The Need for Priority Reproductive Health Services for Displaced Iraqi Women and Girls

Abstract

Disregarding reproductive health in situations of conflict or natural disaster has serious consequences, particularly for women and girls affected by the emergency. In an effort to protect the health and save the lives of women and girls in crises, international standards for five priority reproductive health activities that must be implemented at the onset of an emergency have been established for humanitarian actors: humanitarian coordination, prevention of and response to sexual violence, minimisation of HIV transmission, reduction of maternal and neonatal death and disability, and planning for comprehensive reproductive health services. The extent of implementation of these essential activities is explored in this paper in the context of refugees in Jordan fleeing the war in Iraq. Significant gaps in each area exist, particularly coordination and prevention of sexual violence and care for survivors. Recommendations for those responding to this crisis include designating a focal point to coordinate implementation of priority reproductive health services, preventing sexual exploitation and providing clinical care for survivors of sexual violence, providing emergency obstetric care for all refugees, including a 24-hour referral system, ensuring adherence to standards to prevent HIV transmission, making condoms free and available, and planning for comprehensive reproductive health services.

Résumé

Négliger la santé génésique en cas de conflit ou de catastrophe naturelle a de graves conséquences, en particulier pour les femmes et les jeunes filles touchées par la situation d’urgence. Afin de protéger la santé et sauver la vie des femmes et des jeunes filles placées dans des crises, on a défini les normes internationales de cinq activités prioritaires de santé génésique que les acteurs humanitaires doivent appliquer au début d’une urgence : coordination humanitaire ; prévention et prise en charge de la violence sexuelle ; minimisation de la transmission du VIH ; réduction de la mortalité et de l’invalidité maternelles et néonatales ; planification de services de santé génésique complets. L’article examine dans quelle mesure ces activités essentielles sont appliquées en faveur des réfugiés iraquiens en Jordanie. Il a constaté des manques notables dans chaque domaine, en particulier la coordination, la prévention de la violence sexuelle et les soins aux victimes. L’article recommande aux responsables des interventions dans cette crise de désigner un responsable central chargé de coordonner l’application de services prioritaires de santé génésique, de prévenir l’exploitation sexuelle et de délivrer des soins cliniques pour les victimes de la violence sexuelle, d’assurer des soins obstétricaux à toutes les réfugiées, notamment un système d’orientation des patientes 24 heures sur 24, de garantir le respect des normes pour prévenir la transmission du VIH, de distribuer gratuitement des préservatifs et de planifier des services de santé génésique complets.

Resumen

Hacer caso omiso de la salud reproductiva en situaciones de conflicto o desastre natural tiene graves consecuencias, particularmente para mujeres y niñas afectadas por la emergencia. En un esfuerzo por proteger la salud y salvar la vida de mujeres y niñas en crisis, se han establecido normas internacionales para actores humanitarios respecto a cinco actividades prioritarias de salud reproductiva, que deben implementarse al inicio de la emergencia: coordinación humanitaria, prevención de la violencia sexual y respuesta a ésta, minimización de la transmisión del VIH, reducción de las tasas de mobimortalidad materna y neonatal, y planificación de servicios de atención integral a la salud reproductiva. En este artículo se explora el grado de implementación de estas actividades esenciales en el contexto de los refugiados en Jordania que huyen de la guerra en Iraq. Existen brechas considerables en cada área, particularmente en la coordinación y prevención de la violencia sexual y la atención de las sobrevivientes. Algunas recomendaciones para aquéllos que respondan a esta crisis son: designar un punto focal para coordinar la implementación de servicios prioritarios de salud reproductiva, prevenir la explotación sexual y brindar atención médica a las sobrevivientes de la violencia sexual, incluidos los cuidados obstétricos de emergencia para todas las refugiadas y un sistema de referencia de 24 horas, así como garantizar el cumplimiento de las normas para prevenir la transmisión del VIH, hacer los condones gratuitos y disponibles, y planificar servicios de atención integral a la salud reproductiva.

