Overcoming myths and misperceptions: expanding access to safe abortion services in humanitarian settings

Today, there are over 68.5 million people living in humanitarian settings. This is the largest displacement crisis the world has seen in decades – and it’s getting worse. The number of people displaced due to natural disasters, civil unrest, conflict and human rights abuses is increasing at an  alarming  rate.  So too is the length of time a person spends in displacement, which is now almost 17 years on average. The impact of living in a humanitarian setting is devastating, but for women the hardships are even more life-altering. Many women and girls face increased risks of exploitation, sexual violence and transactional sex, and all have to overcome often seemingly insurmountable obstacles when trying to access sexual and reproductive health (SRH) care at a time when managing their reproductive lives is crucial.

Ipas, an international reproductive health and rights organisation, works globally to reduce the number of maternal deaths due to unsafe abortion by ensuring that all women and girls have access to safe and legal abortion, including those living in humanitarian settings. In partnership with the government of Bangladesh and other international organisations, Ipas is working with healthcare providers to offer comprehensive SRH services, including safe abortion and postabortion care (PAC), to Rohingya refugee women and girls.

Delivering sexual and reproductive health services in the Rohingya crisis

In August 2017, hundreds of thousands of Rohingya fled to neighbouring Bangladesh to escape violence and persecution by the Myanmar army. By the end of the year, over 655,000 had found shelter in Cox’s Bazar, increasing the number of Rohingya refugees already settled in Bangladesh to over 900,000.

Kutupalong camp in Cox’s Bazar is now the largest and most densely populated in the world. Over half of the refugees there are women and girls, many of whom have suffered rape or other forms of sexual violence at the hands of the Myanmar army. Although there are no precise statistics on the number of rape-related pregnancies, the information that is available highlights the importance of providing abortion services –or menstrual regulation (MR) as it is known in Bangladesh – and PAC services in the refugee camps as a basic health service and a human right.

Since 1979, MR in early pregnancy has been practical and a legal part of the nation’s family planning programme, helping to reduce maternal mortality in this large and diverse country. MR is decentralised to even the most remote areas of the country, provided by female welfare volunteers using manual vacuum aspiration (MVA) or a combination of mifepristone and misoprostol to regulate the menstrual cycle when menstruation is absent for a short time.

This national MR programme was rapidly and naturally established for Rohingya refugees. This crisis marks the first known open introduction of safe abortion care in a humani- tarian setting during an acute emergency. Although many in the field saw it as a ‘non-essential service’ or as ‘too com- plicated’, Ipas’s experience working in the camps in Bangladesh, the increasing demand for SRH services plus the experience of thousands of women able to decide when and where to have their next birth, proves those beliefs to be unfounded.

Ipas’s work with Rohingya refugees

‘It was obvious to me this  crisis  was  overwhelming’  says Dr. Sayed Rubayet, country director for Ipas Bangladesh. ‘The Rohingya women and girls suffered sexual torture and humiliation, they needed reproductive health care services that could help alleviate some of their pain’. In September 2017, under Dr. Rubayet’s leadership, Ipas began working in the Rohingya refugee camps with the goal of improving the availability and accessibility of comprehensive SRH services, including MR, PAC and a broader range of contraceptive methods, including long-acting and reversible contraceptive (LARC) methods.

Ipas trained health workers in the camps and, in some cases, embedded a skilled clinician to provide MR services and conduct on-the-job training at selected government and NGO facilities in Cox’s Bazar. ‘We started our work initially at eight facilities’, says Dr. Shamila Nahar, a physician and advisor who manages Ipas’s health provider training in Cox’s Bazar. ‘We arranged and conducted training on MR with medication or MVA in collaboration with partners and the government of Bangladesh for doctors, nurses, family welfare visitors and paramedics at Cox’s Bazar district hospital.’ After getting government approval, Ipas trained clinicians to insert IUDs and contraceptive implants.

Just one and a half years after the influx in 2017, SRH services have been established at 36 facilities and 250 healthcare providers have been trained in comprehensive abortion care provision, including postabortion contraceptive services. Nearly 9,000 Rohingya women have received MR, PAC and family planning services.

Ipas will continue to work with local, national and international organisations in Cox’s Bazar, focusing on increasing health workers’ knowledge of and commitment to MR, PAC and family planning. Strategies for sharing accurate and complete SRH information within the refugee community will continue to be employed.

Early in 2018, Ipas partnered with IDEO.org, an organisation using human-centred design to  develop  creative  solutions to complex social challenges. A team of designers, staff and researchers from Ipas conducted design research, iterating and testing ideas and assumptions, in camps in Cox’s Bazar. After interviewing over 150 women and men about their cultural and religious beliefs and SRH knowledge and decision-making, the team came away with many of their expectations challenged, as well as new insights about how to better reach Rohingya women with SRH information.

