Make safe abortion accessible for displaced, migrant, and refugee women and girls: Part 3

International Campaign for Women's Right to Safe Abortion

28 August 2015

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Make safe abortion accessible fordisplaced, migrant, and refugee women and girls: Part III

Taking Stock of Reproductive Health in Humanitarian Settings:Key findings from the IAWG on reproductive health in crises 2012-2014 Global EvaluationFull report: findings related to safe abortion:The Minimum Initial Services Package (MISP) for reproductive health, a standard of care in humanitarian emergencies, is a coordinated set of priority activities developed to prevent excess morbidity and mortality, particularly among women and girls, which should be implemented at the onset of an emergency.Progress since 2004 includes:Funding of RH in humanitarian appeals· Between 2009 and 2013, proposals that included all of the components of the MISP and those with partial MISP components increased an average of almost 40% and 2.4%, respectively, per year.· Emergency health and protection proposals that include RH increased at an average of 22% per year between 2002 and 2013.· Humanitarian funding received for RH activities increased, amounting to 2.031 billion USD for 2002-2013, which was 43% of the total request.· Maternal and newborn care was the most funded of all RH components, receiving 56% of requested funds, and the most absolute funds – $684.8 million USD.Services · Country studies (Jordan, DRC, Burkina Faso and South Sudan) demonstrated:· Increased awareness of the MISP standard of care and its implementation.· Expanded access to post-abortion care.· Expanded HIV prevention; particularly regarding prevention of mother-to-child transmission and antiretroviral therapy.· Increased attention to, and documentation of gender-based violence.Capacity · Agencies self-reported growth in institutional capacity to address RH in crises, including through instituting organizational policy frameworks and accountability mechanisms, as well as increases in dedicated staff and funding.


SYRIA/JORDANReproductive health services for Syrian refugees in Zaatri Camp and Irbid City, Jordan:An evaluation of the Minimum Initial Services Package were an estimated 355,493 Syrian refugees living in Jordan with 298,025 registered by the United Nations High Commissioner for Refugees and 57,468 awaiting registration at the time of the assessment.As relief agencies ensured that the specific needs of women and girls were factored into humanitarian health response, they relied on the Jordanian Ministry of Health’s established guidelines on maternal, newborn care and post abortion care; HIV prevention and treatment; and family planning. Abortion in Jordan is legally permitted to preserve a woman’s physical and mental health or because of fetal impairment. Abortion in Syria is legally permitted only to save a woman’s life.

Syrian refugee girls use photography to document life in Zaatari camp


This study assessed among many other aspects:

  • Prevention and management of the consequences of sexual violence.
  • Prevention of excess maternal and neonatal morbidity and mortality including the availability of emergency obstetric and newborn care services and an emergency referral system 24 hours per day 7 days per week; the distribution of clean delivery kits; and community awareness of existing services.
  • The plan for comprehensive RH services, integrated into primary health care, including the collection of existing background data; identification of suitable sites for future service delivery of comprehensive RH services; coordination on ordering RH equipment and supplies based on estimated and observed consumption; and assessing staff capacity to provide comprehensive RH services and planning for training of staff.

Assessment of safe abortion care and post-abortion care were covered within these.Three-quarters of respondents reported that RH Medical Kits were available and adequate for this response. However, none of the five facilities visited provided RH outreach services to women.Measures to prevent sexual violence were insufficient and only one site had the human resource capacity and supplies to provide clinical care for rape survivors.In Zaatri Camp, normal deliveries, basic emergency obstetric care and newborn care functions were conducted at the Gynécologie Sans Frontières maternity clinic. Obstetric emergencies, including post-abortion care, were referred to the Moroccan Field Hospital. A few women in Zaatri Camp described deterioration in the quality of services over time, possibly linked to the large influx of refugees.At two Irbid City referral hospitals services for normal deliveries, basic and comprehensive emergency obstetric care, comprehensive abortion care within the law and post-abortion care were available. Despite free services, women showed reluctance to use them as they were perceived to be “bad” quality due to the lack of privacy and female providers.

DEMOCRATIC REPUBLIC OF CONGOAn evaluation of reproductive health service provision in Masisi Health Zone, North Kivu Province, DRC the mid-1990s, the Democratic Republic of the Congo (DRC) has been afflicted by conflict; violence and displacement continue in the Eastern regions. By mid-2013, approximately 2.7 million people were internally displaced, including more than one million in North Kivu Province.1 Host and displaced communities in North Kivu have suffered serious consequences to their reproductive health (RH) due to high needs as well as variable access to and availability of services.

