Each year, the number of people affected by humanitarian emergencies continues to increase. Addressing the sexual and reproductive health needs of people affected by such emergencies is a global issue of critical importance. The respect, protection and fulfilment of sexual and reproductive rights of those affected by humanitarian crisis requires evidence and human rights-based action that informs policies, standards, programme design, implementation and practice.

In 2008, (Sexual and) Reproductive Health Matters (S)RHM) dedicated a journal issue to the theme of conflict and crises – a well-timed issue that shed light on the devastating implications of conflict and crises on women and girls, highlighted ongoing response efforts and identified the unmet SRHR needs of populations in these fragile settings. 10 years later, the 2018 issue titled ‘Humanitarian Crisis: advancing sexual and reproductive health and rights’ drew attention to advances made, shared best practices and discussed challenges in service implementation in crises and protracted humanitarian settings.

SRHM is committed to publishing research and evidence, policy analysis, briefs and commentaries with the vision and mission of contributing to the advancement of sexual and reproductive health and rights of people affected by humanitarian crisis.

Please see our highlighted papers below on programme models responding to demand for reproductive health services in crisis situation in Yemen; historical, social, and political contexts of maternal mortality among Rohingya refugees in Bangladesh; the effects of conflict and displacement on violence against adolescent girls in South Sudan, the impact of US policy decision recognizing domestic violence as a basis for asylum; and more.

When political solutions for acute conflict in Yemen seem distant, demand for reproductive health services is immediate: a programme model for resilient family planning and post-abortion care services
Catherine N Morris, Kate Lopes, Meghan C Gallagher, et al.

The political situation in Yemen has been precarious since 2011 when popular protest broke out amid the Arab Spring, calling for President Saleh to step down. In March 2015, a Houthi insurgency took control of the capital, Sana’a and ignited a civil conflict that is now characterised by foreign political and military involvement. Since 2015, health facilities have been a primary target for airstrikes and bombing. Seaports have been blockaded barring the delivery of essential medicines and supplies, contributing to the near collapse of an already fragile health system. Since 2012, Save the Children (SC) has been implementing a Family Planning (FP) and Post-abortion Care (PAC) programme in two governorates heavily affected by the conflict. Despite the risks associated with the conflict, there remains a strong demand for SC’s FP and PAC services. Ongoing programmatic support and capacity strengthening have allowed quality FP and PAC services to continue for Yemenis even when humanitarian access is impeded. Since the onset of conflict in March 2015, 16 facilities provided services to 43,218 new FP clients (with 23% accepting a long-acting method) and treated 3627 women with PAC. Over 93% of FP clients would recommend FP services at the facility to a friend or family member. Findings support growing evidence that women affected by conflict require family planning services, and that demand does not decline as long as quality services remain accessible. An adaptable reproductive health programme model that embraces innovative approaches is necessary for establishing services and maintaining quality during acute conflict.

Mortality in Rohingya refugee camps in Bangladesh: historical, social, and political context
Parveen K Parmar, Rowen O Jin, Meredith Walsh, et al.

Seventy-seven maternal deaths occurred between September 2017 and August 2018 in the Rohingya refugee camps in Ukhia and Teknaf Upazilas, Cox’s Bazar District, Bangladesh. Behind every one of these lives lost is a complex narrative of historical, social, and political forces, which provide an important context for reproductive health programming in Rohingya camps. Rohingya women and girls have experienced human rights violations in Myanmar for decades, including government-sponsored sexual violence and population control efforts. An extension of nationalist, anti-Rohingya policies, the attacks of 2017 resulted in the rape and murder of an unknown number of women. The socio-cultural context among Rohingya and Bangladeshi host communities limits provision of reproductive health services in the refugee camps, as does a lack of legal status and continued restrictions on movement. In this review, the historical, political, and social contexts have been overlaid below on the Three Delays Model, a conceptual framework used to understand the determinants of maternal mortality. Attempts to improve maternal mortality among Rohingya women and girls in the refugee camps in Bangladesh should take into account these complex historical, social and political factors in order to reduce maternal mortality.

