Where violent conflict displaces people and disrupts societies, maternal and child health suffers, and such instability is widespread today. According to the UN Refugee Agency, there are 65.3 million forcibly displaced people, 21.3 million refugees, and 10 million stateless people over the world. In addition, more than 65 million people who are not displaced are affected by conflict.

The special need for quality maternal health services in fragile settings has been established by various protocols, including the International Conference on Population and Development Program of Action, adopted by 179 countries in 1994, and the concept of Minimum Initial Service Packages, advanced by the United Nations Population Fund and others.

However, the conditions in fragile settings are changing, and too many mothers – especially adolescents – still lack access to quality care.

“We now know that more than 50 percent of refugees don’t live in camps – many of them are in urban areas,” said Dr. Paul Spiegel, director of the Johns Hopkins Center for Humanitarian Health and professor at the Bloomberg School of Public Health, at the Wilson Center on December 8. “In Syria and all the countries surrounding it – Jordan, Lebanon, Turkey, middle-income countries – we’re looking at non-communicable diseases like cancers, more expensive care, and stronger governments with stronger NGOs.” Reaching affected populations in these places and other unique contexts requires a different, more tailored approach, and faster learning processes.

According to a study by the Inter-Agency Working Group on Reproductive Health in Crises, conflict-affected developing countries received almost 60 percent less official development assistance for reproductive health than non-conflict affected countries between 2002 and 2011, “even though most reproductive health indicators in those conflict-affected countries [were] worse,” said Sandra Krause, the program director of reproductive health at Women’s Refugee Commission, a non-profit organization.

Beyond Low-Hanging Fruit

Syria is the largest source of displaced people and it is not hard to see why. According to Massimo Diana of the United Nations Population Fund, 30 percent of health facilities have been damaged, close to 50 percent of primary health care facilities are not functioning properly, and life expectancy has dropped by 20 years.

The numbers on maternal and newborn health are even more staggering: as a result of almost six years of conflict, maternal and child mortality rates have increased by one third. And women and young girls are more likely to face sexual and gender-based violence, said Diana. Weighed against the fear of stigma, many cases go unreported or misreported.

Conflict-affected countries received almost 60% less official development assistance for reproductive health

For humanitarians working in and around Syria, there is no set of clinical guidelines on how health workers should care for survivors of sexual assault, from child marriage to rape, said Krause. Even though sexual and gender-based violence is more prevalent in conflict settings, ministries of health have not developed the standardized protocols and tools necessary to accommodate them.

Part of the problem is a gap between what donors and aid agencies propose to do versus what they actually fund, said Krause. Although maternal and newborn health receive the most funding of all reproductive health components, most money goes to “lower hanging fruit” within that category, such as antenatal care and post-natal nutrition programs, not “life-saving emergency obstetric and newborn care,” she said.

Nor does family planning get prioritized by most donors, despite a major need. It is especially young girls who have less control over whether they become pregnant in crisis settings, said Diana. “Adolescents who are married have both the lowest use of contraception in the highest levels and highest levels of unmet needs.”

Fast Data, Accurate Data

Traditionally, countries facing conflict and crises are assumed to have essentially the same needs, but the true challenge is having a better understanding of contextual differences, said Diana.

For example, it is commonly reported that 60 percent of preventable maternal deaths occur in fragile states. This number is inflated and incorrectly phrased, said Spiegel. Places like Nigeria and the Democratic Republic of the Congo have specific regions that are fragile, but the whole country cannot be characterized in that way. He noted this generalization is partly for advocacy reasons – it helps raise awareness of a problem – but “we need to work on to try to be a little bit more precise.”

“Our challenge is, in terms of data collection [and] data analysis…it’s still scattered at best,” said Diana. What is needed most is “fast data,” which can inform action on the ground with lives on the line. Especially with cases like Syria, where an acute situation is also protracted, data needs to be sufficiently disaggregated at the district level to determine what is needed where to help the most affected populations, said Spiegel, like adolescent girls. Waiting for randomized controlled trials and peer review is not always appropriate either.

“There is not a one-size-fits-all response,” said Spiegel. “We need to have principles, but they need to be applied differently according to context.”

Spiegel and Diana proposed modifying monitoring and evaluation efforts to produce more local quantitative indicators; providing more mental health care, which can be critical for survivors of sexual assault and new mothers; ensuring that in places where institutions are no longer functioning, data on maternal and newborn health is still collected; taking advantage of mobile technology to collect more context-specific data; and encouraging the participation of communities in supporting mothers and their newborns.

Coordinating With Business

Joy Marini of Johnson & Johnson said the private sector can play a role in plugging some of the gaps. The Sustainable Development Goals (SDGs) encourage businesses to get involved in the global development agenda, and indeed private sector funding in fragile and conflict-affected states has increased in recent years, Marini said. It’s important to encourage this shift to help offset the constrained resources of traditional humanitarian organizations, she said.

“We need to have principles, but they need to be applied differently according to context”

Businesses can also bring additional expertise on health service provision and a higher propensity for risk taking that may encourage innovation. “Our businesses can bring real value to these conflicts, in terms of creative ways of thinking and analyzing what can happen,” said Marini.

The biggest element that holds private sector investment back is uncertainty. “There’s this impression that with rapidly changing conditions, we’re not going to be able to scale,” said Marini, “that we will never be able to reach sustainability.”

When making the case for involvement in conflict settings, Marini said she often faces resistance. “I am less of an expert in conflict and crises and more of an expert in being told no,” she said. Her counter is that working in these places is part of good corporate responsibility and a commitment to the SDGs, which could even lead to future markets. If businesses work with local institutions to help people attain basic health services, there is a potential to leverage scale and sustainability in those communities in the long run, she said.

She suggested changing the vernacular to appeal to businesses in a different way, appealing to opportunity and development, rather than risks and crises. When the Ebola epidemic broke out in West Africa in 2014, companies dropped everything that they were working on to find a vaccine, said Marini. However, in conflict settings, companies have been weary of stepping in because of the perceived risk of failure and loss. Marini said that businesses should view maternal and child health in conflict and crises as opportunities too.

Johnson & Johnson has joined the Safe Birth Even Here Campaign, working to provide a full range of health services that protect women’s health and rights in crisis settings. The company has also worked with UNFPA to invest in emergency obstetric care and health system strengthening in Haiti and Liberia. In Syria, Johnson and Johnson is working with Save the Children to support children’s access to health care in resettlement settings.

The New Normal?

Diana pointed out that the majority of services in fragile and conflict-affected settings are actually provided by the private sector. “We need to partner and establish a shared understanding of policies, procedures, recording, and management of pre-natal, post-natal care.”

An all-hands-on-deck approach to meeting maternal, child, and reproductive health needs in fragile and conflict-affected settings is necessary as low-level but widespread instability appears to be the new “humanitarian norm,” said Spiegel. Health needs – which are both universal and incredibly personal – are always changing.

“I think about a woman who was displaced and was traveling through Budapest and had to have her baby under a train trestle,” Marini said. “Without any help, without any skilled birth attendant, and without that beautiful clean maternity ward, she said, ‘That was the most beautiful moment of my life and it happened in the most horrible place.’”

In order to meet the needs of women in fragile and conflict-affected settings, better and faster data; country and community leadership; the right advocacy and business partnerships; and collaboration among a variety of actors is needed.

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Written by Nancy Chong, edited by Schuyler Null and Francesca Cameron.

Cover Photo Credit: A newborn at a clinic in the Zaatari refugee camp, Jordan, March 2016, courtesy of Peter Biro/EU/ECHO.