UNHCR staff member leads 21 refugees from DRC into UgandaPhoto: F Noy/UNHCR

In October 2013, a study of RH services in Masisi Health Zone, North Kivu Province, found that the Reproductive Health Working Group, lead by UNFPA, was functioning well, and the Masisi General Referral Hospital provided a broad range of RH services (clinical care for rape survivors, services for HIV and other STIs, and comprehensive emergency obstetric and newborn care. However, the hospital “qualified” as a post-abortion care and family planning service delivery point, and it lacked adequate supplies for safe blood transfusion.Furthermore, services for safe abortion were not adequately available at any health centres assessed, and availability of adequate post-abortion care, contraceptive services (particularly long-acting methods and emergency contraception), and clinical management of rape among health centres was low.Lastly, many focus group participants were unaware of available RH services in the area. Even when informants knew where and why to access services, significant socio-cultural barriers undermined health-seeking behaviour. Adolescents, particularly unmarried girls, had low knowledge of reproductive health and encountered a variety of impediments to accessing care.Among a long list of recommendations to improve this situation, the report recommended:· Prioritize safe abortion, address barriers to provision of induced abortion and ensure comprehensive abortion care is available to the extent of the law.

SOUTH SUDANAn evaluation of reproductive health service provision in Maban County, Upper Nile State, South Sudan Sudan has been subjected to more than 20 years of war, and since independence in 2011, continues to struggle with internal conflict and displacement. Years of war have decimated the health infrastructure and few reproductive health services are available, particularly in rural areas. In 2012, fighting in the Blue Nile State of Sudan forced thousands of women, men, and children to flee into South Sudan. As of May 2013, 116,000 Sudanese refugees resided in UNHCR-managed camps in Maban County, a remote county in northeast South Sudan.Reproductive health had been neglected since the beginning of the refugee crisis, although progress has been made. An RH Working Group was established in Maban County, and UNFPA and UNHCR signed a memorandum of understanding to scale up implementation of the MISP for RH. UNHCR and implementing partners had developed a roadmap to expand RH service provision.Yet the 2013 assessment found critical gaps in RH service provision at the Maban County hospital. While the hospital met the assessment criteria for a functioning post-abortion care (PAC) service delivery point, it did not adequately provide any other RH services assessed. Services for safe abortion, clinical management of rape, and HIV prevention and treatment were not available at any health facility assessed.

16-year-old refugee tells UNHCR staff member how she was taken in by a foster family. UNHCR is working to find solutions for all unaccompanied minors.Photo: T Irwin/UNHCR

There were significant socio-cultural barriers to accessing services; many were not aware of the few RH services available. Adolescents, particularly unmarried women and girls, had low knowledge of RH and faced additional barriers to accessing care. However, remarkable changes were documented in refugees accessing facility-based delivery services whereas they had previously given birth at home.Among a long list of recommendations to improve this situation, the report recommended:· Implement safe abortion services to the extent of the law and expand post-abortion care service delivery points.

BURKINA FASOAn evaluation of reproductive health service provision for Malian Refugees in the Sahel Administrative Region, Burkina Faso of September 2013, almost 50,000 Malian refugees had fled fighting in their home country and have been granted refugee status by the Government of Burkina Faso. An estimated 60% lived in three consolidated refugee camps – Goudebo, Mentao and SagNioniogo – and up to 20% reside in host villages.The three hospitals assessed – the Sahel regional referral hospital, Soum provincial capital referral hospital, and Oudalan provincial capital referral hospital – provided a range of good quality RH services, including family planning services, post-abortion care, and services for HIV/other STIs. However, only one hospital qualified as a comprehensive emergency obstetric service delivery point and one qualified as a basic emergency obstetric service delivery point.Among the four refugee camp health centres was variable. Only one facility met the criteria as a functioning contraceptive service delivery point, and only one qualified as a functioning post-abortion care service delivery point.Clinical management of rape was not adequately available at any health facilities assessed. None of the hospitals had emergency contraception for rape victims.Health facility assessments found that safe abortion was not available, although one provider at the regional hospital reported that he provided induced abortion during a key informant interview.Drug shortages were a key barrier in all RH areas. The majority of health centres were not authorized to provide assisted vaginal delivery, ART, post-abortion care with misoprostol, or induced abortion. Half were not authorized to provide EC as part of FP. Training gaps regarding permanent FP methods, induced abortion, rape care, and adolescent-friendly services were identified. There were significant socio-cultural barriers to accessing services; many were not aware of the RH services available. Young, unmarried people, particularly young, unmarried women and girls, had low knowledge of RH and faced additional barriers to accessing care.Refugees reported that pregnant women now sought facility-based delivery services whereas they previously gave birth at home, reflecting significant positive changes in this health-seeking behaviour. They reported high satisfaction with maternal health services in the camps and found care better than in their country of origin.Among a long list of recommendations to improve this situation, the report recommended:· Implement safe abortion services to the extent of the law and expand PAC service delivery points.


While it is excellent to read of the improvements reported in maternity care in two of these settings, the failure to achieve this level of change with any other reproductive health service – including and especially safe abortion care and post-abortion care given the high levels of maternal mortality from unsafe abortion – appears to be a deliberate policy choice at a very high level in all sites studied. This deserves more attention.

