ISTANBUL (WOMENSENEWS)–As the war in Syria enters its sixth year, researchers and public health practitioners at the American University of Beirut are working to adapt guidelines for sexual and reproductive health care during emergencies so they’re more relevant to the Middle East and North Africa.

Covering issues ranging from sexual violence to HIV transmission, the global standards, called Minimum Initial Service Package, or MISP, for Reproductive Health in Crisis Situations, guide humanitarian workers in what actions, supplies and equipment are needed when a crisis such as a natural disaster or conflict strikes.

“Our objective is to bring MISP closer to our region because of the specificity of refugees in our region,” Martine Najem, an instructor of public health practice at the American University of Beirut who is involved in the project, told Women’s eNews. “They’re more in informal settings and less in camps…mostly urban. Also, the nature of the crisis itself is different. It’s not acute. It’s protracted.”

She said the team will enrich the manual with examples and case studies from the region so people on the frontlines can better identify with issues they come across, as well as add more comprehensive care. Issues related to early marriage, for example, may be more relevant in her region than in other places.

Working with UNFPA Arab States Regional Office and International Planned Parenthood Federation, or IPPF, they plan to hold the first training for the manual later this month in Beirut for several organizations working with refugees. The final materials are expected in September.

This adaptive approach is just one example of efforts to improve access to sexual and reproductive health care in crises. Some politicians and advocates highlighted that goal as essential to the disaster planning process at the recent World Humanitarian Summit in Istanbul, calling for the prioritization, politically and financially, of sexual and reproductive health and rights in crisis response.

“Sexual and reproductive health is as essential as food, water and shelter. It is not optional,” said Natasha Stott Despoja, Australia’s ambassador for women and girls, at one of the summit’s side events. “Scaling up sexual and reproductive services and protection measures during emergencies saves lives, empowers women and expedites the recovery of affected communities and economies from the crisis.”

The U.N. summit, the first of its kind, drew 9,000 people from 173 countries on May 23-24, including 55 heads of state and government, nongovernmental organizations and others. Delegates focused on global reforms to better protect and assist people affected by crisis.

“The number, frequency and poverty of emergencies that we’re confronted with today is unprecedented, 60 million [forcibly displaced] people in a year alone,” said Rajat Khosla, a human rights advisor at the World Health Organization, during the side event. “We also know that these people are likely to remain in the situation of displacement from anything between 17 to 20 years.”

New Commitments

Panelists at the side event highlighted how sexual and reproductive health remains neglected in these crises and the dire consequences of this oversight, including more unplanned pregnancies and unsafe abortions, the spread of HIV, an increase in sexual and gender-based violence and maternal and newborn deaths.

To help counter this impact, various related commitments and statements were announced during the summit.

The UNFPA committed to reach 40 million people by 2017 with sexual and reproductive health information and services and gender-based violence prevention and response services in crises, while UNICEF will conduct real-time gender-based violence risk-mapping. IPPF, meanwhile, said in a report released last week that it will provide 1.5 billion services by 2022, in preparing for and responding to humanitarian emergencies.

UN Women said it will lead efforts to ensure that, by 2020, at least 15 percent of funding for humanitarian action is devoted to interventions targeting gender equality and women’s and girls’ empowerment. From 2012 to 2013 just 0.4 percent of all funding to fragile states went to women’s groups or women’s ministries, even though women and girls are 14 times more likely to die in a disaster than men.

It’s hoped these efforts will further address the inadequacy of sexual and reproductive health care during crises. Despite progress in meeting these needs, including improved funding, awareness and services, a 2015 report by the Inter-agency Working Group on Reproductive Health in Crises, or IAWG, says significant gaps remain and the needs continue to outweigh financial support. But meeting these needs is more urgent than ever.

Twenty percent of displaced populations are women of reproductive age and 1-in-5 is likely to be pregnant, according to the IPPF report. Globally, 60 percent of preventable maternal deaths and 45 percent of newborn deaths happen in humanitarian and fragile settings, the side event panelists said.

Remedies Proposed

To improve access to reproductive health services in crises, in addition to increased funding panelists called for such remedies as more accountability for reforms and commitments, better coordination between the development and humanitarian sectors, full implementation of the MISP guidelines and improved data collection and services.

“It really puzzles me,” said Khosla, “in spite of knowing the fact that sexual and gender-based violence rises exponentially during conflict, post-conflict situations and in populations of displacement…one set of services that we do not want to provide to women and girls is access to reproductive health services, contraception, safe abortion services.”

Access to comprehensive family planning can reduce maternal deaths by up to a third and avert almost 10 percent of childhood deaths, according to the IAWG report. But these services are often neglected in crises, including limited use of long-acting and permanent family planning methods and emergency contraception. One particularly critical gap the report found is limited availability of comprehensive abortion care. The UNFPA estimates that 25 to 50 percent of maternal deaths in refugee settings are due to complications of unsafe abortion.

Abortion “is a highly contested issue in almost every country, and so when we speak about cultural impediments they go for every culture,” said Lilianne Ploumen, minister for foreign trade and development cooperation of the Netherlands, during the panel. “We need to…work much more with communities and make sure services are available at that level. The medical community, community of leaders, women leaders, really think about how to engage everyone in the community to make sure that access is possible. In some countries we see that legal frameworks are there, policy frameworks are there but still it’s difficult.”

The need for community involvement and local capacity building were highlighted in the IAWG report. It found that even when reproductive health services were available, people in crisis-affected communities often weren’t aware of them or didn’t know their benefits, or social barriers like shame hindered access. Those at the summit called for treating those impacted by crisis as partners in the design and delivery of reproductive health services, rather than beneficiaries.

“We have always suffered in this region from having global knowledge, trends and publications parachuted on us and very often the region’s voice is not reflected in them,” said American University of Beirut’s Najem, who hopes their revised MISP will eventually be translated into Arabic.

“The way you send a message and promote a health issue needs to take into account different religious and cultural factors in a population to make sure the message is getting across while respecting beliefs and traditions,” she added.

Impact on the Internally Displaced

There are also major challenges to accessing reproductive health for internally displaced persons, or IDPs. In Syria, the Syrian Family Planning Association, which has been providing family planning since 1974, grew its services by nine-fold over the last four years to keep up with demand.

“Today, more than half of the Syrian population is in need of humanitarian assistance but only 43 percent of hospitals are functional. Everyday about 1,500 women give birth in very difficult conditions because the health care system is collapsing. We have a major shortage of contraceptive services and supplies,” said Dr. Lama Mouakea, the group’s executive director.

To meet this need, they now have around 45 static clinics and 50 mobile clinics across the country, except in areas outside the government’s control, Mouakea told Women’s eNews. The clinics provide medical, social, psychological and legal services.

The work can be challenging, said Mouakea, in part because those who are displaced have different priorities. “For IDPs, they don’t care about their health, their primary concern is to have food and safe spaces. Especially women don’t care about their health,” she said. “We have to follow them. They aren’t asking for services, usually women are asking to feed their children.”

The numerous commitments from the World Humanitarian Summit to bridge these gaps in disaster response, including those addressing sexual and reproductive health care, will be reflected in a Commitments to Action Platform and the summit’s achievements will be reported to the U.N. General Assembly in September. There will also be an annual update to review progress.

“We do know what needs to be done. Now is the time to make the resolve to do it,” said the WHO’s Khosla. “We really cannot find more excuses to continue to make women’s bodies battlegrounds for national politics.”