The effects of conflict and displacement on violence against adolescent girls in South Sudan: the case of adolescent girls in the Protection of Civilian sites in Juba
Maureen Murphy, Jeffrey B. Bingenheimer, Junior Ovince, et al.

There is a paucity of data on violence against women and girls (VAWG) during times of conflict in general and even less information specifically on violence against adolescent girls. Based on secondary analysis of a larger study on VAWG in South Sudan, this article highlights the specific experience of conflict-affected adolescent girls resident in the Juba Protection of Civilian sites. Quantitative data from a cross-sectional household survey shows that the prevalence of non-partner sexual violence (NPSV) (26.5%) and intimate partner violence (IPV) (43.1% of partnered respondents) was high among a cohort of girls who were of adolescent age during the 2013 crisis. Direct exposure to armed conflict increased the odds of respondents experiencing NPSV (AOR: 7.21; 95%CI: 3.94–13.17) and IPV (AOR: 2.37; 95%CI: 1.07–5.29). Quantitative and qualitative data also showed that patriarchal practices, compounded by poverty and unequal power relationships within the home, remain some of the primary drivers of VAWG even in conflict-affected settings. Prevention activities need to consider these wider underlying drivers of VAWG during times of armed conflict, as they remain key factors affecting violence against adolescent girls.

Impact of a US asylum decision on sexual and reproductive health and rights: a call to action for health and legal professionals
Rose L Molina, Sabrineh Ardalan & Jennifer Scott

The political environment and legal decisions in the United States (US) can impact lives around the globe. A recent attack on women’s sexual and reproductive health and rights (SRHR) occurred in June 2018 when former US Attorney General Jeff Sessions reversed a decision (Matter of A-R-C-G-) in which domestic violence was recognised as a basis for asylum.1 Matter of A-R-C-G-, 26 I&N Dec. 388 (BIA 2014). Available from: https://www.justice.gov/sites/default/files/eoir/legacy/2014/08/26/3811.pdf
Domestic violence is one form of gender-based violence, encompassing sexual and physical assault and reproductive coercion, which disproportionately harm women. Given the global epidemic of gender-based violence, we argue that Sessions’ reversal of this decision and efforts to rollback protection for domestic violence survivors could have far-reaching impacts on women around the world. This article will provide some recommendations for medical and legal professionals in response to this affront on SRHR.

Advancing SRHR in humanitarian crises

Full issue published 2017

Editorial: Care with dignity in humanitarian crises: ensuring sexual and reproductive health and rights of displaced populations
Monica Adhiambo Onyango & Shirin Heidari

Sea-change in reproductive health in emergencies: how systemic improvements to address the MISP were achieved
Sandra K. Krause, Sarah K. Chynoweth & Mihoko Tanabe

The Minimum Initial Services Package (MISP) for reproductive health has been the minimum standard for reproductive health service provision in humanitarian emergencies since 1995. Assessments of acute humanitarian settings in 2004 and 2005 revealed few MISP services in place and low knowledge of the MISP among humanitarian responders. Just 10 years later, assessments of humanitarian settings in 2013 and 2015 found largely consistent availability of MISP services and high awareness of the MISP as a standard among responders. We describe the multi-pronged strategy undertaken by the Women’s Refugee Commission and other Inter-agency Working Group on Reproductive Health in Crises (IAWG) member agencies to effect systemic improvements in the availability of the MISP at the onset of humanitarian responses. We find that investments in fact-finding missions, awareness-raising, capacity development, policy harmonisation, targeted funding, emergency risk management, and community resilience-building have been critical to facilitating a sea-change in reproductive health responses in acute, large-scale emergencies. Efforts were underpinned by collaborative, inter-agency partnerships in which organisations were committed to working together to achieve shared goals. The strategies, activities, and achievements contain valuable lessons for the health sector, including reproductive health, and other sectors seeking to better integrate emerging or marginalised issues into humanitarian action.

The 2018 Inter-agency field manual on reproductive health in humanitarian settings: revising the global standards
Angel M. Foster, Dabney P. Evans, Melissa Garcia, et al.

