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Unseen toll of conflicts on sexual and reproductive health and rights
Women bear a disproportionate and often overlooked burden of war. In today’s conflict zones, women are not only deliberately targeted through gender based violence but also suffer intensely from the collapse of vital systems that support their health and wellbeing. The consequences for their sexual and reproductive health and rights (SRHR) are catastrophic yet routinely sidelined in humanitarian responses. The complexities of different types of conflicts demand nuanced attention to the layered ways in which war devastates women’s bodies, autonomy, and futures.
The most visible manifestations of conflict on SRHR include, for instance, maternal deaths, attacks on health facilities, and the deliberate use of sexual violence as tactics of war. In Gaza over 55 000 pregnant women face urgent need for maternal healthcare, hundreds give birth each day in shelters or unsafe conditions, and neonatal and maternal deaths are climbing.1 With severe shortages of food and starvation affecting one in five people, each missed meal increases the risks of miscarriages, stillbirths, and undernourished newborns.2
Attacks on health facilities are on the rise in conflicts. Women’s access to health services is particularly affected by these attacks. For example, in the Darfur region of Sudan, the destruction of health and road infrastructure and the lack of skilled birth attendants has resulted in limited availability of basic obstetric care.3
The risks of gender based violence, including sexual violence, are known to increase in conflict settings. An analysis of studies from Africa indicates that 48% of women affected by conflict have experienced sexual violence.4 There are also more insidious forms of collateral damage to SRHR in conflicts. Warring parties have pressured women to marry their soldiers, become pregnant, or have abortions. For instance, in Myanmar, military organisations encouraged women to reproduce to dilute opposition ethnic communities.5 The risks of child marriage are found to be higher in fragile and conflict settings (prevalence is twice the global average) as families pressure girls to marry to protect them from insecure environments.6 Intimate partner violence is widely reported to increase in conflict affected settings, exacerbated by the stress of economic hardship and physical insecurity.7
Improving sexual and reproductive health outcomes
International humanitarian and human rights law is unambiguous: medical care must be protected, and attacks on health services are prohibited. State parties must urgently protect frontline health workers. Political and military actors who attack health services must be held accountable. There is precedence for this from previous conflicts (eg, Vietnam, Bosnia and Herzegovina, Palestine, and Afghanistan) where attacks causing severe harm to protected individuals or significant destruction of health facilities were investigated for “grave breaches” or “war crimes” under the Geneva conventions.8
The use of sexual violence to terrorise civilians is recognised as a war crime under international law and must be prosecuted. Survivors of gender based violence must receive medical care, psychosocial support, and access to justice. The International Criminal Tribunal for the Former Yugoslavia is an example of how wartime sexual violence can be prosecuted, perpetrators brought to justice, and the culture of impunity challenged.9
Having a defined package of sexual and reproductive health services for humanitarian settings is an essential step towards safeguarding continuity of care for women. The minimum initial services package (MISP) for acute emergency responses from the Interagency Working Group on Reproductive Health in Crisis and the World Health Organization’s high priority health services for humanitarian response (H3) package for protracted crises provide essential global guidance to prevent morbidity and mortality related to sexual and reproductive health.1011MISP is being widely implemented in humanitarian settings, albeit with varying degrees of success.12 MISP emphasises provision of the most critical needs at the onset of an emergency, including responding to sexual violence, reducing transmission of HIV and sexually transmitted infections, preventing unintended pregnancies, and addressing maternal and newborn health.
Training health professionals, especially those who are part of emergency deployments, to deliver essential sexual and reproductive services, including clinical management of rape and intimate partner violence response, is another important step towards prioritising SRHR in humanitarian responses.13
Evidence based action is essential, even under extreme constraints. Researchers, advocates, and programmes must strengthen safe and ethical data collection, monitoring, and documentation systems. This includes establishing confidential information systems for reporting on sexual and reproductive health outcomes (eg, the health resources and services availability monitoring system (HeRAMS), and gender based violence information management system).1415
Women’s organisations have long been at the forefront of reaching communities with SRHR services in conflict settings. Nearly 60% of women’s organisations surveyed have already reduced critical services after recent cuts in humanitarian assistance.16 Continued and increased investments in women’s organisations is critical.
The global health community must speak with clarity and act with urgency. The international community must stop treating SRHR in conflict as optional. Several provisions in international humanitarian law have been interpreted to require protections under the Geneva convention to include access to sexual and reproductive health services (eg, treatment of women, principle of non-discrimination).17 Its denial, whether through targeted violence or systemic neglect, is a political choice. International and national courts can and should consistently initiate prosecutions, and governments including donor countries should cease arms sales to parties to conflicts that engage in war crimes - be it attacks on health facilities or the deliberate use of sexual violence. Women and girls cannot wait for peace before their rights are respected.