Ignoring Women Imperils the Effort

When lives are disrupted by natural or man-made calamities, women keep menstruating, getting pregnant, having babies, and, all too often, being raped, harassed or exposed to sexually transmitted diseases. Pregnancy and childbirth are vulnerable times in any woman’s life. But crises put pregnant women at far greater risk due to stress, injury, loss of medical support, trauma, malnutrition, disease and exposure to violence.

Women are disproportionately affected by crises. It is they who typically care for the young, the injured and the infirm, and who keep the frayed social fabric from falling apart. Nevertheless, their needs are often neglected and their strengths ignored. Worse, in some countries their very bodies have become battlegrounds, as epidemics of sexual violence have become increasingly ferocious.

Contents

• The Current Situation
  • How crisis disproportionately affects women and girls
  • Maternal Health
  • HIV/AIDS
  • Sexual Violence
• What Must Be Done
  • Links between the ICPD and Millennium Development Goals

The Current Situation

• A total of 1 per cent of the world – more than 60 million people -- are estimated to be displaced internally either by armed conflicts, violence, urbanization, development and natural disasters. ^[1]
• Over the last decade, people in conflict zones have joined the ranks of the world’s displaced at a rate of 100 per hour. ^[2]
   
• The total number of natural disasters has quadrupled in the last two decades – most of them floods, cyclones, and storms. Over the same period the number of people affected by disasters has increased from around 174 million to an average of over 250 million a year. ^[3] Of 15 emergency appeals in 2007, all but one were weather-related.
   
• Women and children account for more than 75 per cent of the refugees and displaced persons at risk from war, famine and natural disaster.^[4]
   
• Some 25 per cent of this population are women of reproductive age. One in five is likely to be pregnant.^[5]
   
• Neglecting reproductive health in emergencies has serious consequences: More than 15 per cent of all pregnancies result in complications requiring emergency obstetric care during delivery, yet obstetric care is often overlooked in the response to crises.^[6] Vulnerability to HIV increases as well.^[7]
   
• Women and adolescents are frequently victims of violence including rape, not only by armed groups but in their own communities.
   
• In conflict zones, more women die from preventable diseases, malnutrition and childbirth complications than from actual violence or brutality.^[8]
   
• Women fleeing crises are often forced to give birth during flight without access even to the barest essentials for a clean delivery, condemning many to fatal infections.
   
• Crisis situations obstruct access to contraceptives and condoms, which leaves women vulnerable to sexually transmitted infections including HIV, hazardous pregnancies and unsafe abortions.
   
• Sexual violence has always been a feature of war, but has likely increased in recent years due to the changing nature of warfare. (See also fact sheet on Sexual Violence)
   
• While there is increasing recognition of sexual violence in conflict and post-conflict as a serious security, health and human rights problem, it is difficult to document and research this violence because of its sensitive nature.^[9]
   
• In some of the world’s most conflict-ravaged places, a woman is more likely to die in pregnancy and childbirth than to complete primary education.^[10]
   
• Reliable data on rape are not available, largely because most cases in conflict zones go unreported, but recent conflicts in Bosnia, the Democratic Republic of the Congo, Rwanda and Sudan, indicate overwhelmingly that brutal sexual violence against women is becoming increasingly prevalent and ferocious. In some parts of the DRC, physicians are treating so many cases of fistula that “destruction of the vagina” is being recorded by doctors as a war injury.^[11]

How crisis disproportionately affects women and girls

In addition to the general effects of violence and lack of health care:

• Women are subject to vitamin and iron deficiencies – particularly anaemia, which can be fatal for pregnant women.
   
• Women often face a lack of supplies and services to address their health and dignity – from obstetrical care to sanitary napkins or cloths.
   
• The stress and disruption of war often leads to a rise in sexual and domestic violence.
   
• Women often shoulder primary responsibility for caretaking children, the sick and the elderly.
   
• Women and girls are usually responsible for collecting water. If the source is far away or in an unprotected area, this burden can be physically exhausting or dangerous.
   
• Desperate conditions may force women to exchange sex, usually unprotected, for food, shelter or protection.

