Conference Proceedings 2000
Findings On Reproductive Health Of Refugees and Displaced Populations
Washington DC, December 5-6, 2000
Co-hosted by InterAction and The Global Health Council
Conference 2000 Highlights
The Reproductive Health Response in Conflict Consortium's Research Conference 2000: Findings on Reproductive Health of Refugees and Displaced Populations was convened as a forum for service providers, researchers, policy makers and donors to share program findings garnered over the last several years. These data must now be used to improve ongoing programs and initiate new ones. Increasing coverage of comprehensive reproductive health services is critical. Agencies questioning the need for reproductive health services can consult the findings presented concerning the heightened risk of refugees for sexually transmitted diseases (STDs), including HIV, and sexual and gender-based violence, their poor pregnancy outcomes, and their expressed desire for reproductive health services. [In this article, the term refugee is used for disaster-affected populations, which may include internally displaced persons, refugees or returned refugees.] Projects should be carefully planned, adapting interventions that have proven to work elsewhere. When new interventions are tested, planners must ensure that there is a strong evidence-based likelihood of success. The following three needs are especially crucial to the ability of a war-impacted society to rebuild and flourish:
- address the reproductive health needs of adolescents specifically;
- stop HIV transmission; and
- embark on a multi-sectoral offensive against sexual and gender-based violence.
In 1993, the Women's Commission for Refugee Women and Children found few or no reproductive health services offered in eight refugee sites it visited. Reproductive health for refugees was a low priority for most organizations; and the assessment team found little interest or awareness among non governmental organizations (NGOs) or donors. Many relief agency staff assumed that refugees did not want reproductive health services, or that these services would be culturally inappropriate. Data were lacking on refugees' stated needs and priorities, the medical and public health impact of providing reproductive health services, and on how these services could be appropriately offered to refugees and displaced people.
The intervening years have brought a substantial change in the attention given to reproductive health in refugee settings. Propelled by the Program of Action of the 1994 International Conference on Population and Development in Cairo and the Platform for Action of the 1995 Fourth World Conference on Women in Beijing, by growing recognition of the human rights and health relevance of reproductive health services, and by UN and NGO agencies' willingness to work together toward a common end, many more groups are now active in the reproductive health service, research and policy areas than in 1993.
Efforts to develop quality programs have been hampered by the lack of
published reports specific to war-affected and displaced populations.
While it is important to utilize the findings and lessons learned from
the development field, an analysis of data from a specific literature review
offers some conclusions about the effects of displacement on a person's
reproductive health -- understanding these effects is essential to the
initiation of effective interventions. Most of the data used in these
analyses were derived from stable camp populations.
- The data indicate that fertility, family planning and Maternal and Newborn Care issues are more influenced by factors similar to those in settled populations than by the fact of displacement. For example, refugee demand for family planning is affected by personal knowledge, attitudes, practices and the availability of services.
- Similarly, poor pregnancy outcomes are common in refugee settings, but not necessarily more common than in settled populations of similar socioeconomic and cultural backgrounds. In fact, refugees in camps may have an advantage, since emergency obstetric services are likely to be more accessible than in their homeland.
- While data suggest little effect of displacement on reproduction, evidence does indicate that displacement increases the transmission of STDs, including HIV. It is important to recognize that transmission moves from a higher prevalence population to one with lower prevalence -- not necessarily from the refugees to the local residents.
- The incidence of rape during conflict is well documented. The literature demonstrates that for women, exposure to armed men -- soldiers, militias, border guards, etc -- is a major risk factor for rape.
- Other forms of gender-based violence, such as coercion of sex for food and domestic violence, are common among the war-affected; but one is unable to say whether they are more common than among the settled due to a lack of substantive data in either settled or displaced settings. One can surmise that sexual and gender-based violence is at least as, and probably more, common among war-affected people as a result of social and economic disruption.