Key Words:

• refugees
• conflict and crisis settings
• reproductive health services
• humanitarian emergencies
• Iraq
• Jordan

Women and girls displaced by conflict or natural disaster face extraordinary difficulties that affect their reproductive health. During displacement, women and girls often lose protection, access to health care and education, livelihoods and community support. They are vulnerable to sexual violence by armed forces and others and face increased risk of exploitation in general. Lack of quality reproductive health services, a common reality for most displaced women and children, can lead to high mortality rates among them, an increase in the spread of sexually transmitted infections, including HIV, an increase in unsafe abortions and increased morbidity related to high fertility rates and poor birth spacing. Pregnant women and girls fleeing conflict often lack access to safe delivery services and lifesaving emergency obstetric care.

This article explores the priority reproductive health needs and service gaps faced by Iraqi refugees in Jordan following a Women’s Commission for Refugee Women and Children (Women’s Commission) field mission to Amman, Jordan, which found that Iraqi refugees have limited access to priority reproductive health services. Findings demonstrated gaps in adherence to international standards for reproductive health in emergencies, including prevention of and response to sexual violence, essential obstetric care and prevention of HIV transmission.

Methodology

The Women’s Commission, a non-governmental organisation that advocates for policies and programmes to ensure the rights and protection of refugee women, children and youth, conducted a field mission to Amman, Jordan, from 6–23 June 2007. The purpose of the mission was to gain a snapshot of the reproductive health situation of Iraqi refugees in Jordan in order to bring their issues to the attention of policymakers. This was achieved by collecting stories and case studies from Iraqi women, men and young people about their reproductive health and other needs during each phase of displacement, including their experiences at home during the war, during flight and as refugees. The Women’s Commission met with five United Nations agencies, six local and eight international non-governmental organisations and talked to eight Iraqi families and over 30 individual Iraqi refugees about their plight. Since Amman is an urban refugee setting, Iraqis are difficult to identify and find. The Women’s Commission initially met with the international coordinator from the NGO Coordinating Committee in Iraq who helped us identify and recruit refugees and representatives from local Iraqi organisations; in turn, these individuals assisted us in identifying and connecting with additional refugees. Informed consent was provided by all participants and strict confidentiality is maintained. Although generalisations about Iraqi refugees in Jordan cannot be made, given the number of interviews and the use of snowball sampling, the study provides a snapshot of the situation on the ground.

Overview: priority reproductive health services

In 1996, United Nations agencies, academic and research institutions as well as governmental and non-governmental organisations came together to develop standards and guidelines on reproductive health in emergency settings in an effort to systematise the inclusion of reproductive health care into humanitarian programming. One outcome of their efforts was the development of the Minimum Initial Service Package (MISP) for Reproductive Health. The MISP is a set of priority reproductive health activities to be implemented at the onset of conflict or natural disaster. It is a standard for humanitarian actors as outlined in the 2004 revision of the Sphere Humanitarian Charter and Minimum Standards in Disaster Response.

The objective of the MISP is to reduce mortality and morbidity related to reproductive health problems among populations affected by emergencies, particularly women and girls. When implemented in the early days and weeks of a crisis, the MISP saves lives and prevents illness. It comprises five key activities:

• identifying an organisation(s) and individual(s) to facilitate the coordination and implementation of the MISP;

• preventing sexual violence and providing clinical care to survivors;

• reducing the transmission of HIV;

• preventing excess maternal and neonatal mortality and morbidity; and

• planning for the provision of comprehensive reproductive health services, integrated into primary health care, once the situation stabilises.

These five components are the most important initial reproductive health activities to implement in an emergency because they prevent death and disability and set the stage for comprehensive reproductive health services. They should be implemented even without the collection of site-specific reproductive health-related data, as documented evidence already justifies the implementation of these activities.¹ Once the priority activities are addressed they should immediately be followed by implementation of comprehensive reproductive health programming, including family planning services; prevention and response to all forms of gender-based violence; maternal, neonatal and child health services; and programmes to address sexually transmitted infections and HIV/AIDS. Neglecting reproductive health in crises has serious consequences: preventable maternal and infant deaths, sexual violence and subsequent trauma, sexually transmitted infections, including the spread of HIV, unwanted pregnancies and unsafe abortions.