Since the 1990s, the Inter-agency field manual on reproductive health in humanitarian settings (IAFM) has provided authoritative guidance on reproductive health service provision during different phases of complex humanitarian emergencies. In 2018, the Inter-Agency Working Group on Reproductive Health in Crises will release a new edition of this global resource. In this article, we describe the collaborative and inter-sectoral revision process and highlight major changes in the 2018 IAFM. Key revisions to the manual include repositioning unintended pregnancy prevention within and explicitly incorporating safe abortion care into the Minimum Initial Service Package (MISP) chapter, which outlines a set of priority activities to be implemented at the outset of a humanitarian crisis; stronger guidance on the transition from the MISP to comprehensive sexual and reproductive health services; and the addition of a logistics chapter. In addition, the IAFM now places greater and more consistent emphasis on human rights principles and obligations, gender-based violence, and the linkages between maternal and newborn health, and incorporates a diverse range of field examples. We conclude this article with an outline of plans for releasing the 2018 IAFM and facilitating uptake by those working in refugee, crisis, conflict, and emergency settings.

Humanitarian response to reproductive and sexual health needs in a disaster: the Nepal Earthquake 2015 case study
Pushpa Chaudhary, Giulia Vallese, Meera Thapa, et al.

This case study describes the health response provided by the Ministry of Health of Nepal with support from UN agencies and several other organisations, to the 1.4 million women and adolescent girls affected by the major earthquake that struck Nepal in April 2015. After a post-disaster needs assessment, the response was provided to cater for the identified sexual and reproductive health (RH) needs, following the guidance of the Minimum Initial Service Package for RH developed by the global Inter-Agency Working Group. We describe the initiatives implemented to resume RH services: the distribution of medical camp kits, the deployment of nurses with birth attendance skills, the organisation of outreach RH camps, the provision of emergency RH kits and midwifery kits to health facilities and the psychosocial counselling support provided to maternity health workers. We also describe how shelter and transition homes were established for pregnant and post-partum mothers and their newborns, the distribution of dignity kits, of motivational kits for affected women and girls and female community health volunteers. We report on the establishment of female-friendly spaces near health facilities to offer a multisectoral response to gender-based violence, the setting up of adolescent-friendly service corners in outreach RH camps, the development of a menstrual health and hygiene management programme and the linkages established between adolescent-friendly information corners of schools and adolescent-friendly service centres in health facilities. Finally, we outline the gaps, challenges and lessons learned and suggest recommendations for preparedness and response interventions for future disasters.

Protecting safe abortion in humanitarian settings: overcoming legal and policy barriers
Akila Radhakrishnan, Elena Sarver & Grant Shubin

Women and girls are increasingly the direct and targeted victims of armed conflict and studies show that they are disproportionately and differentially affected. However, humanitarian laws, policies, and protocols have yet to be meaningfully interpreted and adapted to respond to their specific needs, including to sexual and reproductive health services and rights. In particular, safe abortion services are routinely omitted from sexual and reproductive health services in humanitarian settings for a variety of reasons, including improper deference to national law, the disproportionate influence of restrictive funding policies, and the failure to treat abortion as medical care. However, properly construed, abortion services fall within the purview of the universal and non-derogable protections granted under international humanitarian and human rights law. This commentary considers the protections of international humanitarian law and explains how abortion services fall within a category of protected medical care. It then outlines contemporary challenges affecting the realisation of these rights. Finally, it proposes a unification of current approaches through the use of international humanitarian law to ensure comprehensive care for those affected by armed conflict.

Uptake of postabortion care services and acceptance of postabortion contraception in Puntland, Somalia
Kingsley Chukwumalu, Meghan C. Gallagher, Sabine Baunach, et al.

Unsafe abortion is responsible for at least 9% of all maternal deaths worldwide; however, in humanitarian emergencies where health systems are weak and reproductive health services are often unavailable or disrupted, this figure is higher. In Puntland, Somalia, Save the Children International (SCI) implemented postabortion care (PAC) services to address the issue of high maternal morbidity and mortality due to unsafe abortion. Abortion is explicitly permitted by Somali law to save the life of a woman, but remains a sensitive topic due to religious and social conservatism that exists in the region. Using a multipronged approach focusing on capacity building, assurance of supplies and infrastructure, and community collaboration and mobilisation, the demand for PAC services increased as did the proportion of women who adopted a method of family planning post-abortion. From January 2013 to December 2015, a total of 1111 clients received PAC services at the four SCI-supported health facilities. The number of PAC clients increased from a monthly average of 20 in 2013 to 38 in 2015. During the same period, 98% (1090) of PAC clients were counselled for postabortion contraception, of which 955 (88%) accepted a contraceptive method before leaving the facility, with 30% opting for long-acting reversible contraception. These results show that comprehensive PAC services can be implemented in politically unstable, culturally conservative settings where abortion and modern contraception are sensitive and stigmatised matters among communities, health workers, and policy makers. However, like all humanitarian settings, large unmet needs exist for PAC services in Somalia.

