Lessons and Best Practices from International Planned Parenthood Federation (IPPF)
Abortion in Humanitarian Crisis
By Estelle Wagner
An increasing number of people globally live in areas badly affected by conflict, natural disasters, and other fragile humanitarian settings. As a result, over the past decade the number of internally displaced people has grown from 22.4 million people to 62.5 million people and the number of refugees has more than doubled, from 15 million to 35 million people (UNHCR, 2022). Women and girls are disproportionately affected by these events by a significant margin. They also face a higher risk of sexual violence, unwanted pregnancy and unsafe abortion, yet they often lack access to abortion care and contraception. International Planned Parenthood Federation’s (IPPF) humanitarian programme is in a unique position to respond to the needs of women and girls in crisis settings as our Member Associations (MAs) are established, local, autonomous organizations.
The International Planned Parenthood Federation’s (IPPF) humanitarian strategy focuses on four overarching priority areas:
promoting localized humanitarian action;
ensuring access to lifesaving sexual and reproductive health services,
including safe abortion care; responding to sexual and gender-based violence in emergencies and
responding to the intersection of the climate crisis and sexual and reproductive healthcare.
In 2021, IPPF Member Associations (MAs) responded to crises in 42 countries across acute and protracted settings, reaching 6.1 million humanitarian clients with sexual and reproductive health services.
IPPF and our network of MAs are committed to providing abortion care and advocating for abortion rights for all. IPPF MAs provide person-centred, comprehensive abortion care and post-abortion care in a wide range of social, legal and political settings, including in emergency crisis response and protracted humanitarian settings. The experience of MAs in providing abortion care in these complex situations in stable times means that they are often well-placed to provide abortion care during emergencies and in humanitarian settings.
Abortion is also a priority area of the Minimum Initial Service Package (MISP) of Sexual and Reproductive Health in Crisis settings (IAWG, 2023), the minimum life-saving sexual and reproductive health services to provide at the onset of an emergency.
As a result, over the past decade the number of internally displaced people has grown from 22.4 million people to 62.5 million people, and the number of refugees has more than doubled, from 15 million to 35 million people.
Key challenges
The challenges in providing quality abortion care in crisis settings are numerous and diverse. Health systems become weakened on all fronts. Infrastructure, including facilities, may be damaged, out of action, or inaccessible, making providing services and reaching those servicesa challenge. Weakened infrastructure also disrupts supply chain systems due to challenges with transportation, among other things. An overburdened health workforce attempting to address the significant health needs of the affected populations risks deprioritizing sexual and reproductive health, and in particular abortion care, in the response. Limited mobility of affected populations makes it challenging for people to travel to static facilities for health care.
Restrictive legal and social environments for abortion care, which make it challenging to provide abortion care in stable times, can make it impossible to provide abortion care in crisis situations. For example, laws or policies often require abortion to be provided in a registered facility that meets required standards – a practice that is often not feasible in humanitarian situations. Additionally, there are unique needs of humanitarian populations; for example, women in humanitarian settings can be at high risk of sexual violence and may have additional protection needs.
Photo: UN Women/Allison Joyce/flickr.com; CC BY-NC-ND 4.0 Deed
Good practice solutions
Humanitarian preparedness is essential. Having already established quality, person-centred abortion services during stable times is essential for a strong framework to provide abortion care in humanitarian settings. In establishing quality abortion services in stable environments, IPPF MAs have ensured the availability of adequate facilities and trained health workers. As part of their abortion programmes, they have also built support from local stakeholders, leaders and communities, reducing the risk of backlash or resistance to providing abortion care during an emergency response. A key element of preparedness is to preposition Inter Agency Reproductive Health (IARH) kits to ensure access to essential abortion equipment and supplies during crisis when supply chains may be disrupted. These include Kit 8, which contains medical abortion pills and MVA Kits. Kit 8 is available from UNFPA, other humanitarian actors, or any existing pre-qualified suppliers.
Advocacy to ensure that abortion care is available and accessible in humanitarian settings, including removing non-evidence-based policies and providing flexibility on the provision of abortion care in humanitarian settings in policies and guidelines, is critical to ensuring and maintaining access to life-saving services during crises. Again, this should be incorporated into the preparedness planning so that policies, commodities and facilities are already set up to provide services when an emergency situation strikes.