Displaced Iraqi women and children

Refugee and internally displaced women face enormous challenges to their reproductive health, and the women and girls fleeing Iraq are no exception. The war in Iraq has created the fastest-growing refugee crisis in the world. Since the United States launched Operation Iraqi Freedom in 2003, the conflict has raged, forcing millions to flee in search of safety. Approximately one in every six Iraqis has left her/his home² and an estimated 40% of Iraq’s middle class is believed to have fled.³ As of November 2007, approximately 4.6 million people were displaced: over 2.4 million within Iraq and 2.2 million in neighbouring countries.⁴ Despite the ongoing insecurity, around 3,600 internally displaced Iraqis and some 30,000 refugee families returned to certain areas of Iraq in the last quarter of 2007,⁵ primarily due to impoverishment or because their visas had expired.⁶

Although data on Iraqi refugees is lacking, in every refugee crisis approximately 75–80% of the displaced are women and children;⁷ they are also the most vulnerable. Inside Iraq, women and children make up 83% of the displaced.⁸ Women and children from Iraq who have escaped from the war into surrounding countries continue to face enormous challenges to their survival and well-being.

Neighbouring Jordan, for example, a country of six million people, has received between 450,000 and 500,000 Iraqi refugees,⁹ which is putting a strain on the country’s already limited resources. Women-headed households are commonplace among refugees, as many men have either been killed in the war or have remained in Iraq. The Jordanian government does not recognise Iraqis fleeing the war as refugees; thus, most live in the country illegally and can be deported at any time. They cannot lawfully work and have limited access to basic health services, including reproductive health care. The implementation of the Minimum Initial Service Package for Reproductive Health among Iraqi refugees in Jordan could help save women’s and girls’ lives and prevent long-term disability.

Challenges to service delivery

Humanitarian actors were slow to respond to the flow of refugees pouring out of Iraq until it reached crisis proportions. Once relief agencies geared up for a response, the Jordanian government did not allow new organisations permits to provide services for Iraqis in the country, fearing that aid would encourage refugees to stay permanently. Agencies that were operational before the Iraq crisis were permitted to continue working in Jordan.

In June 2007 only one international agency was allowed to provide minimal health services to Iraqis in Jordan at no or reduced cost. This Catholic organisation had run a small clinic in Amman since 1968, and was thus allowed to respond to the refugee influx from Iraq. This clinic provided basic health services to refugees who could afford these services and were willing to risk deportation by travelling openly to the clinic. However, it offered only limited reproductive health services due to its religious mandate: it did not provide family planning services or emergency contraception for rape survivors, and it denied maternal health services to pregnant women and girls who could not produce a marriage certificate. In addition, it referred patients to a local Catholic charity hospital, which had similar restrictions on reproductive health services. International guidelines set forth by the World Health Organization (WHO) state that religious relief agencies are not required to provide services that violate their mandate. Therefore, it is critical that other agencies be allowed to provide or support health services to ensure Iraqis have access to comprehensive reproductive health care, which is protected under human rights law.¹⁰

A government-funded charity clinic in Amman also provided services to the poor, including refugees, but Iraqis said that the wait for an appointment at this clinic was at least two months.

Thus, the overall humanitarian response for Iraqis was minimal at best. Coordination of relief agencies providing health services – the first activity outlined in the MISP – to Iraqi refugees in Jordan was non-existent at the time of the field mission in June 2007. Health coordination meetings were not yet established, and a coordinator for the MISP had not been identified.

Many of the representatives the field team met with, including from local and international organisations as well as UN agencies, did not think reproductive health was a priority activity in this refugee crisis. One representative from a prominent non governmental relief organisation said: “Why focus on women and girls? It’s the men and boys who need help.” Another representative from a UN agency chuckled when he heard that the field team was focused on reproductive health. While it was disconcerting to hear these comments, it was encouraging that after the field mission, five major UN agencies have appealed for over US$84 million to support improved access to local health care, including reproductive health services, for Iraqi refugees in Syria, Jordan and Egypt.¹¹ The UN High Commissioner for Refugees (UNHCR), UN Population Fund (UNFPA), UNICEF, WHO and World Food Programme launched this interagency appeal in September 2007.¹¹ The appeal gives substantial support to reproductive health care, including the priority services outlined in the MISP. However, as of January 2008, only 2% of the appeal had been funded.¹²

Sexual violence

Sexual violence increases during war and conflict.¹³ Many refugee women and girls in Jordan experienced or witnessed sexual violence in Iraq, where they are increasingly targeted for violence,¹⁴¹⁵ particularly rape, by armed groups and civilians. Rape in war is often used to control, degrade and humiliate a community or population. Women and adolescents are especially vulnerable.

