In Refuge: Family Planning in Humanitarian Settings

 “Family planning saves lives, even in times of crisis,” said Gwen K. Young, Managing Director at the Global Emergency Response Coalition at a Wilson Center event on October 8 on the importance of providing family planning and reproductive health services in humanitarian settings. Speakers from Save the Children, CARE, the International Rescue Committee, and FP2020 spoke to programmatic successes, innovative solutions, and local partnerships in fragile settings. Young highlighted that 1 in 70 people worldwide need humanitarian assistance and a quarter of these are women and girls of reproductive age. All told, more than 30 million women and girls in 42 countries.

Sixty percent of maternal deaths occur in countries experiencing conflict, displacement, or natural disasters. Family planning needs do not disappear during a crisis. In fact, these needs may grow more urgent as women may want to avoid pregnancy particularly during a crisis or period of displacement. As the average length of a crisis situation is nine years, speakers emphasized the importance of promoting sustainable solutions and programs to meet women’s and girls’ family planning needs in humanitarian settings.

In light of the 25th anniversary of the International Conference on Population and Development (ICPD), Jennifer Schlecht, Senior Advisor of Emergency Preparedness and Response at FP2020, spoke about the progress that has been made in the last 25 years. Family planning services were completely unavailable in refugee settings, and the needs of women of reproductive age were often ignored, according to the 1994 report, Refugee Women and Reproductive Health Care: Reassessing Priorities.  The past decade has seen progress on family planning in humanitarian contexts, said Schlecht.

Family Planning in Humanitarian Settings

“Contraception in crisis is the key to saving lives,” said Erin Wheeler, Contraception and Abortion Care Advisor for the International Rescue Committee (IRC). Speakers discussed the importance of training providers and program staff on the Minimum Initial Service Package (MISP) for reproductive health, a series of crucial, life-saving activities to respond to reproductive health needs in any humanitarian emergency. Speakers also discussed the importance of integrating family planning into primary care.

“Contraception in crisis is the key to saving lives”

Wheeler described the International Rescue Committee’s goal of delivering primary care interventions to displaced populations and their efforts to prioritize family planning, safe abortion, and post-abortion care as a part of primary health care when working with Venezuelan refugees in Colombia. She also emphasized that in fragile states with weak health systems, you cannot look at preparedness without integrating it with health strengthening efforts – “Resilience is part of the broader package.” Nancy Ibrahim, Advisor for Reproductive Health in Emergencies at Save the Children also discussed how their programming in Syria and for Syrian refugees prioritizes family planning as a crucial aspect of primary care for refugees and displaced populations.

Panelists discussed the successes of programs in three different humanitarian contexts with unique demands and barriers. In the crisis-affected population, 14,000 pregnancies in Syria and 6,500 pregnancies among Syrian women will end in miscarriage and unsafe abortion in the next three months, said Ibrahim. She also pointed to data showing that the maternal mortality ratio, or the number of women who die as a result of pregnancy and childbirth complications per 100,000 live births in a given year, has increased since the beginning of the crisis. Save the Children has worked across eight facilities in crisis-affected areas since 2016 to provide quality family planning and primary care services. As a result, there are 19,000 new family planning users in Syria. More than one-third (36 percent) of new users have chosen a long-acting method. Seema Manohar, Sexual and Reproductive Health and Rights (SRHR) Specialist at CARE discussed their programming in North Kivu in the Democratic Republic of Congo (DRC), an area in crisis with a severely compromised health system. CARE’s successful programming utilized community involvement and was then applied to an emerging crisis in the Kasai region of the DRC. With the help of local partners, CARE established a family planning committee to train emergency response teams and healthcare providers. As a result, CARE saw nearly 11,000 new family planning users in the region.

In Colombia, an area where Venezuelan refugees cannot easily access the regulated and insurance-based health system, the IRC, in collaboration with Profamilia (the International Planned Parenthood Federation affiliate in Colombia), and the local health system established Comprehensive Care Centers in Cúcuta in 2018 and Medellin in 2019 to act as a “one-stop-shop” for preventive health, including family planning. The program saw a dramatic increase in new family planning users in both facilities and an increase in women and girls accessing the formal health system for safe abortion care and primary healthcare.