It was clear that accurate knowledge about MR and LARC was absent. Men and women were operating in separate spheres, with little overlap. Despite men being the main decision-makers on whether to use family planning, they had unreliable health information. Only women were receiving SRH information, but they were unable to act on it on their own. ‘Most of us are forced by our husbands to become pregnant’ said one 25-year-old woman. ‘Whatever our husbands say, we have to do.’ The religious beliefs of the Rohingya were also initially perceived to be a barrier to the adoption of family planning but, ultimately, Imams were flexible and willing to change their originally tentative views in light of the conditions the refugees found themselves in. One Imam, when speaking to the team about reproductive health services and MR, said: ‘Life is hard here. It goes against the Quran, but now we are in a troubled condition, so you should go to the hospital and take the advice of the doctor’.

The team saw an opportunity and began to prototype a board game about contraception, Kele-Kele shiki – Rohingya for ‘learning through playing’. The aim is to reach women and men separately with information about – and gain men’s acceptance of – family planning and the availability of MR, by involving Imams, local administrative leaders known as Mahjis, doctors and community health workers as trained facilitators. Players are given decision cards to facilitate a discussion between husbands and wives about desired family sizes in their homes. Finally, women are consulted by community health workers about the results of their discussions, and given more detailed information on contraceptive methods and MR using a flip chart developed to answer questions identified during the human-centred design process.

Although Ipas will move forward with its work in the refugee camps, the need for SRH services goes beyond the Rohingya crisis: all women and girls deserve access to safe reproductive health services, including safe abortion and family planning. As such, Ipas is also working to build capacity in the humanitarian sector so that organisations working in fragile and crisis settings can more rapidly respond to the SRH needs of displaced women and girls. ‘I think Ipas’s work with Rohingya refugees can be a model for other countries, governments, donors and aid groups. Through our work in the refugee camps, we know it is possible to offer reproductive health services, including menstrual regulation, quickly and safely in humanitarian settings’, says Rubayet. ‘We need to show everyone that women and girls need safe reproductive health services. We need to dismantle the myth that abortion services cannot be offered in crisis settings’.

Myths, misinformation and stigma: abortion in humanitarian settings

At the onset of any crisis, humanitarian organisations prioritise shelter, food and water but, historically, not all organisations have prioritised the need for reproductive health services, particularly safe abortion. Indeed, many humanitarian prac- titioners and leaders in the field have said that it is impossible to provide safe abortion care in humanitarian settings. In 2016, researchers from Columbia University, Therese McGinn and Sara Casey, surveyed practitioners from humanitarian organisations to determine why safe abortion services were not provided to refugee women T. McGinn and S. E. Casey, ‘Why Don’t Humanitarian Organizations Provide Safe Abortion Services?’, Conflict and Health, 10(8), 2016 (https://www.researchgate.net/publication/297592236_Why_don’t_humanitarian_organizations_provide_safe_abortion_services) .Their findings highlighted four myths that continue to impede the provision of abortion services in humanitarian settings.

• Myth one: there is no need.
• Myth two: abortion is illegal.
• Myth three: donors don’t fund it.
• Myth four: abortion is too complicated to provide in crises.

These myths are perpetuated by misinformation, stigma and a lack of commitment to the basic human rights of women. Additionally, the restrictive legal and policy environment around abortion in many countries, including the United States, makes it easier to ignore the need for it. These myths need dismantling so that women can access reproductive health services, including safe abortion, in emergency settings

Debunking myth one: there is no need

Unsafe abortion occurs in every country, regardless of the legal or social context, because women everywhere experience unwanted and unintended pregnancies and many are determined to end them. Although there is little to no research on the topic, the need for safe abortion services likely increases in humanitarian settings.

Debunking myth two: abortion is illegal

Ninety-three per cent of the world’s population lives in a country where safe abortion is permitted under one or more circumstances.  Only  three  countries  ban  abortion  entirely: El Salvador, Nicaragua and Malta. Many international and regional agreements support the imperative to provide safe abortion in crisis settings. International agreements such as the Geneva Convention, UN Security Resolutions 2106 and 2122 and the Maputo Protocol support access to safe abortion care for survivors of rape, regardless of national law. That is not to say that navigating the legal landscape is easy. For example, although Médecins Sans Frontières (MSF) took a policy decision to provide safe abortion in 2004, it has taken time for the organisation to fully act on the policy. C. Schulte-Hillen and J.-F. Saint-Saveur, ‘Why Médecins Sans Frontières (MSF) Provides Safe Abortion Care and What that Involves’, Conflict and Health, 10(19), 2016 (https://www.researchgate.net/publication/305877361_Why_Medecins_Sans_Frontieres_MSF_provides_safe_abortion_care_and_what_that_involves).