After the fall of Saddam Hussein’s regime, Human Rights Watch documented an acute escalation of sexual violence in Baghdad.¹⁶ More than 400 Iraqi women were abducted and raped within the first four months of the US invasion,¹⁷ and more than half of these reported rapes resulted in the murder of rape victims by their families.¹⁴ One Iraqi legislator commented: “These attempts to intimidate women are attempts to terrorise society.”¹⁸

According to a local group, the Organization for Women’s Freedom in Iraq (OWFI), trafficking and sexual exploitation have increased since the beginning of the war.¹⁹ Fifteen per cent of Iraqi women widowed by the war are seeking “temporary marriages” or sex work for protection and/or financial support.¹⁹ Four thousand Iraqi women, one-fifth of whom are under 18, have disappeared since the 2003 invasion, reports OWFI; many are believed to have been trafficked.¹⁹ The US State Department also reports that Iraqi women and girls are believed to have been internally and internationally trafficked for sexual exploitation.²⁰ According to Asuda, a local Iraqi organisation, most women in Iraq now only go outside with a male escort, and rape is commonly committed by all armed groups; they also report that the killing of women is increasing.²¹ In Basra, in southern Iraq, local police reported 40 cases in five months alone of women killed by religious vigilantes because of how they were dressed. Their mutilated bodies were found with notes warning against “violating Islamic teachings”.²² The actual number of murdered women is believed to be much higher since many cases go unreported for fear of reprisals.

Sexual violence against women in detention in Iraq has also been reported. The Women’s Commission field team met two former detainees of Abu Ghraib prison who described the systematic rape of women prisoners. A researcher from the Iraqi Justice Ministry confirmed that guards were raping women prisoners at two detention centres, including Abu Ghraib.¹⁴ The American Civil Liberties Union has also documented rape of Iraqi women prisoners in detention centres.²³

International support to address sexual violence and other forms of gender-based violence in Iraq has been minimal.²⁴ Due to ongoing insecurity, a small number of relief agencies operate in Iraq, and the country’s health care system is overburdened. Further, up to 75% of doctors, pharmacists and nurses have left their jobs, according to the Iraqi Medical Association.²⁵ Male gynaecologists have been specifically targeted for violence and intimidation by extremist groups for “invading the privacy of women”.²⁶ Few women report rape due to shame and stigma and because the likelihood of survivors of sexual violence seeking and receiving medical care and psychosocial support in Iraq is virtually nil.

Due to the widespread sexual violence and lack of medical care for survivors in Iraq, Iraqi refugees in Jordan need particular help. The refugee women and girls who have survived rape in their home country are left to cope by themselves with the emotional and physical effects of the sexual violence. One refugee woman described her ordeal:

“After the war [began], my husband started working for [an international humanitarian agency]. After a while he was kidnapped. We paid the ransom for him. After that, my daughter and I were kidnapped while we were shopping. We stayed there for 19 days… I was nine months pregnant at the time. We were tortured very much… They raped me. I had just one week to deliver the baby, but she was dead inside me. She was a girl, a daughter… We are threatened here. We were tortured there. Our life is full of fear.”

Awareness among Iraqi refugees of the benefit of medical care for rape survivors is low. In addition to cultural norms that discourage rape survivors from coming forward, doctors in Jordan are required to report to the police any woman who seeks medical care for rape. Moreover, clinical care for rape survivors, which includes emergency contraception to prevent pregnancy and prophylaxis against HIV transmission, was not available at the clinics or hospitals visited by the field team. Indeed, the medical director of the main referral hospital for refugees said he had never heard of medicine to reduce the likelihood of HIV infection. Emergency contraception was not made available at this hospital because it was against their policy as a Catholic institution. No refugees with whom the field team met were aware of emergency contraception.

As refugees’ savings are depleted and families struggle to survive, women and girls are becoming more vulnerable to sexual abuse and exploitation. Representatives from local and international organisations as well as refugees themselves noted that sexual exploitation of Iraqi women and girls is a problem in Jordan, but the extent has not been documented at the time of this writing. Commercial sex work generally does not take place in the public sphere; customers come directly to women’s homes or to other private venues. Sex workers are often identified by word of mouth, according to an international aid worker.