“Without this program, women can lose their lives”: migrant women’s experiences with the Safe Abortion Referral Programme in Chiang Mai, Thailand
Ellen Tousaw, Ra Khin La, Grady Arnott, et al.

For displaced and migrant women in northern Thailand, access to health care is often limited, unwanted pregnancy is common, and unsafe abortion is a major contributor to maternal death and disability. Based on a pilot project and situational analysis research, in 2015 a multinational team introduced the Safe Abortion Referral Programme (SARP) in Chiang Mai, Thailand, to reduce the socio-linguistic, economic, documentation, and transportation barriers women from Burma face in accessing safe and legal abortion care in Thailand. Our qualitative study documented the experiences of women with unwanted pregnancies who accessed the SARP in order to inform programme improvement and expansion. We conducted 22 in-depth, in-person interviews and analysed them for content and themes using deductive and inductive techniques. Women were overwhelmingly positive about their experiences using the SARP. They reported lack of costs, friendly programme staff, accompaniment to and interpretation at the providing facility, and safety of services as key features. Financial and legal circumstances shaped access to the programme and women learned about the SARP through word-of-mouth and community workshops. After accessing the SARP and receiving support, women became community advocates for reproductive health. Efforts to expand the programme and raise awareness in migrant communities appear warranted. Our findings suggest that referral programmes for safe and legal abortion can be successful in settings with large displaced and migrant populations. Identifying ways to work within legal constraints to expand access to safe services has the potential to reduce harm from unsafe abortion even in humanitarian settings.

Programme potential for the prevention of and response to sexual violence among female refugees: a literature review
Gianna Maxi Leila Robbers & Alison Morgan

Continuing international conflict has resulted in several million people seeking asylum in other countries each year, over half of whom are women. Their reception and security in overburdened camps, combined with limited information and protection, increases their risk and exposure to sexual violence (SV). This literature review explores the opportunities to address SV against female refugees, with a particular focus on low-resource settings. A systematic literature review of articles published between 2000 and 2016 was conducted following PRISMA guidelines. Databases including Medline (Ovid), PubMed, Scopus, PsychINFO, CINAHL and the Cochrane Library. Grey literature from key refugee websites were searched. Studies were reviewed for quality and analysed according to the framework outlined in the UNHCR Guidelines on Prevention and Response of Sexual Violence against Refugees. Twenty-nine studies met the inclusion criteria, of which 7 studies addressed prevention, 14 studies response and 8 addressed both. There are limited numbers of rigorously evaluated SV prevention and response interventions available, especially in the context of displacement. However, emerging evidence shows that placing a stronger emphasis on programmes in the category of engagement/participation and training/education has the potential to target underlying causes of SV. SV against female refugees is caused by factors including lack of information and gender inequality. This review suggests that SV interventions that engage community members in their design and delivery, address harmful gender norms through education and advocacy, and facilitate strong cooperation between stakeholders, could maximise the efficient use of limited resources.

Sexual violence against men and boys in conflict and forced displacement: implications for the health sector
Sarah K Chynoweth, Julie Freccero & Heleen Touquet

Sexual violence against men and boys is commonplace in many conflict-affected settings and may be frequent in relation to forced displacement as well. Adolescent boys, forming the majority of unaccompanied minors globally, are a particularly vulnerable group. Yet sensitised health services for adult and adolescent male sexual violence survivors are scarce, and barriers to accessing care remain high. We describe current challenges and gaps in the provision of health care for male survivors in settings affected by conflict and forced displacement, and provide suggestions on how to improve service provision and uptake.

