Commentary Health Systems

How We Are Failing Women and Girls in Humanitarian Emergencies

Jamie J. Hagen

“Protecting the sexual and reproductive rights of women and girls in crisis settings is essential and a matter of human rights, but it is also complicated and unsustainable without a change in the way humanitarian assistance is provided and funded,” states a recently published report from the UN Population Fund.

Every day, 507 women and adolescent girls die due to a lack of reproductive health services in humanitarian emergencies. There are now 13 million displaced refugees globally. This number will only continue to grow as more people seek refuge from war and violence.

In addition to this growing refugee population, there is an ever-increasing population of internally displaced people: about 38 million in 2014, equaling 30,000 per day. These individuals fleeing conflict within their own country spend an average of 17 years displaced from their home relying on international humanitarian assistance. Although the international community first recognized providing reproductive health services as a human right with widespread economic and social benefits 20 years ago, barriers remain to meeting these needs for the 25 million women and girls living in emergency settings.

A report from the UN Population Fund (UNFPA), titled Shelter From the Storm: A Transformative Agenda for Women and Girls in a Crisis-Prone World, urges new directions in financing for sexual and reproductive health to address this problem.

“Protecting the sexual and reproductive rights of women and girls in crisis settings is essential and a matter of human rights, but it is also complicated and unsustainable without a change in the way humanitarian assistance is provided and funded,” states the report.

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Two critical ways for the global community to begin making progress include, as the report notes, increasing the international community’s focus on the availability and accessibility of safe abortion and post-abortion care, and cultivating a culture of preparedness and prevention when it comes to providing a full range of such services in communities prior to any crisis. 

Access to Safe Abortion as a Human Right

An oft-cited 1999 UNFPA report estimates that 25 to 50 percent of maternal deaths in refugee settings are due to complications of unsafe abortions. (Little research has been done in the past two decades to learn more about this crisis.) This is a startling statistic, yet abortion remains politicized and difficult for non-governmental organizations and leaders to talk about in the international arena, let alone fund.

Few displaced women are in a position to demand access to abortion or organize to advocate for these services. Societal forces are a large part of this disenfranchisement, including pressure from family and the broader community to bring a pregnancy to term to replace lost family or to hide a pregnancy that is a result of rape, which can increase the stigma they are facing. In addition, clinics in most crisis settings are not outfitted with the necessary medical equipment to provide safe abortion care or even to address complications of abortion. Also, many organizations receiving international funding to provide relief to refugees are religiously affiliated and do not offer reproductive health care, including abortion, according to a report about safe abortion for refugees.

As a result, research specifically addressing the state of abortion and post-abortion care in conflict zones often is neglected, creating a gap in information around this specific program area.

Sandra Krause, director of Reproductive Health at the Women’s Refugee Commission, explained to Rewire that, according to a 2012-2014 Global Evaluation from the Inter-Agency Working Group on Reproductive Health in Crises (IAWG), access to post-abortion care in crisis settings has expanded since 2004 but “comprehensive abortion care—in particular, safe abortion care,” is still lacking. The IAWG has since formed a working group to address this gap.

However, the results of that working group are unknown, and much of this work remains unfunded. On a hopeful note, Krause said that she believes the working group will create a sea change in the conversation around funding safe abortion access in humanitarian emergencies. “We did just receive some funding to update the global guidelines for reproductive health and humanitarian settings to better integrate safe abortion care,” she added.

Economic Case for Funding Reproductive Care Services

In addition to recognizing these services as a human right, the UNFPA report points to obstetric care, safe abortion and post-abortion care, and services for those who experience gender-based violence as keys to achieving sustainable development. There are measurable economic impacts from denying these services to women and girls.

“It prevents girls from being able to go to school, it prevents girls and women from accessing education more generally, and seeking higher education. It pulls women out of the workforce and makes them unable to provide for their families and for themselves,” Katherine Mayall, a global advocacy adviser at the Center for Reproductive Rights, told Rewire.

“There is a strong economic case to be made for meeting the reproductive health needs of a country’s population in humanitarian emergencies,” added Kade Finnoff, an economics professor at the University of Massachusetts. “In lower-income countries where many humanitarian emergencies occur, we now have empirical studies that document the economic impact to individuals and local economies.”

One study of Ghana and Bangladesh about the impact of increased access to reproductive health services found that improved access to family planning services led to “improved birth spacing” and an increase in women’s earnings and participation in paid employment. Further, children of women with access to family planning were better educated than those without these services. Another study of Nigeria found, “reproductive health is a panacea towards reversing the stalled socio-economic growth of Nigeria as evident from the linkage between reproductive health and development.”

