WUNRN
The
Lancet, Early Online Publication, 8 November 2013
RESPONDING TO THE SYRIA CRISIS: THE
NEEDS OF WOMEN & GIRLS
Women
and girls are disproportionately affected by conflict because of a lack of
access to essential services, as learnt from humanitarian crises in recent
years.1, 2
Poor access to sexual assault treatment and emergency obstetric care can
contribute to negative health outcomes.1 In Syria,
women and girls are strongly affected by the recent conflict and, according to
the UN Population Fund, about 1·7 million women and girls might need access to
reproductive health services.3 Because women
often have an essential role in pos tconflict reconstruction, their basic needs
should be met so they can emerge from this ongoing crisis as essential
stakeholders in the recovery process.
The
Syrian civil war has entered its third year, resulting in 6·8 million people
who need humanitarian assistance, with 5·1 million people internally displaced
and 79% of refugees living in urban settings (not camps).4, 5 These estimates change
daily as the fighting intensifies. Access to internally displaced people for
international organisations is becoming more difficult in Syria.6 The poor
access to civilians restricts humanitarian assistance and is a violation of
international humanitarian law, which could ultimately result in loss of life.7
Numbers of displaced Syrians are expected to continue to rise.8 The Regional
Response Plan for Syria,9
released in June, 2013, requests the humanitarian community to respond to this
crisis. At present, only 40% of the total funding requested for Syria has been
received.4 Inclusion of
long-term planning of comprehensive reproductive health services is imperative
to reduce risk factors for reproductive-health-associated causes of morbidity
and mortality.
Previous
crises in Afghanistan and Sierra Leone have shown that women and girls are at
an increased risk of exposure to gender-based violence, particularly sexual
violence, deteriorating mental health, and maternal and newborn complications.10 These risks
are related to a rise in female-headed households, which cause additional
burdens for women as caregivers and providers, and to diminished access to
reproductive health services, including family planning and emergency obstetric
care.1
Women and girls can face stress-related mental illness due to hardships
associated with war, which can be compounded by displacement. If adequate
psychosocial services are not in place, then women face long-term consequences
related to anxiety and post-traumatic stress disorder.11
Additionally, prolonged emergencies can weaken health systems, with
long-lasting effects on maternal and infant mortality, as seen in countries
previously affected by conflict.10, 12
As
in most conflicts, Syrian women and children comprise the largest proportion of
displaced people, at present about 78%.3 Similar to the
Iraqi crisis, a recent assessment from Jordan noted that Syrian women view
reproductive health to be a crucial issue, but that barriers prevent them from
accessing services.13, 14 An assessment in Egypt
reported that primary health care is expensive and not easily accessible for
Syrian refugees.5 In Lebanon,
Syrian refugee women have reported that they attend few antenatal care visits
and delay pregnancy because of high out-of-pocket costs associated with these
services.15 Additionally,
the effect of the refugee influx has been felt in the host community and health
sector. A report described a 50% increase in patient caseload at health clinics
in Lebanon and an increase in ambulance wait times because of a high demand for
transport.16
In view of the high cost of referral care in Lebanon, up to 75% of the cost is
covered by UN High Commissioner for Refugees. For vulnerable people, provision
is made for coverage to be increased to up to 90% and, for some disorders, is
up to 100%. All victims of torture or survivors of sexual and gender-based
violence will be covered for up to 100% after the incident. By contrast, the UN
High Commissioner for Refugees in Jordan pays 100% of the costs for patients referred
from Zaatri camp or for those who are unregistered. Urban refugees in Jordan
identified the scarcity of female doctors, distance to clinics, and high costs
for private clinics and transport as obstacles to people obtaining care.17
This situation is similar to that of Iraqi refugees in Jordan, where reports of
expensive transport and private clinics, and scarcity of knowledge of free
services, had prevented women from obtaining reproductive health services.14 The fact that
more than three-quarters of the refugee population are women and children
emphasises that humanitarian organisations should be aware of findings of
assessments as they work to improve reproductive health services.
The
humanitarian community acknowledges the importance of protection for women and
girls fleeing Syria.8 The defence of
vulnerable populations is often seen as the responsibility of only those
agencies with a mandate for protection. However, protection issues occur in
areas such as health, livelihood, education, and food security. The risks to
refugee women and children are substantial, and gender-based violence might be
exacerbated as the situation in Syria continues. The scarcity of adequate
shelter in this crisis because of high rent in urban centres, congested camps,
and informal settlements (which are rapidly increasing in Lebanon) increases
risks for women, particularly those in female-headed households.8 For example,
in an assessment of urban refuges in Jordan, nearly half of female-headed
households had no monthly income and depended on donations.15
In the community, women and girls face harassment, including offers for
transactional sex and marriage, and, in the home, they might face domestic
violence by male relatives as frustrations intensify.13
Inside
Syria, about 1·7 million women of reproductive age are in need of assistance
and do not have access to reproductive health services.3
The human rights violations occurring in Syria, such as attacks on civilians
and hospitals,6
affect women's access to safe deliveries, and antenatal and postnatal care.