Let’s talk about sex work in humanitarian settings: piloting a rights-based approach to working with refugee women selling sex in Kampala
Jennifer S. Rosenberg & Denis Bakomeza

Although it is well known that refugees engage in sex work as a form of livelihood, stigma and silence around this issue persist within humanitarian circles. As a result, these refugees’ sexual and reproductive health and rights, and related vulnerabilities, remain overlooked. Their protection and health needs, which are significant, often go unmet at the field level. In 2016, the Women’s Refugee Commission and Reproductive Health Uganda partnered to pilot a peer-education intervention tailored to meet the needs of refugee women engaged in sex work in Kampala. Findings from the pilot project suggest the feasibility of adapting existing rights-based and evidence-informed interventions with sex workers to humanitarian contexts. Findings further demonstrate how taking a community empowerment approach can facilitate these refugees’ access to a range of critical information, services and support options – from information on how to use contraceptives, to referrals for friendly HIV testing and treatment, to peer counselling and protective peer networks.

Clinical outreach refresher trainings in crisis settings (S-CORT): clinical management of sexual violence survivors and manual vacuum aspiration in Burkina Faso, Nepal, and South Sudan
Nguyen Toan Tran, Kristen Harker, Wambi Maurice E. Yameogo, et al.

During the early humanitarian response to a crisis, there is limited time to train health providers in the life-saving clinical services of the Minimum Initial Services Package (MISP) for Reproductive Health. The Training Partnership Initiative of the Inter-agency Working Group on Reproductive Health in Crises developed the S-CORT model (Sexual and reproductive health Clinical Outreach Refresher Training) for service providers operating in acute humanitarian settings and needing to rapidly refresh their knowledge and skills. Through qualitative research, this study aimed to determine the operational enablers and barriers related to the implementation of two S-CORT modules: clinical management of sexual violence survivors (CMoSVS) and manual vacuum aspiration (MVA). Across three participating countries (Burkina Faso, Nepal, and South Sudan), 135 health staff attended the CMoSVS refresher training and 94 the MVA refresher training. Results from the focus group discussions and in-depth interviews suggest that the S-CORT approach is respectful of human rights and quality of care principles. Furthermore, it is potentially effective in enhancing the knowledge and skills of existing trained service providers, strengthening their capacity, and changing their attitudes towards abortion-related services, for example. The S-CORT is a promising model for implementation in the acute phase of an emergency upon stabilisation of the security situation. The model can also be integrated into broader post-crisis capacity development efforts. Future operational research should emphasise not only an assessment of new modules’ contents, but whether implementing this refresher training model in remote outreach settings is feasible, effective, and efficient.

Training reproductive health professionals in a post-conflict environment: exploring medical, nursing, and midwifery education in Mogadishu, Somalia
Abdiasis Yalahow, Mariam Hassan & Angel M Foster

Following two decades of civil war, Somalia recently entered the post-conflict rebuilding phase that has resulted in the rapid proliferation of higher education institutions. Given the high maternal mortality ratio, the federal government has identified the reproductive health education of health service professionals as a priority. Yet little is known about the coverage of contraception, abortion, pregnancy, childbirth, and sexual and gender-based violence (SGBV) in medicine, nursing, or midwifery. In 2016, we conducted a multi-methods study to understand the reproductive health education and training landscape and identify avenues by which development of the next generation of health service professionals could be improved. Our study comprised two components: interviews with 20 key informants and 7 focus group discussions (FGDs) with 48 physicians, nurses, midwives, and medical students. Using the transcripts, memos, and field notes, we employed a multi-phased approach to analyse our data for content and themes. Our findings show that reproductive health education for medical and nursing students is inconsistent and significant content gaps, particularly in abortion and SGBV, exist. Students have few clinical training opportunities and the overarching challenges plaguing higher education in Somalia also impact health professions programmes in Mogadishu. There is currently a window of opportunity to develop creative strategies to improve the breadth and depth of evidence-based education and training, and multi-stakeholder engagement and the promotion of South–South exchanges appear warranted.

“You have to take action”: changing knowledge and attitudes towards newborn care practices during crisis in South Sudan
Samira Sami, Kate Kerber, Barbara Tomczyk, et al.

