During the International Conference on Population and Development in 1994, the international community for the first time defined reproductive health, not in a demographic context, but as a right and matter of choice for every individual. In the years that followed, other international conferences, such as the 1995 Fourth World Conference on Women reinforced this consensus. Governments agreed that, in crisis situations, they and the rest of the international community should honour all relevant legal obligations and live up to international commitments to protect and promote the rights of refugees and displaced persons, including reproductive rights.

Human rights relevant to reproductive health include:

• the right to life and health
• the freedom to marry and determine the number, timing and spacing of children
• the right to access information
• the right to non-discrimination and equality for men and women
• the right to liberty and security of the person, including freedom from sexual violence and coercion
• the right to privacy

Refugees of course have the same reproductive health needs as people unaffected by displacement. Moreover, the factors that influence the involuntary movement of populations across and within national frontiers render them extremely vulnerable, including to reproductive health problems. This increases their needs for preventive and curative care, including services related to safe motherhood, family planning, prevention of unsafe abortion and treatment of complicated abortions, prevention and treatment of HIV/AIDS and other sexually transmitted infections (STIs), prevention and management of the consequences of sexual violence, and sex education. Forcibly-displaced persons have left behind the support of traditional values, extended families, friends and familiar ways of life. They have often lost their loved ones, their possessions, their jobs and income, their social status, and even their human dignity. Provision of adequate reproductive health services in these situations is always very difficult.

At every stage of a conflict, women and adolescent girls and boys are vulnerable to sexual violence. While rape and other forms of violent sexual assault have always been used as weapons of war, this problem seems to be worsening. Many women and girls are forced to offer sex in exchange for food, shelter or protection. Emergency contraception and other medical and psychological support are rarely available. Sexual violence has a disastrous effect on people's physical and mental health, leading to unwanted pregnancies, unsafe and complicated abortions, abandoned babies, HIV/STI transmission, sexual dysfunction, rejection by family and community and even suicide. Programmes aimed at preventing sexual violence have to involve the community as well as the police and military.

STIs and HIV/AIDS

Poverty, powerlessness and social instability promote the spread of both HIV and other STIs. Populations may be forced to migrate into areas with a higher incidence of HIV/STIs. An influx of armed forces or peace keepers consisting of young, sexually active men can also lead to increased HIV/STI transmission. Rape and sexual abuse often increase and people may be forced to exchange sexual favours for money or basic resources as a survival strategy. Soldiers may have minimal knowledge of HIV/STI prevention and can be victim and vehicle of transmission at the same time. Fighting leads to more surgical interventions and an increased demand for blood transfusions. In addition, HIV transmission through contaminated blood transfusions may be high if there is a breakdown in the normal system of blood screening and universal precautions.

The impact of an increased HIV/STI prevalence on the public health of a community is very serious. A high prevalence of STIs is known to increase HIV transmission. There are physical sequelae, such as the debilitating chronic complications of AIDS like tuberculosis and diarrhoea. STIs can lead to long-term pain, infertility and complications during pregnancy and childbirth. Children may also be affected with increased risk of morbidity and mortality.

Having to support a high number of people living with HIV/AIDS affects the economic and emotional well-being of the refugee community. HIV/AIDS can lead to social rejection, isolation and loss of income, poverty and economic dependence. The community may have to support an increasing number of orphans.

Fertility and family planning

Data on the fertility of displaced persons are not readily available and there is no conclusive evidence to support that their fertility is higher than before the crisis. In general, however, women in refugee settings seem to have higher fertility rates than they would in ordinary circumstances. As the situation stabilises, fertility rates can go up for several reasons: couples may want to replace lost children; mother and child health (MCH) programmes in the camps increase infants' chance of survival; and there may be political pressure to rebuild the community. Nevertheless, given the choice, many refugee couples would prefer to limit their family size and space their children.