Figure 1 Desperate mother searches for her two children, who disappeared amid a huge fire at an illegal petrol station, Baghdad, May 2003

Obstetric complications

Approximately 4% of any population, including those displaced by crises, will be pregnant at any given time.²⁷ Fifteen per cent of pregnant women experience an unforeseen obstetric complication, such as obstructed or prolonged labour, pre-eclampsia or eclampsia, sepsis, ruptured uterus, ectopic pregnancy or complications of (unsafe) abortion.²⁸ Women and girls without access to emergency obstetric services may die or suffer preventable long-term health consequences.

Emergency obstetric services for Iraqi refugees in Amman are generally good. Maternal mortality in Jordan overall is low, 41 deaths per 100,000 live births.²⁹ The Catholic clinic – the only clinic in Amman that specifically serves Iraqi refugees – provides free emergency obstetric care and refers Iraqi refugees to the local Catholic charity hospital. Care for women and girls injured from unsafe abortion, which does occur among refugees according to a clinic case worker, is available at the referral hospital.

Nevertheless, significant gaps remain. Many Iraqis are not aware of the availability of free primary health care for pregnant women, and tend to use the private sector for delivery care.¹¹ In addition, the referral hospital is located far from many refugees’ homes, and money for transportation is scarce. Others are too scared of deportation to access services. Pregnant women and girls must present a marriage certificate to receive any pregnancy-related care, as mentioned earlier. In addition, women must have registered with the UN refugee agency before receiving care; although this policy was officially rescinded, it was still being enforced at the time of the mission. According to UNHCR, a little over 50,000 refugees had registered as of December 2007; the vast majority had not registered.³⁰ Furthermore, a staff member of the faith-based clinic said that refugee emergency cases were not guaranteed care, even in life or death situations. One Iraqi woman described the lack of access to medical care:

“If I have money, I will go to the doctor, if I don’t, then I am quiet… We need a doctor, we need to get medicine. We need help. No one is helping us.”

HIV transmission

While isolation and lack of mobility during displacement may prove to be a protective factor against HIV infection,³¹ sexually transmitted infections, including HIV, generally spread faster where there is poverty, powerlessness and instability. These infections can thrive in emergencies where access to prevention and treatment is limited. As such, efforts to stop and reverse any increase in new infections are essential.

Both Jordan and Iraq have very low HIV prevalence, an estimated .02%.³²³³ However, reported cases have increased in the past three years in Iraq, primarily around the capital.³⁴ At the end of 2005, 61 people were known to have HIV in Iraq; 26 new cases were reported since then.³⁴³⁵ The Iraqi Aid Association for Chronic Patients, a local non-governmental organisation, noted that there has been an increase in general discrimination toward people who are HIV-positive.³⁶ In addition, a lack of antiretroviral drugs and HIV testing equipment have prompted health authorities in northern Iraq to deport foreigners who have been found to have HIV.³⁷ The sole clinic in all of Iraq that provides free treatment for people living with HIV suffers from a dearth of appropriate medicines and trained health staff.³⁸ Further, approximately 70% of young people in Iraq had never heard of HIV or AIDS according to a 2005 survey by UNICEF.³⁸

Although both refugee and host populations have low HIV prevalence, the conditions for transmission are ripe in Jordan. Iraqi refugees are plagued by poverty, diminished resources, lack of access to health services and sexual exploitation. In addition, prophylaxis against HIV transmission after rape or unprotected sex does not appear to be available. Condoms are available for purchase in pharmacies in Amman, although scarce resources limit the ability of Iraqis to buy them. Moreover, interviewed refugees reported that pharmacists would not sell contraceptives to young or unmarried women and girls.

Planning for comprehensive reproductive health services

It is essential to plan, in collaboration with displaced women, youth and men, for the integration of comprehensive, good quality reproductive health activities into primary health care as soon as possible. The reproductive health of adolescents should also be prioritised as they have specific needs which are often neglected. Collecting background data on the reproductive health needs of the displaced population, identifying suitable sites to provide comprehensive care, assessing staff capacity and ordering appropriate supplies will help to ensure that comprehensive reproductive services are established after the other activities of the MISP have been put in place and when a more stable phase of the emergency has been reached.

