Women in embattled regions have limited access and means to use contraceptives

Study finds that in embattled regions like Darfur and Congo, most women want to limit childbearing, but only 4 percent to 16 percent have access and means to use contraceptives

Violent conflict disrupts all aspects of society, including the delivery of the most basic reproductive health services: prenatal and maternal care, family planning, prevention of HIV and other sexually transmitted infections, abortions and emergency caesarian care. A new study by researchers at Columbia University's Mailman School of Public Health and collaborators demonstrates and quantifies the alarming gap between the desire of women in war-torn areas to limit their childbearing and the availability of resources and knowledge to enable them to do so. The situation leads to unintended pregnancy among women already contending with the stresses of violence and, in many cases, displacement.

The researchers surveyed married women from six areas in Sudan, northern Uganda and Democratic Republic of Congo, about their views on family planning. Full study findings are published in BioMed Central's open access journal Conflict and Health.

Participants were young, with mean ages between 27.3 and 28.9 years; they had little education; and, depending on location, their average number of children ranged from 3.2 to 4.2. Study results showed that 30% to 40% of the women did not want to have another child in the next two years and an additional 12% to 35% of the women did not want any additional children. Despite these numbers, the proportion of women who were using modern contraception was under 4% at four of the sites and 12% and 16% in two sites, where there had been some prior family planning services. These rates are low, even for sub-Saharan Africa, and illustrate the gap between what women want and what services are available to them.

An assessment by researchers and program staff of 38 local healthcare facilities mandated to provide family planning services revealed that, at most, only one-third of those had the necessary staff, equipment and supplies. In some areas, no facilities were equipped to provide these services.

"It is clear that many women are unable to obtain family planning services during a time when few would choose to become pregnant, and women who have complications due to unsafe abortions have no access to treatment," observed Therese McGinn, DrPH, lead author of the paper and associate professor of Population and Family Health at Columbia's Mailman School.

"It is vitally important that family planning services are made available for conflict-affected men and women as part of strengthening local health services and aid packages," said Dr. McGinn, who directs RAISE Initiative, New York, which works with a variety of partners to provide reproductive health services to populations in six conflict-affected regions.

While providing such services is challenging, the study found good evidence that programs to provide family planning services in culturally sensitive ways do make a difference. Of the six regions studied, use of contraceptives and awareness of modern contraceptive methods was highest in northern Uganda and West Darfur, where RAISE partner organizations Marie Stopes Uganda and Save the Children had established programs offering family planning services.

Inadequate funding remains an obstacle. The authors cited a 2009 study showing that less than $1.30 per capita was spent between 2003 and 2006 on reproductive health in 18 conflict-affected countries, of which less than 2% was for family planning.

While the investigators note that political violence often occurs in areas of the world where access to health care is poor even before the conflict began, violence and destruction disrupt health services even further. Access to facilities that can provide safe delivery, emergency caesarean sections, treat complications of pregnancy and childbirth and offer family planning services becomes limited for those who flee and those who remain behind. Women and girls who are raped or subjected to other violence are vulnerable to unwanted pregnancy and sexually transmitted infections but they can get treatment when staff are skilled and facilities prepared to assist them.

Dr. McGinn and her co-authors point out that progress has been made in the field of reproductive health in crisis settings in terms of policy and practice. But reproductive health services are not yet regularly available, so many women and men are denied this basic health care. "We can do better," said Dr. McGinn, "and that is the challenge facing us as we move the field ahead."