ReliefWeb

Summary

Refugees have the right and a need to access sexual and reproductive health (SRH) services, including family planning. SRH services saves lives yet access to quality SRH services decreases during humanitarian crises as these services are compromised. In general, they are underfunded and overlooked or deprioritised, even as demand for these services increases with refugees wanting to prevent having children due to their situation and lack of family support, and an increased risk of forced sex, risk-taking behaviours and exposure to high-risk situations. In one study of reproductive health programmes in conflict areas, 30% to 40% of women reported that they did not want a child within two years and an additional 12% to 35% wanted no additional children highlighting a clear need for family planning services in conflict settings. Emergency responders, governments and development actors need to collectively scale-up access to contraception for women and girls affected by crises.

Tanzania hosts around 300,000 refugees mostly from the Democratic Republic of Congo (DRC) and Burundi in three camps, Nyarugusu, Mtendeli and Nduta, located in the Kigoma Region in northwest Tanzania. These camps extend beyond original capacity, having had to cope with a large and rapid influx of Burundians. They offer minimal SRH services and do not provide a safe environment for women and girls who experience sexual violence on the way to/from latrines and showers and whilst collecting water for drinking and washing and firewood for cooking outside the camp, owing to limited camp supplies. There remains therefore opportunity to scale up quality SRH services and improve safety and security related to camp infrastructure and services.

Knowledge of contraceptive methods, STIs and HIV/AIDS are limited in general among refugee, migrant and displaced girls and young women and this group often experiences gender-based and sexual violence and abuse. Access and availability of SRH services are often limited due to distances, costs and stigma. In the Tanzanian refugee camps, factors contributing to teenage pregnancy - education, culture, poverty and unstable family relations – have been found to be exacerbated.

Understanding barriers to family planning uptake in the countries from which the refugees in the Tanzanian camps fled could help understand barriers to be faced in scaling up family planning in these camps where specific evidence is minimal. Barriers preventing uptake of modern contraception among women and men in the DRC include socio-cultural norms (especially the husband’s role as primary decision-maker and the desire for a large family), poor spousal communication, fear of side-effects and a lack of knowledge. Many of the women studied though were open to using a modern family planning method in the future offering potential for positive changes in behaviour and perceptions of contraceptive use. Likewise, in Burundi, unmet need for contraception among married women of reproductive age was associated with being poor, rural, no education, living with four, five or six plus children, not visiting a health facility within the past 12 months and lacking access to radio or television messages. Furthermore, availability of modern contraceptives among women of reproductive age in rural Burundi was found not to ensure uptake. A lack of available and trained health professionals to provide contraceptive services; a lack of fit between methods preferred by women and those easily available; a climate of fear surrounding contraceptive use; and provider refusal to offer family planning services have been identified as barriers to uptake.

Evidence shows uptake of SRH services in humanitarian settings if they are of quality. The 2018 Inter-Agency Field Manual (IAFM) on SRH in humanitarian settings places emphasis on human rights, principles and obligations; a new focus on preventing unintended pregnancy and addressing safe abortion; and provides practical guidance on transitioning from the Minimum Initial Service Package (MISP) to comprehensive SRH services grounded in wider health system strengthening. The manual also highlights the importance in understanding community and cultural beliefs, values and norms around fertility, family planning and contraception. Multiple barriers at multiple levels need to be addressed when providing client-centred services. Examples include, public information campaigns considerate of literacy levels; engaging with influential leaders and adolescents to provide knowledge and understanding of family planning, acceptance and involvement of awareness raising among their community; knowledge and skills training for health professionals and community health workers; strengthening health infrastructure, human resources and providing a sustainable and consistent supply of contraceptives women would like to use; reaching out beyond the health facility through community-based distribution of family planning by community health workers; providing private and respectful services; promoting spousal communication, involving males and providing education.

Trained health cadres (doctors, midwives, clinical officers, community health workers, etc.) exist within nearly every crisis-affected community so effort should be taken to identify them, verify their skills, and mobilise them for service delivery. Engaging local providers will support rapid scale-up of both clinical and community-based contraceptive services and establish more sustainable service delivery models that will more effectively transition to recovery.

This review drew on academic and grey literature, as well as media reports. Literature specific for the Tanzanian refugee camps was less robust. There is minimal peer-reviewed literature on SRH related aspects among refugee, migrant and displaced girls and young women in Africa. Track20 is working with Burundi, DRC and Tanzania, FP2020 pledging countries, to build their capacity to improve the quality of data being collected on SRH and the use of this data to inform regular monitoring and strategic decision-making.

Agencies are working together to provide SRH services in the Tanzanian camps. For example, the United Nations Population Fund (UNFPA) have partnered with Tanzania Red Cross Society, the International Rescue Committee (IRC) and Médecins Sans Frontières (MSF) to support Burundian and Congolese refugees with SRH services including the provision of short and long-term modern contraceptives and providing family planning awareness campaigns.