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.

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