Highest rates of neonatal mortality occur in countries that have recently experienced conflict. International Medical Corps implemented a package of newborn interventions in June 2016, based on the Newborn health in humanitarian settings: field guide, targeting community- and facility-based health workers in displaced person camps in South Sudan. We describe health workers’ knowledge and attitudes toward newborn health interventions, before and after receiving clinical training and supplies, and recommend dissemination strategies for improved uptake of newborn guidelines during crises. A mixed methods approach was utilised, including pre–post knowledge tests and in-depth interviews. Study participants were community- and facility-based health workers in two internally displaced person camps located in Juba and Malakal and two refugee camps in Maban from March to October 2016. Mean knowledge scores for newborn care practices and danger signs increased among 72 community health workers (pre-training: 5.8 [SD: 2.3] vs. post-training: 9.6 [SD: 2.1]) and 25 facility-based health workers (pre-training: 14.2 [SD: 2.7] vs. post-training: 17.4 [SD: 2.8]). Knowledge and attitudes toward key essential practices, such as the use of partograph to assess labour progress, early initiation of breastfeeding, skin-to-skin care and weighing the baby, improved among skilled birth attendants. Despite challenges in conflict-affected settings, conducting training has the potential to increase health workers’ knowledge on neonatal health post-training. The humanitarian community should reinforce this knowledge with key actions to shift cultural norms that expand the care provided to women and their newborns in these contexts.

Using a quality improvement approach to improve maternal and neonatal care in North Kivu, Democratic Republic of Congo
Michelle Hynes, Kate Meehan, Janet Meyers

Providing quality health care services in humanitarian settings is challenging due to population displacement, lack of qualified staff and supervisory oversight, and disruption of supply chains. This study explored whether a participatory quality improvement (QI) intervention could be used in a protracted conflict setting to improve facility-based maternal and newborn care. A longitudinal quasi-experimental design was used to examine delivery of maternal and newborn care components at 12 health facilities in eastern Democratic Republic of Congo. Study facilities were split into two groups, with both groups receiving an initial “standard” intervention of clinical training. The “enhanced” intervention group then applied a QI methodology, which involved QI teams in each facility, supported by coaches, testing small changes to improve care. This paper presents findings on two of the study outcomes: delivery of active management of the third stage of labour (AMTSL) and essential newborn care (ENC). We measured AMTSL and ENC through exit interviews with post-partum women and matched partographs at baseline and endline over a 9-month period. Using generalised equation estimation models, the enhanced intervention group showed a greater rate of change than the control group for AMTSL (aOR 3.47, 95% CI: 1.17–10.23) and ENC (OR: 49.62, 95% CI: 2.79–888.28), and achieved 100% ENC completion at endline. This is one of the first studies where this QI methodology has been used in a protracted conflict setting. A method where health staff take ownership of improving care is of even greater value in a humanitarian context where external resources and support are scarce.

Legal strategies to protect sexual and reproductive health and rights in the context of the refugee crisis in Europe: a complaint before the European Ombudsperson
Elena Laporta Hernández

In the context of the refugee crisis in Europe, the measures taken by the institutions and bodies of the European Union as they relate to respecting, protecting, and ensuring human rights have proven to be woefully inadequate. The development of a restrictive, defensive, security-based immigration policy has led to failure by European countries and the European Union to fulfil their human rights obligations. Specifically, the Agreement struck between the European Union and Turkey on 18 March 2016, in addition to externalising borders, placed economic and political considerations centre stage, leading to serious violations of the human rights of refugees and migrants, including their sexual and reproductive rights. In an effort to identify the failures and the institutions responsible for promoting the necessary measures to mitigate the negative impacts these policies have had, the international human rights organisation Women’s Link Worldwide lodged a complaint with the European Ombudsperson. In its complaint, Women’s Link alleges maladministration by the European Commission for its failure to carry out a human rights impact assessment of the 18 March 2016 EU-Turkey Agreement and the reports on its implementation. Such an assessment should include a gender perspective and a children’s rights approach, and its omission is not only a failure to comply with international human rights standards, but also directly and negatively affects women’s and children’s rights.