A long-term strategic focus on providing sexual and reproductive health services could also allow non-governmental organizations to increase their support for prevention and preparedness before a humanitarian emergency.

As the UNFPA report notes, “Humanitarian funding is mainly directed towards the response to crisis, with relatively little directed to prevention and preparedness.” This lack of preparation often exacerbates already devastating situations, as we’re seeing now in countries affected by the Zika virus. Some government leaders in these affected nations are advising their citizens not to get pregnant for fear that their fetuses will develop a life-threatening anomaly. But many of these same countries don’t have the health-care systems in place to assist the women in need of contraception or abortion care, because of restrictive anti-choice laws.

Ultimately, meeting the needs of every community requires a holistic approach that includes support for prevention and preparedness as well as emergency services.

Cultivating a Local Response

IAWG encourages all communities to implement the Minimum Initial Service Package (MISP) for reproductive health, which is a “life-saving” set of guidelines “to be implemented at the onset of every humanitarian crisis,” the website reads. “It forms the starting point for reproductive health programming and should be sustained and built upon with comprehensive reproductive health services throughout protracted crises and recovery.” For example, a MISP checklist includes a form with sections on how to gather information about the demographics of a humanitarian setting, how to prevent sexual violence and respond to the need of survivors, how to reduce the transmission of HIV, and how to prevent excess maternal and newborn morbidity and mortality. And a yes/no checklist fosters the development of a weekly monitoring initiative at the onset of a response and then tapers down to a monthly review of the status of reproductive health-care services in the humanitarian setting.

“We know in every crisis women and girls are going to have these priority needs, even if it’s in New York City,” said Krause. “Pregnant women are going to need emergency obstetric care because of the breakdown in civil society in cities. There is always an increase in risk for sexual violence and so women are going to need access to care. A certain percentage of women who are pregnant are going to have emergency complications. Newborn care is essential.”

Some local communities are already focusing on prevention and preparedness. “There are some wonderful efforts—led by displaced communities themselves—to address these issues, such as the Adolescent Reproductive Health Network (ARHN) on the Thai-Burma border and Association for Refugees with Disabilities in Uganda,” noted IAWG researcher Sarah Chynoweth. Both organizations work on issues often overlooked in emergency situations.

Rewire reported on the work of ARHN to meet the needs of adolescent refugees, such as providing condoms, peer sex education, and birth control pills. The UN Human Rights Council has recognized the Association for Refugees with Disabilities in Uganda as an example of good practices for allowing refugees living with disabilities to advocate on their own behalf.

Chynoweth emphasized the importance of focusing on those who are particularly marginalized when preparing for emergency response and outreach. “Displaced adolescents, people with disabilities, LGBTQ individuals, and sex workers are particularly vulnerable to sexual violence and exploitation, and they also have specific [sexual and reproductive health] needs. We can’t just keep ‘doing business as usual’—targeted outreach must be conducted to engage these groups, something which humanitarian agencies often neglect.”

As the UNFPA report and other researchers have shown, the best way to provide for immediate and long-term support for sexual and reproductive health services is to fund both global and local initiatives aimed at spurring sweeping improvements in the lives of women and girls.

Analysis Human Rights

El Salvador Bill Would Put Those Found Guilty of Abortion Behind Bars for 30 to 50 Years

Kathy Bougher

Under El Salvador’s current law, when women are accused of abortion, prosecutors can—but do not always—increase the charges to aggravated homicide, thereby increasing their prison sentence. This new bill, advocates say, would heighten the likelihood that those charged with abortion will spend decades behind bars.

Abortion has been illegal under all circumstances in El Salvador since 1997, with a penalty of two to eight years in prison. Now, the right-wing ARENA Party has introduced a bill that would increase that penalty to a prison sentence of 30 to 50 years—the same as aggravated homicide.

The bill also lengthens the prison time for physicians who perform abortions to 30 to 50 years and establishes jail terms—of one to three years and six months to two years, respectively—for persons who sell or publicize abortion-causing substances.

The bill’s major sponsor, Rep. Ricardo Andrés Velásquez Parker, explained in a television interview on July 11 that this was simply an administrative matter and “shouldn’t need any further discussion.”

Since the Salvadoran Constitution recognizes “the human being from the moment of conception,” he said, it “is necessary to align the Criminal Code with this principle, and substitute the current penalty for abortion, which is two to eight years in prison, with that of aggravated homicide.”

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The bill has yet to be discussed in the Salvadoran legislature; if it were to pass, it would still have to go to the president for his signature. It could also be referred to committee, and potentially left to die.