IRAQ, SYRIA, SOMALIA, NIGERIA, CENTRAL AFRICAN REPUBLICUN: IS and Boko Haram using rape as weapon of war in ‘shocking trend of sexual violence’15 April 2015 General Ban Ki-moon said 2014 was marked by hundreds of accounts of rape, forced marriage and sexual slavery in war-torn countries such as Iraq, Syria, Somalia, Nigeria and Central African Republic.Ban expressed concern over the findings of the UN annual report, which analysed rates of sexual violence against women and girls, men and boys in 19 countries. The report concluded that sexual violence was not incidental, but purposely committed by terror groups.”The confluence of crises wrought by violent extremism has revealed a shocking trend of sexual violence employed as a tactic of terror by radical groups,” Ban said, adding that defeating terror groups around the world is “an essential part of the fight against conflict-related sexual violence.”The report said that there has been an increase in cases of sexual violence since mid-2014, following the insurgence of IS last summer, that resulted in the abduction, rape and sexual enslavement of thousands of girls from the Yazidi community, which mostly bears the brunt of IS’s persecution of non-Muslims and non-Sunnis.

June 2014: Schoolgirls who escaped from Boko Haram kidnappers (AFP)

In a separate report, UNICEF warned that some 800,000 children have been displaced due to violence by Boko Haram. Many of them have been separated from their families and subjected to abuse such as rape and forced marriage. Some of them are also being used by the terrorists as combatants and for suicide bomb missions.More about sexual violence and terror groups:Nigeria Chibok girls’ kidnapping anniversary: Boko Haram still rapes, tortures and kills thousandsIsis: 9-year-old pregnant after being gang-raped by militants could dieIraq: Yazidi girls ‘raped in public’ and sold to Isis fighters before releaseIsis Iraq: UN reports war crimes – genocide, chemical weapons, mutilation, rape and execution

CAMBODIA, HAITI, KENYA, MALAWI, SWAZILAND, TANZANIA, AND ZIMBABWEPrevalence of sexual violence against children and use of social services – seven countries, 2007-2013CDC Morbidity and Mortality Weekly Report, June 5, 2015 / 64(21);565-569 global public-private partnership Together for Girls, collaborated with Cambodia, Haiti, Kenya, Malawi, Swaziland, Tanzania, and Zimbabwe to conduct national household surveys of children and youthaged 13-24 years to measure the extent of violence against children. The lifetime prevalence of experiencing any form of sexual violence in childhood ranged from 4.4% among females in Cambodia to 37.6% among females in Swaziland, with prevalence in most countries greater than 25.0%. In most countries surveyed, the proportion of victims that received services, including health and child protective services, was ≤10.0%. Both prevention and response strategies for sexual violence are needed.

MALAWIMalawi: new study reveals violence against children widespreadUNICEF Eastern and Southern Africa in Malawi has become a social norm. A March 2015 study found that 60% of children tell someone about their experience of abuse, usually a friend or family member; however, less than 10% ever receive professional services.A majority of boys do not report the physical violence they suffer because they do not view it as a problem. On the other hand, one-third of 13-17 year old girls who did not report the physical violence they experienced did not so because they thought it was their fault. 42% of young women believed it was acceptable for a husband to beat his wife under certain circumstances and 41% believed a woman should tolerate violence to keep the family together.In Malawi, there are 300 Community Victim Support Units, 6,000 Community based Childcare Centres and 2500 children corners. With funding from DFID, UNICEF-Malawi supports initiatives such as Police Victim Support Units, Community Victim Support Units, Child Helpline and One-Stop-Centres – all aimed at ensuring that children are protected from violence, abuse, exploitation and neglect.

CAMBODIARoyal Government of Cambodia launches report of Violence against Children Survey and pledges core commitments for action research found that over half of Cambodian children had experienced at least one form of violence before the age of 18. Roughly a quarter were emotionally abused and 5% experienced some form of sexual abuse prior to age 18. The children were usually physically abused by people they knew and trust: parents (especially mothers) and teachers (especially male teachers). Neighbours, friends, romantic partners and family members were the most common perpetrators of sexual abuse, not strangers.As a result of this survey, 13 Ministries and governmental agencies have jointly agreed on a set of core commitments which will form the basis of a costed national multi-sectoral action plan to prevent and respond to violence against children in Cambodia.The UN Secretary-General’s Special Representative on Violence against Children, Marta Santos Pais, said six steps are key for governments to eliminate violence against children:

  • develop a national, child-centered, integrated, multidisciplinary and time-bound strategy to address violence against children;
  • enact an explicit legal ban on violence against children backed by effective enforcement;
  • increase efforts to make violence against children socially unacceptable;
  • ensure the social inclusion of girls and boys who are at special risk in the prevention and response to violence against children;
  • build or enhance strong data systems and sound evidence to prevent and address violence against children; and
  • join with other governments to ensure the protection of children from violence is at the heart of the post-2015 international development agenda.

Santos Pais emphasized that violence against children also has far-reaching costs for society:”[It diverts] billions of dollars from social spending, slowing economic development and eroding human and social capital. The economic returns from investment in early child development are now well established, yet violence severely limits young children from reaching their full potential resulting in huge losses to society. Ending violence against children is an ethical imperative, but it also makes economic sense as the figures on the costs of violence show.”


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