Maternal health

• Pregnancy and childbirth in developing countries are always dangerous: one woman dies every minute from pregnancy-related causes. Crises put pregnant women at greater risk due to sudden loss of medical support, trauma, malnutrition, disease and exposure to violence.
   
• Countries with the highest maternal mortality rates, such as Afghanistan and the Democratic Republic of the Congo, have experienced years of conflict. Pregnancy and childbirth are the leading cause of death among Afghan women of childbearing age, over 90 per cent of whom give birth without assistance. Afghan women have a one in eight lifetime risk of maternal death.^[12] Women who die in childbirth leave behind devastated families. Their other children are more likely to die before reaching adolescence. Even those who survive are less likely to complete their education. According to UNICEF, babies whose mothers die in the first six weeks of their lives are far more likely to die in the first two years of life than those whose mothers survive. A study in Afghanistan found that about three-quarters of infants born to mothers who died, also subsequently died.^[13]
   
• Young girls are especially vulnerable. In displaced communities in Colombia, girls were three times more likely to become pregnant before age 15.^[14] By the end of its recent decade-long civil conflict, more than 80 per cent of displaced Liberian girls were estimated to have had abortions by this same age. Girls aged 10 to 14 are five times more likely to die in pregnancy and childbirth than women aged 20 to 24.^[15]
   
• Maternal care – especially during and after delivery – can save the lives of both mother and child. The most critical interventions are providing women with skilled delivery assistance (including emergency obstetric care for the 15 per cent expected to experience complications) and post-partum care, as up to 50 per cent of all maternal deaths happen after delivery.

HIV/AIDS

• Sexually transmitted infections including HIV significantly increase during times of war and instability.
   
• The incidence of unprotected sex may spike in emergencies due to the disintegration of families, communities and social activities, disruption of social norms governing sexual behavior, and a rise in sexual exploitation, combined with the sudden unavailability of condoms.
   
• Large movements of people can also lead to the mixing of populations with higher rates of HIV infection. In the Democratic Republic of the Congo, five per cent of the population was HIV-positive before the war, while the rate of infection has now surpassed 20 per cent in the parts of the country that have been most ravaged by the conflict. In 2008, the United Nations reported that large population movements in Sudan were contributing to the spread of HIV as well.^[16]
   
• Equipment for screening blood may be destroyed at the same time that the need for transfusions increases.
   
• In an emergency, condoms, enforcing universal precautions in health facilities, and other means of HIV prevention may seem less urgent than other humanitarian assistance but can be just as important for saving lives.
   
• The vast majority of HIV infections are sexually transmitted. Condoms, combined with basic information about HIV and how to avoid infection, are the surest way to arm crisis-affected populations with dual protection against STIs and unwanted pregnancy.

Sexual violence

• Sexual and gender-based violence occurs at every stage of a conflict, from before flight to the return home.
   
• Sexual violence is often systematic, and rape may be used as a weapon of war. In Bosnia, Muslim women were targeted for rape and forced impregnation as part of a campaign of “ethnic cleansing;” more than 20,000 were raped during the war.^[17]
   
• In addition to rape, other forms of gender-based violence that increase during war may include early or forced marriage, female infanticide, domestic violence, forced prostitution and sexual exploitation, and intentional HIV transmission. In Rwanda, where rape was used systematically as a weapon of war, a survey of genocide widows showed that two-thirds tested HIV-positive.^[18]
   
• Widespread sexual violence is also endemic in many post-conflict situations, where it can perpetuate a cycle of fear and recrimination that may impede recovery and development.
   
• The impact of violence, especially rape, can be disastrous. Physical consequences include injuries, unwanted pregnancies, sexual dysfunction, infertility and HIV. Psychological consequences include anxiety, depression, post-traumatic stress disorder, and suicide.
   
• Survivors who fail to receive appropriate treatment and counselling can suffer these effects for years, greatly diminishing their ability to care for themselves or their families.
   
• Sexual violence is not inevitable in conflict zones. Better policing, involving women in humanitarian planning, and ending impunity for perpetrators can help to minimize it.