Under El Salvador’s current law, when women are accused of abortion, prosecutors can—but do not always—increase the charges to aggravated homicide, thereby increasing their prison sentence. This new bill, advocates say, would worsen the criminalization of women, continue to take away options, and heighten the likelihood that those charged with abortion will spend decades behind bars.

In recent years, local feminist groups have drawn attention to “Las 17 and More,” a group of Salvadoran women who have been incarcerated with prison terms of up to 40 years after obstetrical emergencies. In 2014, the Agrupación Ciudadana por la Despenalización del Aborto (Citizen Group for the Decriminalization of Abortion) submitted requests for pardons for 17 of the women. Each case wound its way through the legislature and other branches of government; in the end, only one woman received a pardon. Earlier this year, however, a May 2016 court decision overturned the conviction of another one of the women, Maria Teresa Rivera, vacating her 40-year sentence.

Velásquez Parker noted in his July 11 interview that he had not reviewed any of those cases. To do so was not “within his purview” and those cases have been “subjective and philosophical,” he claimed. “I am dealing with Salvadoran constitutional law.”

During a protest outside of the legislature last Thursday, Morena Herrera, president of the Agrupación, addressed Velásquez Parker directly, saying that his bill demonstrated an ignorance of the realities faced by women and girls in El Salvador and demanding its revocation.

“How is it possible that you do not know that last week the United Nations presented a report that shows that in our country a girl or an adolescent gives birth every 20 minutes? You should be obligated to know this. You get paid to know about this,” Herrera told him. Herrera was referring to the United Nations Population Fund and the Salvadoran Ministry of Health’s report, “Map of Pregnancies Among Girls and Adolescents in El Salvador 2015,” which also revealed that 30 percent of all births in the country were by girls ages 10 to 19.

“You say that you know nothing about women unjustly incarcerated, yet we presented to this legislature a group of requests for pardons. With what you earn, you as legislators were obligated to read and know about those,” Herrera continued, speaking about Las 17. “We are not going to discuss this proposal that you have. It is undiscussable. We demand that the ARENA party withdraw this proposed legislation.”

As part of its campaign of resistance to the proposed law, the Agrupación produced and distributed numerous videos with messages such as “They Don’t Represent Me,” which shows the names and faces of the 21 legislators who signed on to the ARENA proposal. Another video, subtitled in English, asks, “30 to 50 Years in Prison?

International groups have also joined in resisting the bill. In a pronouncement shared with legislators, the Agrupación, and the public, the Latin American and Caribbean Committee for the Defense of the Rights of Women (CLADEM) reminded the Salvadoran government of it international commitments and obligations:

[The] United Nations has recognized on repeated occasions that the total criminalization of abortion is a form of torture, that abortion is a human right when carried out with certain assumptions, and it also recommends completely decriminalizing abortion in our region.

The United Nations Committee on Economic, Social, and Cultural Rights reiterated to the Salvadoran government its concern about the persistence of the total prohibition on abortion … [and] expressly requested that it revise its legislation.

The Committee established in March 2016 that the criminalization of abortion and any obstacles to access to abortion are discriminatory and constitute violations of women’s right to health. Given that El Salvador has ratified [the International Covenant on Economic, Social and Cultural Rights], the country has an obligation to comply with its provisions.

Amnesty International, meanwhile, described the proposal as “scandalous.” Erika Guevara-Rosas, Amnesty International’s Americas director, emphasized in a statement on the organization’s website, “Parliamentarians in El Salvador are playing a very dangerous game with the lives of millions of women. Banning life-saving abortions in all circumstances is atrocious but seeking to raise jail terms for women who seek an abortion or those who provide support is simply despicable.”

“Instead of continuing to criminalize women, authorities in El Salvador must repeal the outdated anti-abortion law once and for all,” Guevara-Rosas continued.

In the United States, Rep. Norma J. Torres (D-CA) and Rep. Debbie Wasserman Schultz (D-FL) issued a press release on July 19 condemning the proposal in El Salvador. Rep. Torres wrote, “It is terrifying to consider that, if this law passed, a Salvadoran woman who has a miscarriage could go to prison for decades or a woman who is raped and decides to undergo an abortion could be jailed for longer than the man who raped her.”

ARENA’s bill follows a campaign from May orchestrated by the right-wing Fundación Sí a la Vida (Right to Life Foundation) of El Salvador, “El Derecho a la Vida No Se Debate,” or “The Right to Life Is Not Up for Debate,” featuring misleading photos of fetuses and promoting adoption as an alternative to abortion.