Recent reports document that a growing proportion of total deliveries are done
by caesarean sections in Homs (66%), Aleppo (60%), and Damascus (52%) because
of safety concerns and fears of having an unattended birth. Similarly, more
women are giving birth at home than were before the crisis.18
Both caesarean section deliveries and at-home births pose risks that can
threaten the life of the mother and newborn baby.
Since
the formation of the UN Department of Humanitarian Affairs in 1991, the Sphere
Project and other global initiatives were founded to establish standards for
humanitarian assistance.19
The Minimum Initial Service Package for Reproductive Health (MISP), which prioritises
lifesaving measures to prevent excess morbidity and mortality at the onset of a
humanitarian emergency, has become a recognised humanitarian standard as part
of their targeting of the health-care needs of women of reproductive age.
Overall, MISP aims to improve coordination of reproductive health services,
prevent and respond to sexual violence, prevent maternal and neonatal morbidity
and mortality, reduce HIV transmission, and plan for comprehensive reproductive
health services as part of primary health care.10 Case studies
from crises in Goma (Congo) and Afghanistan have shown the challenges in the
implementation of MISP services due to scarcities in trained staff and
resources needed to meet minimum standards in humanitarian emergencies.20
Collection
and analysis (by sex and age) of reproductive health data are crucial to
understand the scope and magnitude of the health situation, characterise unmet
needs, identify at-risk populations, and target scarce resources to where they
are needed most. Additionally, with most Syrian refugees residing outside
camps, data are urgently needed for the status and coverage of reproductive
health in urban settings so that interventions can be better targeted. Data
availability and use is far better in camp-based settings with health
information systems. In Jordan, data from Zaatri camp indicated that, in the
first 3 months of 2013, only 29% of women had four or more antenatal visits at
the time of delivery.4
This information assists in the design of lifesaving interventions and in the
planning of comprehensive MISP services for women and girls.20
The
realities of a continuing acute emergency, in addition to the situation of
Syrian refugees who have crossed the border into neighbouring countries, challenge
the implementation of services, including MISP, mainly when attempting to
scale-up and expand services. As the Syrian crisis continues, the humanitarian
response will be faced with provision of both comprehensive reproductive health
services and additional MISP priority services for the newly displaced. Other
priorities include the importance of maintaining of a contraceptive supply
chain, continuing training of staff, and provision for community education. The
use of syndrome-based treatment for sexually transmitted infections is
essential, since infections, if left untreated, can lead to serious long-term
health effects. The continuation of antiretroviral drugs to those on treatment
for HIV needs to be maintained to prevent drug resistance, and the provision of
culturally appropriate sanitary materials to women and girls could become a
part of hygiene non-food-item distribution.10
Despite the complexities of the situation, relief agencies emphasise that the
focus on women is a key strategy in the effort to improve the health of the
Syrian community.8
Reproductive
health needs are increasingly being recognised in crises. Although guidelines
and standards now exist, the 2004 Global Evaluation of Reproductive Health in
Crises reported gaps in funding, institutional capacity, and access to
effective interventions.12
The Syrian crisis is complex; the refugee numbers continue to increase and the
strain on host communities is exacerbated. The long-term implications for
reproductive health services have been noted by host governments and UN
agencies in an effort to support the continued, rather than sporadic, provision
of essential services. These services include human resources for health-care
provision, health technologies and pharmaceuticals, health-information systems,
and health-care financing.5
Despite
the increased complexity of these settings, the humanitarian community has
improved the status of reproductive health in displaced populations.20 Reports from
the Iraqi crisis have improved the humanitarian response for refugees overall.14
Nevertheless, lessons learnt from more than a decade of emergencies20
emphasise that health systems are under substantial strain, and that attention
must be given to the integration of services within national health systems to
support host governments with equity between host and refugee populations.5
Recommendations to support women and girls include new approaches for reaching
hard-to-access populations within Syria, and improved coverage of out-of-camp
refugees. Additionally, increased access to cash assistance, in place of
in-kind support, is needed to mitigate risks for sexual exploitation and abuse.
Expedited registration of refugees needs to be continued to ensure continuing
access to life-saving reproductive health services and to offer protection for
women and girls who are at increased risk for abuse. Despite the opening of
additional refugee camps in neighbouring countries, long-term strategies must
address the growing tensions about access to livelihoods and services in host
communities.5
Ultimately, because of the extended nature of the conflict, the humanitarian
response and development agendas need to be integrated to provide opportunities
to strengthen health, education, and sanitation infrastructure to accommodate
the refugees and host communities.