Family planning services, as well as comprehensive gender-based violence programmes, must be established as soon as possible for Iraqi refugees in Jordan. Although some contraceptives are available over the counter, these birth control methods were unaffordable for many refugees. In addition, pharmacists may discriminate against younger or non-married women and girls and refuse to sell to them. The Women’s Commission has also received anecdotal reports that abandoned newborns have been found in predominantly Iraqi neighbourhoods in Amman.

Domestic violence was also reported as a widespread problem by the Iraqis interviewed in Jordan. The stress of living in cramped quarters, the trauma of violence and loss experienced in Iraq compounded by the lack of employment have contributed to extensive domestic violence. Marital rape, which is not illegal in Jordan, was also reported. One Iraqi refugee mother of seven explained her situation:

“We are having this situation [of domestic violence] here. Nobody is patient with the other. Even the youngest man won’t accept any kind of criticism. Everybody is tense… Women always get the lion’s share of this. The lady stays at home, suffering.”

Recommendations

Based on the findings of the mission, the following recommendations were developed for humanitarian actors to fully address the priority reproductive health needs of Iraqi refugees in Jordan:

• The interagency health sector appeal, Meeting the Health Needs of Iraqis Displaced in Neighbouring Countries, should be fully funded as soon as possible by international donors.

• UNFPA should designate a reproductive health focal point to coordinate implementation of the Minimum Initial Service Package for Reproductive Health.

• The Jordanian Ministry of Health, UN agencies and national and international non-governmental organisations working in the direct provision of health services should all be competent to directly provide comprehensive clinical care for survivors of sexual assault, including post-exposure HIV prophylaxis, emergency contraception, prophylactic antibiotics, post-abortion and other care as needed.

• Appropriate, culturally sensitive psychosocial care for rape survivors should be available.

• Humanitarian actors should undertake an information campaign to inform the refugee community about the urgency of and procedure for referring survivors of sexual violence.

• UN agencies and donor governments should encourage the Jordanian government to allow Iraqis to work and to engage in viable income generation activities to address acute poverty and women’s vulnerability to sexual abuse and exploitation as well as help to develop and implement economic programmes that benefit both the refugee and host communities.

• All pregnant women, regardless of their marital status, should have access to round-the-clock emergency obstetric care, including post-abortion care.

• All agencies should make condoms free and available to humanitarian staff and refugees in culturally sensitive locations, for example, at registration sites, at clinics and from community health/outreach workers, including for young people, unless their mandate explicitly forbids the provision of these services.

• All agencies working in the health and community services sectors should plan for comprehensive reproductive health services with the involvement of refugee women, men and youth to include essential obstetric services, the management of sexually transmitted infections, family planning and comprehensive gender-based violence programming.

• Where an agency’s mandate explicitly forbids the provision of any of these services, UNFPA and other agencies should ensure they are available and accessible elsewhere.

Conclusion

Although research shows that there is growing awareness and support for the Minimum Initial Service Package for Reproductive Health in standards, practice and funding,³⁹ this has not been translated into the availability of these critical services for displaced populations and others affected at the onset of new emergencies. Recent assessments showed that most humanitarian actors in the field were not familiar with the MISP or its key objectives and priority activities.^40–43 As a result, millions of displaced people, especially women and girls, are still at unnecessary risk. Humanitarian actors are bound by international standards to ensure that priority reproductive health activities are implemented. The refugees in Jordan who have fled the war in Iraq have a right to this life-saving care. Sexual violence in Iraq abounds, and sexual exploitation has the potential to flourish among refugees in Jordan. Care for Iraqi refugees with problems in pregnancy and delivery is limited to the married and the well-off. The international community must act now to protect the lives and preserve the health of women and girls who have endured the horrors of the war in Iraq and struggling to survive in Jordan.

Acknowledgements

This article would not have been possible without the efforts of the two additional field team members, Megan McKenna and Mary Jane Escobar Collins of the Women’s Commission for Refugee Women and Children. Thanks are due to the following individuals who reviewed the article and provided insightful feedback: Sandra Krause, Joan Timoney, Susan Purdin, Mihoko Tanabe and Diana Quick. Special thanks go to all the Iraqi refugees who participated in this project, in particular three whose support and help were invaluable. This project was funded by the William and Flora Hewlett Foundation.