The Agrupacion countered with a series of ads and vignettes that have also been applied to the fight against the bill, “The Health and Life of Women Are Well Worth a Debate.”

bien vale un debate-la salud de las mujeres

Mariana Moisa, media coordinator for the Agrupación, told Rewire that the widespread reaction to Velásquez Parker’s proposal indicates some shift in public perception around reproductive rights in the country.

“The public image around abortion is changing. These kinds of ideas and proposals don’t go through the system as easily as they once did. It used to be that a person in power made a couple of phone calls and poof—it was taken care of. Now, people see that Velásquez Parker’s insistence that his proposal doesn’t need any debate is undemocratic. People know that women are in prison because of these laws, and the public is asking more questions,” Moisa said.

At this point, it’s not certain whether ARENA, in coalition with other parties, has the votes to pass the bill, but it is clearly within the realm of possibility. As Sara Garcia, coordinator of the Agrupación, told Rewire, “We know this misogynist proposal has generated serious anger and indignation, and we are working with other groups to pressure the legislature. More and more groups are participating with declarations, images, and videos and a clear call to withdraw the proposal. Stopping this proposed law is what is most important at this point. Then we also have to expose what happens in El Salvador with the criminalization of women.”

Even though there has been extensive exposure of what activists see as the grave problems with such a law, Garcia said, “The risk is still very real that it could pass.”

News Abortion

Parental Notification Law Struck Down in Alaska

Michelle D. Anderson

"The reality is that some young women face desperate circumstances and potentially violent consequences if they are forced to bring their parents into their reproductive health decisions," said Janet Crepps, senior counsel at the Center for Reproductive Rights. "This law would have deprived these vulnerable women of their constitutional rights and put them at risk of serious harm."

The Alaska Supreme Court has struck down a state law requiring physicians to give the parents, guardians, or custodians of teenage minors a two-day notice before performing an abortion.

The court ruled that the parental notification law, which applies to teenagers younger than 18, violated the Alaska Constitution’s equal protection guarantee and could not be enforced.

The ruling stems from an Anchorage Superior Court decision that involved the case of Planned Parenthood of the Great Northwest and the Hawaiian Islands and physicians Dr. Jan Whitefield and Dr. Susan Lemagie against the State of Alaska and the notification law’s sponsors.

In the lower court ruling, a judge denied Planned Parenthood’s requested preliminary injunction against the law as a whole and went on to uphold the majority of the notification law.

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Planned Parenthood and the physicians had appealed that superior court ruling and asked for a reversal on both equal protection and privacy grounds.

Meanwhile, the State of Alaska and the notification law’s sponsors appealed the court’s decision to strike some of its provisions and the court’s ruling.

The notification law came about after an initiative approved by voters in August 2010. The law applied to “unemancipated, unmarried minors” younger than 18 seeking to terminate a pregnancy and only makes exceptions in documented cases of abuse and medical emergencies, such as one in which the pregnant person’s life is in danger.

Justice Daniel E. Winfree wrote in the majority opinion that the anti-choice law created “considerable tension between a minor’s fundamental privacy right to reproductive choice and how the State may advance its compelling interests.”

He said the law was discriminatory and that it could unjustifiably burden “the fundamental privacy rights only of minors seeking pregnancy termination, rather than [equally] to all pregnant minors.”

Chief Justice Craig Stowers dissented, arguing that the majority’s opinion “unjustifiably” departed from the Alaska Supreme Court’s prior approval of parental notification.

Stowers said the opinion “misapplies our equal protection case law by comparing two groups that are not similarly situated, and fails to consider how other states have handled similar questions related to parental notification laws.”

Center for Reproductive Rights (CRR) officials praised the court’s ruling, saying that Alaska’s vulnerable teenagers will now be relieved of additional burdensome hurdles in accessing abortion care. Attorneys from the American Civil Liberties Union, CRR, and Planned Parenthood represented plaintiffs in the case.

Janet Crepps, senior counsel at CRR, said in a statement that the “decision provides important protection to the safety and well-being of young women who need to end a pregnancy.”

“The reality is that some young women face desperate circumstances and potentially violent consequences if they are forced to bring their parents into their reproductive health decisions. This law would have deprived these vulnerable women of their constitutional rights and put them at risk of serious harm,” Crepps said.

CRR officials also noted that most young women seeking abortion care involve a parent, but some do not because they live an abusive or unsafe home.

The American Medical Association, the American College of Obstetricians and Gynecologists, and the Society for Adolescent Medicine have said minors’ access to confidential reproductive health services should be protected, according to CRR.