditions often are poor, many displaced groups already suffer from ill health, including malnutrition and STIs (18). Moreover, most refugees have few possessions left and cannot afford to buy health care, food, or much else. Conflicts and natural disasters differ in important ways. Most communities are surprised by a natural disaster and have little chance of responding adequately, unless they have emergency plans already in place (26). In contrast, conflicts usually result from worsening political or social conditions, which may provide warning before the situation deteriorates into violence and chaos. Conflicts are unstable, preventing providers from responding effectively. Episodes of tension and violence can punctuate periods of relative calm. In contrast, in a natural disaster the extent of the damage can be determined, and relief workers and providers can respond more quickly (56). Conflicts by definition involve groups fighting each other. One or more of the opposing sides, including the government, may have no regard for the health and welfare of the refugees. Refugee camps are not sanctuaries and have been attacked. Health care staff themselves can be the targets of armed groups. In contrast, a natural disaster often evokes an outpouring of support, and the government of the affected country takes on the responsibility of mounting a response (56). As a result, survivors of natural disasters often receive more aid and support than survivors of armed conflicts. Conflicts force some people to live as refugees for years (110). In contrast, natural disasters displace most people for weeks or months rather than years, although the damage and disruption may take a long time to repair (26).
International Response Improving Helping to speed the transition from relief to recovery, construction workers in the village of Nusa, Subdistrict Lhoknga, Aceh, Indonesia, begin renovating a health clinic destroyed by the December 2004 tsunami. USAID Indonesia is funding the renovation through the Health and Environmental Services Programs. In the last 20 years the international community has paid increasing attention to the reproductive health needs of refugees (80). Leaders of these efforts are UNHCR, the Reproductive Health Response in Conflict Consortium (RHRC Consortium), and the Inter-Agency Working Group on Reproductive Health in Refugee Situations. UN agencies, international nongovernmental organizations (NGOs), and a few donor governments all provide substantial support for reproductive health in crisis situations (72, 80) (see 'International Relief Agencies Provide Reproductive Health Care').
Following a natural disaster or armed conflict, local NGOs and community organizations are often the first to respond.They typically have an advantage over international relief agencies because they know the area and its people (72). Few local reproductive health programs, however, have the mandate or funding to provide full services in a crisis situation. Community-based programs and organizations, including reproductive health care providers, can play important roles in improving response to crisis situations. Community involvement is particularly valuable where many international aid organizations, local NGOs, local self-help groups, district public health systems, and regional administrations are all operating at the same time. Working together, local services and relief agencies can help avoid duplication of services and wasting of resources (73). For example, the Colombian organization PROFAMILIA has provided reproductive health care to refugees from the continuing armed conflict and political violence in that country. PROFAMILIA found that local organizations were already providing services in some communities. As a result, they were able to re-allocate funds to other projects and thus help to assure that, overall, more people received services (73). Community-based organizations also can identify and raise awareness of specific problems, identify appropriate preventive measures, and sometimes take the lead in helping survivors (93). For their part, international NGOs and relief agencies that collaborate with communities can help build the capacity of local institutions and bolster the confidence of their service providers (6). Not Enough Funding An effective and coordinated humanitarian response to an emergency requires substantial sums of money (103). Relief agencies often cannot provide complete reproductive health care for refugees because they lack the funds for this purpose.More and more, donors are allocating money for specific programs and telling relief agencies how they want their money spent (49). Just a few bilateral donors, chiefly the United States and the European Union, provide most of the financial assistance for reproductive health care in crisis situations. Overall levels of funding for humanitarian assistance increased from $2.1 billion ($2.8 billion adjusted for inflation) in 1990 to $5.9 billion in 2000 (49). Since 2000 funding for reproductive health care in crisis situations has declined, however, as donor priorities have shifted to other areas of humanitarian assistance (100). Donor funding tends to focus on a few large-scale emergencies. Often, political priorities within donor countries determine how much funding goes to specific emergencies. In addition, emergencies that are covered extensively by the news media tend to generate more public interest and thus attract more money (49, 100). Sometimes, donors focus on one aspect of reproductive health at the expense of other important aspects. Funding for HIV/AIDS programs in conflict situations has increased in recent years. Some donors see AIDS prevention as separate from other reproductive health care, however, rather than an integral part.The perception that comprehensive reproductive health care in crisis situations is not as important may lead to decreased funding (49, 100). |
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