During a crisis, collaboration with humanitarian coordination bodies (SRH cluster or equivalent) is needed to strengthen referral mechanisms, share data and information, and maximize impact while avoiding duplication. Task sharing with a range of health workers including midwives, nurses, community health workers and pharmacists is essential to ensure adequate skilled health workers are available to provide abortion care to women in humanitarian crises. Facilities may not be accessible; therefore, adapting models of abortion care during crises may be necessary to reach and meet the needs of affected populations. Additional models of care may include providing medical abortion through mobile clinics or outreach, or supporting services for medical abortion self-care.
Finally, integration of complementary services and support for related sexual and reproductive health (SRH) needs including for sexual and gender-based violence (SGBV) and contraception improves efficiency of service delivery for both providers and clients, and can be bolstered by establishing strong referral networks.
Advocacy to ensure that abortion care is available and accessible in humanitarian settings, including removing non-evidence-based policies and providing flexibility on the provision of abortion care in humanitarian settings in policies and guidelines, is critical to ensuring and maintaining access to life-saving services during crises.
In Pakistan, Rahnuma Family Planning Association of Pakistan (Rahnuma-FPAP) mobilized an emergency response to the devastating floods in Pakistan in 2022. Through its humanitarian response network, the MA provided SRH services including post-abortion care to women and girls in flood-affected districts, supported by community engagement strategies. As a result, Rahnuma-FPAP provided 16,096 clients in humanitarian settings with post-abortion care and contraception services in 2022. Rahnuma-FPAP’s integration of post-abortion care within clinics in its humanitarian response network in disaster-prone areas of Pakistan helped strengthen the provision of SRH services, including post-abortion care and contraception, to women and girls in affected areas. .
In Sudan, Sudan Family Planning Association (SFPA) currently operates clinics in two refugee camps and settlements for Ethiopian refugees in Um Rakuba and Tunaydbah. SFPA built a minor operation room at the Tunaydbah camp clinic, enabling them to provide MVA for treatment of incomplete abortion. The team at the clinic is building a referral network of community health workers and NGO workers to facilitate access to care for women who experience incomplete abortion or miscarriage and require care. SFPA also continued to provide services to people living in protracted humanitarian settings in other areas of Sudan. The Abu Shouk clinic provides integrated SRH services including abortion care and contraception to people living in an IDP settlement in the Darfur region. The clinic also added a specialized service for SGBV, enabling it to improve support for survivors of SGBV.
The team at the clinic is building a referral network of community health workers and NGO workers to facilitate access to care for women who experience incomplete abortion or miscarriage and require care.
In Ethiopia, Family Guidance Association of Ethiopia (FGAE) operates several clinics in conflict-affected areas in the northern region. These clinics provide abortion care as part of an integrated package of SRH services in areas severely affected by the conflict, including in Woldeya, Dessie and Kombolcha. Throughout 2022, FGAE worked hard to restore its clinics to their previous capacity following damage and looting, with the majority now providing services at full capacity. FGAE works closely with government health extension workers and service providers to facilitate the referral of clients to FGAE for services, including abortion care. In addition, the MA has built the capacity of public and private health facilities to provide quality contraceptive and abortion services. Onsite mentoring of service providers, post-training follow-up, and the provision of job aids and supplies enabled public and private facilities to deliver abortion and contraceptive services to clients in areas not reached by FGAE clinics.
References
IAWG 2023. Inter-Agency Working Group on Reproductive Health in Crisis. Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings. Chapter 3: Minimum Initial Service Package (MISP) https://iawgfieldmanual.com/manual/misp
Estelle Wagner is the International Advocacy Officer at International Planned Parenthood Federation, Geneva Liaison Office, where she develops and implements advocacy strategies to advance sexual and reproductive health and rights at the United Nations human rights mechanisms. She has extensive experience in human rights, coordinating civil society at the international and regional levels, and advising on advocacy strategies to advance human rights at the national level through UN engagement. Estelle holds a Juris Doctor from Fordham Law School, where she focused on international human rights, and received her B.A. in Liberal Arts from Sarah Lawrence College in New York. E-Mail