Debunking myth three: donors don’t fund it.

The US government, a major humanitarian donor, doesn’t fund abortion care under the Helms Amendment, and foreign organisations that receive USAID funding are prevented from offering advice, referring clients for abortion services or advocating for abortion law reform irrespective of funding source. However, many other bilateral and foundation donors do fund safe abortion care.

Under its Feminist International Assistance Policy,Canada has allocated CA$650 million for the sexual and reproductive health and rights (SRHR) of women and girls. The policy promotes a comprehensive package of SRH services including safe abortion care, comprehensive sexuality education, gender- based violence interventions and services to meet the needs of women and girls in humanitarian crises.

Debunking myth four: abortion is too complicated

The perception that abortion is too complicated for humani- tarian actors to provide is simply wrong. With proper training, early abortion is among the safest and simplest medical procedures. Manual vacuum aspiration and medication abor- tion, abortion methods recommended by the World Health Organization (WHO), can be safely and effectively performed in the first trimester by primary care providers, and in the case of medication abortion by women themselves. Neither method requires electricity, running water or sophisticated equipment.

Moreover, most of the equipment, medications and infection- prevention procedures needed for safe abortions are the same as those needed for basic emergency obstetric care and other gynaecology services. The procedure is very similar to PAC, used for treating complications arising from unsafe abortion or to manage miscarriages, and any organisation supporting primary healthcare in humanitarian settings could provide safe abortion services with little additional input.

That doesn’t  mean  that   there   aren’t   unique   challenges to providing safe abortion care in humanitarian settings. Abortion stigma exists at all levels within humanitarian aid organisations, from top leaders to frontline health workers. There is also a severe lack of trained healthcare providers, as many countries still needlessly exclude abortion care from the scope of practice of primary and mid-level providers, such as nurses and midwives. There is a false belief that established safe abortion training models aren’t feasible during an acute crisis, but models can and have now been adapted to be nimbler; Ipas’s work training health providers in the Rohingya camps shows that providing safe abortion services during an acute emergency can be done.

‘We have struck down many barriers by offering women access to safe abortion services during this crisis. I have seen how women have reacted and what it meant to them’, says Nahar. ‘But there is more work to be done and we need to see more humanitarian organisations delivering reproductive health services to refugee women, it is their human right’.

The way forward

While there is a dearth of evidence on SRHR, and especially abortion, in humanitarian settings to guide programming and service implementation, we know safe abortion care reduces unsafe abortions and ultimately saves lives – in any context. Unfortunately, we also know that sexual violence against women in humanitarian settings is not only a risk during flight, but continues during protracted emergencies, when women are supposed to be safe from coercion and assault.

The Inter-Agency Working Group (IAWG) on Reproductive Health in Crises is a coalition of governmental, non-governmental and donor organisations and United Nations agencies working to expand and strengthen comprehensive SRH services for people living in crisis settings. (See http://iawg.net/). The IAWG advocates that ‘safe abortion services must be accessible, adequate, and available at any time during displacement, of good quality, without discrimination, violence or coercion’ and that ‘health care providers in crises should be trained to provide high-quality, rights-based safe abortion services’. One area of focus for IAWG is ensuring that women and girls have access to safe abortion care during all phases of a crisis, or as early as possible during an emergency. The Minimum Initial Service Package (MISP) for reproductive health, developed by IAWG, outlines a set of priority activities that should be implemented in every humanitarian crisis. The activities in the MISP form part of a comprehensive reproductive health package – including safe abortion and PAC – that should be implemented and sustained throughout protracted emergencies.

Ipas’s work in the Rohingya camps has the support of the Bangladeshi government and many aid agencies, and we know it is possible to offer reproductive health services, including menstrual regulation, quickly. Let this be a model and a call to action for other countries, governments, donors and aid groups: it is vital that humanitarian NGOs normalise and integrate abortion into maternal healthcare and commit to ensuring that all women have access to high-quality and non- discriminatory health services. The availability of safe abortion in conflict-affected settings is not only a matter of urgency – it is also a moral imperative. Women’s rights – including access to comprehensive reproductive health – are human rights.

Tamara Fetters is a Senior Researcher at Ipas, where Bill Powell is Senior Medical Scientist. Dr. Sayed Rubayet is Country Director for Ipas Bangladesh. Dr. Shamila Nahar is Senior Advisor for Ipas Bangladesh. The authors would like to acknowledge the contributions of Dr. Sharmin Sultana, Md. Abul Monsur, Dr. Kaneez Husnain, Sujan Barua, and the field paramedics and other health workers who have worked tirelessly  to  ensure  Rohingya  women have access to safe reproductive health services.