An understanding of the effects of displacement, along with an awareness
of reproductive rights, demands delivery of good quality reproductive health
services for refugees and other displaced persons. This is not an
argument for the prioritizing of resources to meet reproductive health
needs over the delivery of other basic health services. Rather, we
are obliged to build on what we know and to adapt programs to respond to
all of the demonstrated needs of war-affected persons.
Seven years after the Women's Commission assessment, we ask "Have things
improved?" One study revealed that most US-based international NGOs
supporting or providing services in the health sector in refugee settings
include some component of reproductive health. This finding is corroborated
by a Johns Hopkins University/Centers for Disease Control and Prevention
study which found at least three methods of family planning available in
51 of 52 refugee camps surveyed in the post-emergency phase. However,
it is critical to note that this does not reflect the situation in all
camps or in new and chronic emergency settings.
Conference 2000 played a vital role in presenting new data from
programs in the field that we can now use to improve and/or initiate quality
reproductive health interventions. Some 250 people from 27 countries
attended, an indication in itself of the extraordinary interest and desire
for information in this evolving field. We heard from colleagues
presenting the results of their work in approximately 40 settings around
the world. Participants shared new ideas and renewed their commitment
to provide good quality reproductive health services to refugees and other
displaced populations.
Sharing ideas and information is, however, just a first step in improving services. Now, it is essential that we take this new knowledge and apply it in the real world. For example, we no longer need worry that talking about reproductive health is culturally inappropriate. Several studies showed that if, rather than assuming we know what refugees need, we ask them, they will discuss their interests and concerns regarding reproductive health. Other findings show that refugees are fully capable and highly interested in participating in the design, monitoring and evaluation of reproductive health programs in their communities. Service providers should be trained in counseling to help individuals make informed decisions with regards to Maternal and Newborn Care, family planning, STDs/HIV/AIDS, and sexual and gender-based violence. Effective community outreach and participation has proven to be vital to the success of programs from the inception of an intervention.
From the presentations, we also see that reproductive health is for everyone, not just for women or married couples, but for men, women and adolescents. Men should be involved in education and decision-making. A need for adolescent-specific programming has been clearly identified. The transition from child to sexual adult is the defining characteristic of adolescents; however, adolescents represent a traditionally ignored population that is at high risk of reproductive health problems due to a lack of knowledge. They also represent the future leaders of their communities. If they are uninformed and unhealthy, the future will be bleak. Programmers concerned about the sensitivity of providing information and services to young people can reference presentations on the reproductive health status of adolescents and successful community-accepted approaches for reaching these groups.
The findings demonstrate that appropriate interventions can improve the reproductive health status of refugees. Good quality services must be provided and integrated with primary health care. We must collect reliable data. As several studies noted, we need to standardize definitions and procedures in order to do this. Finally, we must reiterate the need to use the data to improve programs, as well as to document and publish findings so others have access to valid information.
The information presented at the conference has important implications for reproductive health policies and programs:
- Adolescent-specific programming is crucial to enabling war-affected societies to rebuild for the future.
- War-affected populations are disproportionately at risk for STDs, including HIV, and for sexual and gender-based violence. More attention must be focused on these issues.
- To reduce women's risk of death from unsafe abortion, programs must provide comprehensive post-abortion care, as well as family planning to prevent unwanted pregnancy.
- Collection of data, including demographic information, for decision-making must be included in project plans.
- Projects must be planned carefully, using evidence to make decisions and select interventions that have demonstrated success.
- Multi-year funding for programs is essential for sustainability, given that war-affected populations often remain displaced for years at a time.
- Collaborative, inter-agency efforts, including coordination with host governments, yield far-reaching results.
- Internally displaced persons lack an internationally recognized status, which adds to their neglect and the dearth of services available to them. Programs must be extended to these populations.
Conference 2000 represents an important milestone in the reproductive health for refugees movement as an occasion for practitioners to share applied research, program findings and data to improve reproductive health programs serving populations in crisis. The interest in and success of Conference 2000 illustrate the importance for continued research and dialogue to support improved reproductive health among war-affected populations around the world.
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