RHO : Topics : Refugee Reproductive Health

Key Issues

This section provides summaries of research issues in reproductive health for refugees, internally displaced people, and other populations caught up in situations of conflict. Click article references to read article abstracts from the Annotated Bibliography. Also see the Program Examples for more information.

Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.

Impact of displacement and conflict on women's health

When they flee their homes to escape persecution or conflict, both the physical and mental health of displaced persons suffer. Refugees lose their material possessions, a regular income, and access to routine preventive medical care, such as immunizations and prenatal care, as well as to curative care (Gardner and Blackburn, 1996). Most become dependent on humanitarian aid for minimal food, shelter, and health care. At the same time, displaced women are subjected to high levels of sexual and gender-based violence by combatants, authorities, and other refugees because of disruptions in the social systems that support and protect women, including family ties, social norms governing sexual behavior, and law enforcement systems.

The results are many and vary by situation (McGinn, 2000). Crowded, unsanitary conditions, the mixing of different populations, and risky sexual behavior can increase the risk of infectious disease transmission, including HIV/AIDS and other sexually transmitted infections (STIs) among displaced populations (Holmes, 2001; Kalpieni and Oppong, 1998, Khaw et al., 2000). However, new evidence from four settings in Africa suggests that although the transmission risks are higher, that the actual conditions of isolation and reduced mobility caused by conflict may keep the HIV prevalence lower than the surrounding communities (Spiegel 2003). Poor nutrition, untreated illnesses such as malaria and anemia, and limited health care contribute to increased rates of pregnancy complications, miscarriages, and maternal and perinatal mortality and morbidity of displaced populations (Jamieson, 2000; Palmer, 1998; Carballo et al., 1996). Current evidence suggests that these risk factors may contribute to higher levels of morbidity and mortality in early stages of migration but that these risks tend to decline after women begin to benefit from the dedicated services in stable refugee settings (Bartlett et al., 2002). Services provided by relief organizations are often of higher quality, more accessible and available, and result in better pregnancy outcomes than those in the war-torn country of origin or indeed in poor surrounding host communities (Bartlett et al., 2002; Hynes et al., 2002 ).

However, some reproductive health services, such as safe abortion care, are rarely provided in complex emergencies and refugee situations. During the war in the Balkans, where abortion is legal and demand for family planning was low, abortion rates in Sarajevo increased to the point that there were two abortions for every pregnancy taken to term. In light of the conditions under which these pregnancy terminations were conducted and the lack of necessary equipment available to the health staff, the implications for the health of the women concerned were considerable (Carballo et al., 1996). Of 43 displaced Burmese women living in Thailand who were interviewed after seeking care for abortion complications, 28 percent reported having had a previous abortion experience (Belton, 2003). Two-thirds of the 43 women induced their own abortions using cleaning agents, herbal medicines, sticks, and pummeling of the pelvic area, which often resulted in gynecological morbidity. Recognizing the heightened level of sexual violence and gender discrimination in complex emergency settings, comprehensive reproductive health care requires that health professionals are trained and equipped to provide safe abortion for indications allowed under the law and postabortion care for war-affected populations.

Gender biases may create or exacerbate problems facing the displaced, especially women and girls. Decades of conflict in Afghanistan weakened women's rights and their access to resources and services (Wali et al., 1999). Relief agencies may increase women's vulnerability to sexual violence by placing latrines in poorly lit or isolated areas, while the refugee men controlling the distribution of food and shelter may require sexual favors for these essentials (Marshall, 1995). While relief officials who are sensitive to gender issues can help women overcome harmful aspects of traditional gender roles and make social and economic gains (Walker, 1995), changing relief workers' attitudes toward women's issues is a slow process (Berthiaume, 1995). Reproductive health problems are but one aspect of the harm caused by sexual and gender-based violence. Given the complexity of this issue and the need for broad intersectoral response, we will address gender-based violence in a separate section below.

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Assessing the reproductive health needs of displaced populations

Research shows that the reproductive health needs of refugees vary, depending, in part, on the health status and attitudes of the population before the conflict broke out and, in part, on conditions created by the conflict, such as malnutrition and sexual violence (Busza and Lush, 1999). This makes it essential to conduct a thorough and systematic needs assessment essential before expanding reproductive health services beyond minimum emergency interventions. In addition to gathering published information on the prior health status of the refugee population, relief workers can conduct rapid assessments of refugees' current needs. Interviews with service providers and refugee leaders, together with group discussions and community surveys, can quickly compile information on attitudes toward reproductive health practices, local medical practices, needed services, and the degree to which current services fill those needs (Palmer, 1999; RHR Consortium, 1997). Ongoing monitoring of HIV levels also may require creative approaches (Salama and Dondero, 2001). Community input into needs assessments is essential to provide a complete picture of refugee reproductive health problems, to understand the role of culture and religion, and to shed light on refugees' own priorities.

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Designing reproductive health services for refugees

A consensus has formed that refugees living in stable situations ideally should be offered comprehensive reproductive health services that address safe motherhood, HIV/AIDS, family planning, and violence against women (Davidson and Lush, 1995; PATH/Outlook, 1999; UNHCR 1999). Achieving the ideal of comprehensive services has proven difficult, however. Relief agencies face many challenges, including a lack of human resources, supplies, and infrastructure; rapid staff turnover; short-term funding; and the conflicting mandates of various relief organizations (Poore, 1995; Palmer, 1998; Krause et al., 2000). Refugees' own attitudes and culture also may pose an obstacle to comprehensive programming (Morrison, 2000). Refugee reproductive health programs have found that there is no one ideal model for service delivery in refugee settings; services must be tailored to fit the local situation, including available resources, refugee settlement patterns and culture, and prospects for resolving the refugees' situation (RHR Consortium, 1998). It also is important that interventions are sensitive to gender issues and do not marginalize women any further (Byrne and Baden, 1995). Successful programs, however, have been able to raise reproductive health outcomes among refugees to levels higher than either the host country or the country of origin (Hynes et al., 2002). For insights into offering health services to refugees, see the program examples from Sri Lanka and Sudan.