Social Norms and Taboos Shift in Times of Crisis

“The real heroes are on the ground,” Ibrahim said. Organizations rely on people who are on the ground, like women’s groups and faith leaders, as they will continue efforts to help women long after international organizations leave. However, in order to reach these communities and deliver the necessary services, it is important to address deep-rooted social and gender norms and transform these ideas to have a positive impact and increase access to SRHR services. “Norms have a way of changing in an acute setting,” Manohar said. She discussed how living in a crisis situation often leads people and communities to shift their health behaviors, as well as their gender norms.

“The real heroes are on the ground,” like women’s groups and faith leaders, as they will continue efforts to help women long after international organizations leave

Panelists spoke about the demand for family planning regardless of how conservative the social and gender norms are in a particular region. They emphasized the importance of engaging men and religious leaders to impact the entire community. Wheeler spoke of her success in framing family planning in a different way by discussing it with male and religious leaders in terms of family health, proper birth spacing, and reducing the burden of maternal mortality. “Everyone knows someone who died in childbirth. Everyone knows children who are spaced too close together who are malnourished,” Wheeler said, also emphasizing that the community leaders care deeply about their communities’ health.

Ibrahim also discussed Save the Children’s success in integrating family planning with a comprehensive service package when they could not speak to families about family planning directly. They gained the trust of the community, leading to an increase in the uptake of family planning after this integration. The speakers all discussed meeting people and communities “where they are” to build trust and link their interventions to existing efforts. Changing gender norms comes down to having a dialogue and finding a way to negotiate. “The starting point is not the end point,” Manohar said. Eventually, as communities trust international organizations to help provide quality services, social norms shift towards supporting family planning and more equitable joint decision-making in households.  

Partnerships are Critical to Program Success

The shifts in social and gender norms in communities experiencing humanitarian crises has only been possible through prioritizing and valuing local partnerships with community and local governments. In the DRC, CARE relies on community facilitators to address community needs, work with CARE staff during visits, and hold the health system and government accountable to their commitments to family planning. Because of CARE’s local partnerships, they replicated their successful family planning model in the emerging crisis in Kasai in just eight months.  In Colombia, the IRC’s strategic partnerships with Metrosalud, Profamilia, and other health systems and providers helped create context-specific programs to meet the needs of crisis-affected women and girls. Additionally, the IRC’s programming in Colombia saw significant successes in contraceptive coverage only after their facilities hired a family planning nurse via local partnerships. Save the Children’s programming in Syria and with Syrian refugees relied heavily on local partners to deliver services, perform monitoring and evaluation, and ensure the sustainability of the training provided, said Ibrahim. “Local partnerships, those relationships with communities, can just not be underestimated,” Manohar said.

Advocacy is Crucial to Strengthen Global Commitments and Research Priorities

At a global level, Schlecht discussed the importance of keeping an eye on advocacy and working with committed countries to improve their preparedness, response, and recovery for humanitarian crisis events, focusing on family planning. When advocacy is not maintained, she said, we “slide back” on gender issues, SRHR, and family planning. She discussed steps that countries partnering with FP2020 have taken, including incorporating the Minimum Initial Service Package into Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH) training and making disaster preparedness a focal point in countries’ action plans. Schlecht also spoke to the importance of having humanitarian actors commit “predictable and sustainable funding” in the response to crisis settings.

When advocacy is not maintained, we “slide back” on gender issues

The panelists discussed the need to use these partnerships to collect more robust data on the costs and benefits of investing in family planning preparedness, though this is difficult data to obtain. Speakers also discussed what could be best practices in public health—supportive supervision, community engagement, and local government engagement. However, we are still looking for the evidence on the right package of services and training to ensure provider competence in a crisis setting, Wheeler said. Family planning, they emphasized, is a cost-effective intervention that can help reduce strain on already limited resources.

“The world is increasingly unstable. We see conflict, climate crisis, and displacement as the new operating environment,” Schlecht said. “The time is now to accelerate action.”

Read More:

• High fertility rates in the largest Syrian refugee camp demonstrates the need for accessible reproductive and maternal health services.
• Displaced women are often overlooked when providers deliver health information to communities.
• Transportation issues contribute to maternal death outside of refugee camps.
• Addressing the unmet need for family planning would reduce maternal death worldwide.

 Continue the conversation on Twitter by following @Wilson_MHI using the hashtag #InRefuge and #MHDialogue and find related coverage on our blog at NewSecurityBeat.org/dot-mom. Event Co-Sponsors:   Photo Credit: Clients walking through the hospital grounds with their children. Susan Warner, Save the Children.