Maternal mortality and morbidity

Most conflict situations affect populations from poor countries, where women already have an increased risk of maternal mortality and morbidity. Their flight aggravates this issue. Of the women of reproductive age in the refugee population, an estimated 20% is pregnant at any one time. During the exodus and emergency phases of a conflict situation, pregnant women may become malnourished and anaemic and are at high risk of serious infectious diseases. They are exposed to psychological and physical violence. They are often alone, living in temporary shelters and may have to give birth under hazardous conditions. Skilled help and surgical referral services are usually not available for the estimated 15% of deliveries that will develop complications. All these factors greatly increase the risk of maternal morbidity and mortality: after the emergency phase, the main causes of death among women refugees of childbearing age are pregnancy-related complications.

Complications of abortion

Spontaneous and induced abortions are common among forcibly-displaced persons. Refugee women are vulnerable to rape and coercive sex, especially in the early stages of the emergency. The breakdown in family ties often leads to increased unprotected sexual activity among young persons. As men lose their traditional roles and status and have little work to do, excessive drinking and violence may result. Methods of family planning and emergency contraception are not always provided or information about the availability of these methods may be lacking. All this may lead to an increased number of unwanted pregnancies. When abortion is not legally available, women may resort to dangerous procedures.

Complications from abortions constitute a major cause of death and of morbidity such as haemorrhage, sepsis, chronic pelvic infections and infertility. Management of these complications is time-consuming and expensive and diverts scarce resources from other health services. Providing protection against sexual violence (e.g. through extra security in camps), family planning methods --including emergency contraception-- and safe abortion services is the only way to decrease the number of unsafe abortions.

Harmful traditional practices

There is anecdotal evidence that in stabilised refugee situations and in the returnee phase, the traditional practice of female genital cutting (FGC) is sometimes revived as communities attempt to reassert their cultural identity. However, FGC frequently results in serious, life-long health consequences, including complications during and after pregnancy and delivery. Therefore, FGC should never be "medicalised" by health services in refugee camps, or carried out by professional health workers.

Adolescent sexual healthAdolescent sexual health

Like adults, refugee adolescents are at serious risk for HIV/STIs, unintended pregnancy and unsafe abortion, sexual and gender violence or pregnancy-related morbidity and mortality.  The refugee situation creates instability in the sexual and reproductive development of teenagers, with often severe, even life-threatening consequences. They are at increased risk of suffering sexual and physical violence, especially because adolescents live unaccompanied in many camps. Older teenagers may have increased responsibilities for younger siblings. Schooling or training has been interrupted and career opportunities are lost, resulting in feelings of disempowerment. Adolescents' removal from traditional guidance, their own culture and the uncertainties of their present lives can result in confusion about sexual behaviour. Boredom may lead to increased drug and alcohol use and an earlier onset of unprotected sexual activity. Their precarious economic situation increases the chances that adolescents will engage in prostitution to feed themselves or their families. Teenagers are often not able to access reproductive health services as youth-friendly health services are rarely available.

International responses

In response to these problems, a number of organisations have adapted their policies to include reproductive health and rights for people living in conflict or post-conflict situations. In 1995, an Inter-Agency Working Group (IAWG) for Reproductive Health in Refugee Situations was established under the co-ordination of UNHCR. Its members include some 30 UN and governmental agencies, NGOs, academic and donor institutions. The group has a guidance role in strengthening reproductive health services in refugee situations. The IAWG produced a field manual that describes a Minimum Initial Service Package (MISP) of reproductive health interventions to be put in place as soon as possible in a refugee situation. The MISP incorporates all that is needed to provide basic reproductive health services during the emergency phase of a crisis situation. Its aim is to reduce mortality. As soon as the situation stabilises, comprehensive reproductive health service provision should follow. The field manual advises on how to put the MISP into practice.

Today, many agencies working in the field implement only one element of reproductive health-care in their projects. Very few comprehensively address the reproductive health needs of forcibly displaced people; e.g. many programmes place insufficient emphasis on involving men and boys in reproductive health. Much more effort needs to be put into translating policies and resolutions into practical measures that will give these people access to comprehensive reproductive health services of their choice. After all, the total worldwide yearly cost of better reproductive health-care is less than one week of world expenditures on armaments.

The article is based on an earlier publication for UNFPA.