When comprehensive services are unrealistic, reproductive health programs must make difficult choices and prioritize services. Considerable progress has been made in designing and implementing interventions that address single health issues. Projects have focused on reducing the transmission of HIV/AIDS (Benjamin, 1996; Mayaud, 2001; Nersesian and Brady, 1995; UNAIDS, 1997), providing adolescents with reproductive health information and services (Ecker, 1998; Waszak and Tucker, 1995), and reducing violence against women (see following section). Helping refugees make a smooth transition when they return home remains a challenge (Project Counseling Services, 1999).

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Sexual and gender-based violence

The breakdown of law and order, social norms, and family structures leads to high levels of violence against women during complex emergencies but the type of violence varies by setting (Ward, 2002; Swiss et al., 1998). Rape and forced pregnancy have been used as deliberate military tactics to terrorize civilian populations during ethnic conflicts (Human Rights Watch, 1996; Reis, 2002; Human Rights Watch, 2000; Shanks et al., 2001; Bjorken, 2003). Male authorities, including police, border guards, refugee leaders, and local relief officials, may demand sexual favors from women in return for safe crossing, food, shelter, and protection. A survey of Burundian women in a Tanzanian camp found that 26 percent had experienced sexual violence since becoming refugees (Nduna and Goodyear, 1998). In settings such as Tanzania and Kosovo, refugee women faced an increased risk of domestic violence as male partners reacted to the stress of the situation (Mabuwa, 2000; Palmer, 2002). In contrast, a study conducted in East Timor found that levels of violence by intimate partners did not significantly change between the time of conflict and the post-conflict period. However, incidents of violence by perpetrators outside the family were high during the crisis: 27.1 percent of women surveyed reported at least one incident of physical violence and 25 percent reported at least one incident of sexual violence. The rates of violence fell significantly after the crisis with a 75.8 percent decrease (P<0.001) in physical assault, and 57.1 percent reported decrease (P=0.046) in sexual assault (Hynes et al., 2003). Victims of violence suffer from unwanted pregnancies, STI infections, physical injuries, mental trauma, and social stigma (Donovan, 2002; Kozaric-Kovacic et al., 1995).

Gender-based violence prevention and response require a multisectoral response from relief agencies. Figure 1 describes all the actors and sectors that need to coordinate their efforts to effectively prevent and respond to gender-based violence. A concerted effort to reduce violence involves many elements, such as designing the physical layout of the camp and the distribution of food with women in mind, training camp guards, and consistently punishing assailants (UNHCR, 2001; Ward, 2002; Vann, 2002). Trained health care providers can treat victims' injuries, provide emergency contraception, offer psychological counseling, and link women to legal and protective services (Goodyear and McGinn, 1998; Swiss and Giller, 1993; WHO and UNHCR, 2002). (Also see the discussion of violence against women in RHO's Gender and Sexual Health section). In some regions, programs to discourage female genital mutilation (FGM) also may be needed (see RHO's Harmful Health Practices section). Preventing violence and reintegrating survivors back into the community, however, requires changing the attitudes of the refugee community, camp authorities, and health care providers, so that they recognize that violence against women is reprehensible, unacceptable, and prevalent (Nduna and Rude, 1998).

Prevention and response is not complete without attention to justice for which a human rights framework and access to legal representation are useful (Steinitz, 2001). In 2000, the United Nations Security Council Adopted the historic resolution 1325, which “calls upon all parties to armed conflict to take specific measures to protect women and girls from gender-based violence, particularly rape and sexual violence.” For insights on how to reduce violence at refugee camps and help its victims, see the program example from Tanzania.

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Guidelines and tools

Over the past decade, refugee relief and reproductive health organizations have collaborated on new strategies to meet the reproductive health needs of displaced populations. Two groups, both dating from 1995, have led the way in producing and field-testing the technical materials needed to guide the implementation of reproductive health services for refugees. The Inter-Agency Working Group on Reproductive Health in Refugee Situations has drawn on the experience of more than 50 United Nations, governmental, and nongovernmental agencies to create a basic field manual for reproductive health interventions in refugee settings (UNHCR, 1999), which has been complemented by a guide for managers (WHO, 2000). The Reproductive Health Response in Conflict Consortium (formerly the Reproductive Health for Refugees Consortium) is a smaller group of seven organizations that have pooled their public health, field service, and public advocacy expertise to lobby for reproductive health care for war-affected populations. Member organizations have developed and field tested technical materials to improve needs assessment (RHR Consortium, 1997), training (RHRCC, 2004; CARE, 2002), HIV prevention and care (IRC, 2003), and logistics (Dixon, 1999) in refugee settings. United Nations relief and health agencies also have produced guidelines and training materials on a variety of refugee health issues, including mental health (WHO, 1996), sexual violence (UNHCR, 1991; UNHCR, 2003; WHO, 2001), HIV/AIDS (UNAIDS, 1996), and the special needs of adolescents (UNHCR and WCRWC, 2002).

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