What Must Be Done

Addressing the physiological vulnerability, and the social strengths of women, should be an integral part of all humanitarian assistance. Specifically:

• Access to safe, effective contraception must be restored as quickly as possible. Condoms are a good first step for providing dual protection against sexually transmitted infections and pregnancy. Care for women around the time of childbirths is one of the most effective ways to reduce preventable death and disability during a crisis. HIV prevention may save just as many lives over the long run as seemingly more urgent interventions. Sexual violence can be minimized in a crisis or refugee setting through provision of separate living facilities for unaccompanied women and girls, information and awareness campaigns, involving women in the design of safety features, ending impunity for perpetrators, and training military and police about sexual violence and exploitation.
   
• When sexual violence has occurred, laws and protocols ensuring the protection of survivors are an important step in encouraging survivors to come forward to receive the care and protection they need. A comprehensive response to survivors includes medical services, counseling and community support. In many situations, literacy and skills can minimize vulnerability to further abuse and exploitation.
   
• Women’s concerns are more likely to be addressed when women are consulted during aid planning and camp design.

Links between the ICPD and the Millennium Development Goals

The right to reproductive health applies to all people at all times. The International Conference on Population and Development (ICPD) Programme of Action, endorsed by 179 countries in Cairo in 1994, recognized the need to ensure reproductive rights and provide reproductive health care in emergency situations, especially for women and adolescents.( Paragraph 10.24)

Five years later, countries participating in a special session of the UN General Assembly agreed that, “Adequate and sufficient international support should be extended to meet the basic needs of refugee populations, … including reproductive health and family planning.” – Key actions for the further implementation of the ICPD (1999), paragraph 29.

Although the MDGs do no specifically address emergencies, it is no a coincidence that the countries in crisis have the lowest indicators of human development and are farthest from reaching the MDGs. Where a large segment of a population is displaced, addressing their needs can have a big impact. For example, reproductive health care can have a positive impact on MDGs 4,5 and 6. Promoting access to water and security for women and girls can spur progress toward MDG 2 and 3 by keeping girls from dropping out of school.

References

1. http://ochaonline.un.org/News/InFocus/InternallyDisplacedPeopleIDPs/FactsandFiguresaboutDisplacement/tabid/5137/language/en-US/Default.aspx
2. ibid
3. http://www.oxfam.org.uk/resources/policy/climate_change/bp108_weather_alert.html
4. UNHCR.
5. UNHCR.
6. RAISE Initiative Fact Sheet on Emergency Obstetric Care, http://www.raiseinitiative.org/library/pdf/fs_emoc.pdf
7. Reproductive Health: A Right for Refugees and Internally Displaced Persons, http://www.raiseinitiative.org/library/pdf/rhm31.pdf
8. http://www.womenwarpeace.org/issues/health/health.htm
9. Summary Meeting Report: Sexual Violence in Conflict: Data and Data Collection Methodologies
   18 and 19 December WHO, Geneva http://www.stoprapenow.org/pdf/Datameetingreport-2pager.pdf accessed feb 26 2009
10. http://www.rhrc.org/rhr_basics/sm_emoc/
11. J. Ward, M. Marsh. Sexual Violence Against Women and Girls in War and Its Aftermath: Realities, Responses and Required Resources, A Briefing Paper for the Symposium on Sexual Violence in Conflict and Beyond, UNFPA, Brussels, UNFPA, June 2006.
12. WHO, Maternal Mortality in 2005: estimates developed by WHO, UNICEF and UNFPA.
13. UNICEF State of the World’s Children 2009, http://www.unicef.org/sowc09/
14. PROFAMILIA. 2001. Sexual and Reproductive Health in Underserved Conditions: A Survey of the Situation of Displaced Women in Colombia. Bogotá: PROFAMILIA.
15. http://www.irinnews.org/webspecials/GBV/feahea.asp
16. AP/International Herald Tribune, “Poverty, population movement contributing to spread of HIV in Sudan,” August 2008, http://www.news-medical.net/?id=40703
17. http://www.womenwarpeace.org/issues/violence/violence.htm
18. Adrian-Paul, A. 2004. “HIV/AIDS.” Inclusive Security, Sustainable Peace: A Toolkit for Advocacy and Action. Washington and London: Hunt Alternatives Fund and International Alert. 36. Web site: http://www.womenwagingpeace.net/content/toolkit/chapters/HIV_AIDS.pdf