Dr. Ouahiba Sakani Afzal

(WOMENSENEWS)–When Mary Otieno switched tracks three years ago from doing development work in Kenya to refugee relief work for the International Rescue Committee, she soon noticed something was amiss: Very few programs designed to address refugee women’s health were incorporating men.

“I realized we were not at all talking about men as we had been doing in Kenya,” said Otieno, a senior technical adviser with the committee’s reproductive health program in New York. “But we were talking about gender based violence, HIV/AIDS and reproductive health and there was no way we were going to leave men out.”

Health programs for women must include men, Otieno says, citing this example from her own experience in development work in Africa:

“The Burundi refugees in Tanzania have the lowest rate of use of contraceptives, but when you ask the women why they feel they need to have babies so young and to have so many they will say, ‘Well, the men make the decisions.'”

Refugee women are likely to have similar experiences. In recognition of that reality, after years of treating refugee women’s health as a women-only concern, a number of relief organizations operating in Africa, the Middle East and Central Asia are now beginning to take their cue from development agencies and incorporating men into the female health picture. As the development groups had learned, men’s involvement in understanding women’s health is crucial to female survival rates. Men in many societies tend to have the authority to make crucial decisions regarding domestic matters.

The need for effective reproductive health services for the 13 million refugees worldwide is considered a pressing matter of life and death. A 2002 study by Linda Bartlett, a medical officer in the reproductive health program at the Centers for Disease Control and Prevention in Atlanta, found that 41 percent of deaths among Afghan refugee women living in a camp in Pakistan that had healthcare services were related to pregnancy and childbirth, making them the leading cause of death. Researchers expect that in less developed refugee camps this number would be even higher.

Reproductive Health Formerly a Low Priority

In the 1980s, development agencies began to take the lead in incorporating men into discussions of female reproductive health and domestic violence. But it took until the 1990s before refugee aid agencies, which were faced with the immediate obstacles of providing food and shelter to the world’s displaced, even began thinking about reproductive health, said Therese McGinn, administrative director of Columbia University’s Heilbrunn Department of Population and Family Health.

“In refugee camps, relief is for emergencies,” said McGinn in a phone interview with Women’s eNews. “Relief organizations’ main focus is to decrease mortality. You have to worry about housing, food, sanitation, cholera, measles. And so there was never any active decision not to do reproductive health, but, in the scheme of things, it just didn’t come up.”

In 1993, after a seminal report by the Women’s Commission for Refugee Women and Children of New York underscored the need for a wider array of reproductive health services, aid organizations began to act, developing neo- and postnatal care services for women.

Today, many organizations are expanding their services to discuss broader family planning issues. And, as they do that, they are also realizing that without the buy in from men, many of their efforts are unlikely to take root.

Dr. Ouahiba Sakani Afzal, a reproductive health consultant in Pakistan for the Women’s Commission for Refugee Women and Children, said she was working with the United Nations High Commission on Refugees to encourage Afghan healthcare volunteers in camps in Pakistan to add discussions about child spacing and condom use to their package of services.

In addition to providing antiseptics, basic medical supplies and information on topics such as sanitation, water and cholera, these healthcare workers are now being trained to talk to couples about the importance of using condoms to space the birth of children and to avoid multiple births within a short interval. Discussing such topics with men as well as women is crucial.

“If you don’t work on educating the male population, targeting them, explaining to them why child spacing is important, why they have to use a condom, it is less likely that you improve the women’s health, because women don’t have decision-making over their bodies,” said Afzal during a recent visit to New York. She said that it was too soon to tell whether the efforts are succeeding.

In addition, many Afghan volunteers are also being trained to discuss domestic violence and HIV/AIDS transmission. In the past, aid organizations educated people about HIV/AIDS by talking to women who came in for post-birth healthcare. This, however, resulted in many men thinking of HIV/AIDS as a “woman’s disease,” Afzal said.

Discussing Sex Is Difficult

The International Rescue Committee is also beginning to incorporate men in their 20 global projects on reproductive health and nine initiatives on gender-based violence. But incorporating men has sometimes proved difficult, said Otieno of the committee.

While experience has shown that men and women have generally been receptive to discussing gender-based violence, Otieno said that in many cases people are too sensitive about sex to discuss the topic. “Especially with family planning and HIV/AIDS, it’s a sensitive issue with regard to sexuality,” she said.

In order to break the taboo of discussing sex and sexuality, many non-governmental organizations focus on looking at these issues from a medical perspective rather than from a cultural one. For instance, healthcare workers may focus on the health risks multiple births pose to women or the effect HIV/AIDS can have on communities.

This is an important distinction because aid agencies must be careful to avoid treading on cultural values as they try to encourage people to change risky behavior, experts said. And as they incorporate men, agencies must also be careful to avoid another potential pitfall: excluding women.

“Male involvement sometimes cuts women out of programs because the programs have limited resources,” said McGinn of the Heilbrunn Department of Population and Family Health. “If they focus on men because we say, ‘Okay, men are the decision makers,’ I have a problem with that.”

She added that she feared that male involvement could translate into not insisting that “women remain in the equation.”

Jennifer Friedlin is a writer based in New York City.

For more information:

Women’s Commission for Refugee Women and Children:

The Joseph L. Mailman School of Public Health of Columbia University–
The Harriet and Robert Heilbrunn Department of Population and Family Health:

The International Rescue Committee: