LONDON — Advocates campaigning for refugees to have access to safe abortion in humanitarian settings say they have made major progress at a recent high-level meeting — but they added that “political sensitivities” among countries and some United Nations agencies are holding back efforts to get the full spectrum of sexual and reproductive health services to those who need them.
Some experts also warned that pushing the abortion agenda could derail efforts to reach refugees in some settings and distract from more immediately urgent obstetric needs.
Earlier this month, representatives from the Inter-Agency Working Group on Reproductive Health in Crises, or IAWG, which includes U.N. agencies and civil society groups, gathered in Greece to discuss a range of issues, including revising the field manual for aid workers providing reproductive health services in the initial phase of a humanitarian crisis.
For many IAWG members, the meeting posed an opportunity to update the range of contraceptive options put forward in one of the manual’s key chapters — known as the Minimum Initial Service Package (MISP) for Reproductive Health — notably to include safe abortion for the first time.
While some progress was made, their efforts to introduce a standalone objective on safe abortion were rejected by the U.N. Population Fund and United Nations High Commissioner for Refugees, which expressed concern it could cause country governments to reject the overall package, advocates told Devex.
Experts also referred to a lack of strong evidence that it is feasible or sensible to include abortion as a minimum guideline considering how divisive the issue is.
As a result, the IAWG steering committee agreed to add a separate “note” on safe abortion to the MISP chapter. Stronger progress was made in other areas, including the addition of a standalone objective around the importance of offering contraception, including long-acting methods, to reduce unintended pregnancies.
"A lot of progress was made during the meeting that will catapult the agenda for sexual and reproductive health and rights forward," Sandra Krause, director of sexual and reproductive health at the Women's Refugee Commission and a member of the IAWG steering committee, told Devex. She added that the inclusion of safe abortion in the language of the MISP chapter was a “huge achievement” and potentially a “watershed moment in the history of IAWG's mission to ensure displaced women and girls have access to the sexual and reproductive health services they need regardless of their circumstances.”
However, that it appears only as a supplementary note is “disappointing and shows there is still work to be done,” she said.
But Catrin Schulte-Hillen, head of Médecins Sans Frontières’ working group on reproductive health and sexual violence care, said she was concerned the MISP was being used as an advocacy tool by activists and actors with little or no field experience.
“Trying to put safe abortion into the MISP with such prominence seems to be more about advocacy rather than what is feasible and what can actually be done in the field,” she said.
The meeting also highlighted a number of other areas where work is still needed, including greater focus on research and monitoring at the field level; and better coordination around implementing sexual and reproductive health services in humanitarian settings, Krause added.
The MISP was first developed in 1995 in light of the International Conference on Population and Development in Cairo, which was held the year before and raised awareness about the fact that women in humanitarian settings face greater risks of sexual violence and unwanted pregnancy, and their associated health complications, Krause explained. Displaced people are also more likely to have had their contraceptive coverage interrupted.
The IAWG deliberations on the MISP come at a time when more women and girls are refugees than ever before, but funding for sexual and reproductive health services is being cut, most notably by the United States. In January, U.S. President Donald Trump implemented an expanded version of the “global gag rule,” which effectively stops all U.S. government funding to foreign NGOs that carry out, or offer information about, abortion.
In the past, IAWG’s annual meeting was funded by the U.S. State Department, but this year they had to seek alternative financing, which they secured from an anonymous donor. But losing U.S. funding also meant the organizers had greater freedom over what to cover, according to Sarah Knaster, IAWG coordinator for the Women’s Refugee Commission, which hosts the IAWG secretariat. “We were able to fully incorporate safe abortion care [into the agenda],” she said.
Progress on voluntary contraception
Last updated in 2010, “the MISP needed an update,” Ugochi Daniels, head of the UNFPA’s humanitarian and fragile contexts branch, told Devex, explaining that “humanitarian needs have increased significantly and we’ve learned a lot about providing sexual and reproductive health services for women and girls in crisis situations since it was first rolled out.”
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A key revision agreed upon during this month’s meeting was around access to voluntary contraception. Whereas under the previous MISP, contraception offered was generally limited to short-term methods such as pills and condoms, which also fell under the wider objective of preventing maternal and newborn mortality, the revised guidelines contain a standalone objective on access to contraception to prevent unintended pregnancy based on demand from women and girls.
“The MISP is about preventing maternal and child death, but it is also to enable women who choose not to get pregnant in these settings to get the services they need,” Daniels explained, adding that the aim is to “enable their right to freely choose when and how many children to have, and that right should not be eroded because you’re in a humanitarian setting.”
Krause said the agreement to elevate contraception was possible because “much better evidence” is now available on both the demand and uptake for such services in emergency settings.
Bill Powell, a senior clinical advisor at Ipas, a reproductive rights NGO and member of IAWG, said that while the addition is good news, the revision does not go far enough since “people still need abortion even when good contraception is available.”
Safe abortion moves up the agenda
Although a standalone objective could not be agreed upon, language around safe abortion has now been included in the MISP guidelines for the first time — first as a sub-point under the objective on preventing excess maternal and child deaths, which states practitioners must “ensure the availability of lifesaving post-abortion care in health centers and hospitals”; and second in the form of a “note,” which states that it is “important to ensure that safe abortion care is available, to the full extent of the law.”
Unsafe abortion is one of the main causes of maternal mortality in developing countries, according to the World Health Organization. But historically, safe abortion has been “completely neglected in terms of funding, attention, and programming,” according to Knaster. This is largely due to concerns from donors and implementers about the feasibility and legality of carrying out abortion in conflict settings, and also political resistance from governments, she said.
According to Powell, there are very few organizations, with the exception of MSF and the International Rescue Committee, that currently offer safe abortion in these contexts. Although abortion in some form is legal in most countries, it is often “highly restricted” and “stigmatized,” Powell said, meaning NGOs often withhold abortion services even where they are legally permitted. The reintroduction of the global gag rule has made NGOs even more cautious, he added.
Considering these challenges, Powell said it was tricky to reach agreement among IAWG’s members on how safe abortion should appear in the MISP. While representatives from the WHO were in favor of a greater focus on abortion, UNFPA and UNHCR were opposed, he said, because of political sensitivities.
While the MISP and field manual are intended to be used by implementing agencies, getting governments to endorse them can help ensure the guidelines are followed and the kits are readily available. In the past, a number of Arab countries and some African nations have opposed including abortion as a sexual and reproductive health right. In June, the Vatican, which has observer status at the U.N., opposed the inclusion of abortion services in the MISP and the associated kits.
“Political opposition to abortion can often derail support for the MISP without taking into account the life-saving focus,” said UNFPA’s Daniels, who has been advocating for the adoption of the revised MISP at the U.N. level. UNFPA’s aim, she said, was to ensure that abortion services are provided where legal and accessible, but not in a way that could jeopardize the MISP overall.
MSF’s Schulte-Hillen, who also attended the IAWG meetings, said the discussions led her to “question how strategically smart it is to put abortion in the MISP,” especially in negotiations with “hostile states.” It could prove “unhelpful in advancing negotiations about getting access to vulnerable populations,” she said. MSF is not on the IAWG steering committee but has a role as an observer and partner.
The resulting “note” on abortion was a compromise between viewpoints, and while advocates say it is a sign of progress, it falls short of what the IAWG safe abortion working group had hoped to achieve: a separate, standalone objective on safe abortion.
“It’s an advancement from the previous MISP chapter where safe abortion was not mentioned” at all, Powell said, but including it as a “note” could “make it easier for implementing agencies to ignore it.”
On the other hand, Krause pointed out that things that start out as notes “can eventually get into the MISP.” Powell said Ipas and other NGOs would be working to strengthen the case that it is possible to carry out abortions in humanitarian settings, and that the demand is there, by running demonstration projects.
Allie Doody, a senior advocacy associate at the U.S. family planning organization PAI, who was also at the IAWG meeting, told Devex that “this update was sorely needed and underscores the feasibility and importance of access to safe abortion services at the onset of emergencies.” But she added that “we have much more work to do to ensure that guidelines, policies, and programs accurately reflect the most effective available interventions — regardless of political sensitivities — and that quality care is ultimately delivered to women and girls.”
While a strong advocate for safe abortion in humanitarian settings, Schulte-Hillen argued that when it comes to meeting the needs of women and girls within the first days of an emergency, safe abortion is not the biggest priority and that the IAWG discussions were in danger of losing sight of that.
“Emergency obstetrics is where you save women’s lives immediately, for example postpartum hemorrhage,” the MSF expert said. Access to safe abortion “is really important, but there is a bit more time to make related care available,” she said. There was a danger that the IAWG discussions had been “sidetracked” by the issue of abortion, she said, when it needed to focus more on compiling the best evidence-based clinical and technical guidelines.
“I think the process for future revision needs to be reconsidered,” she said, pointing to the WHO technical reports as a possible template.
Other significant changes discussed at this month’s meeting included new guidelines for newborn care. Logistics and supply management also now receive more attention in the field guide, Krause said, in order to help think through how countries make the transition from implementing the MISP to providing more comprehensive health services.
Providing services to marginalized populations, including adolescents, people with disabilities, and LGBT groups, also received a lot of attention. There was agreement that more needs to be done to better understand and serve sub-groups within those populations, such as married adolescents, Krause explained. The field manual was also updated to be “more inclusive generally,” she said, and to affirm that people of all gender and sexual orientations have rights to sexual and reproductive health services.
The importance of offering care and services to male survivors of sexual violence and exploitation was also highlighted during the meetings as an area that needs more research and focus, Krause said, adding that organizations need to start thinking about how to reach these groups and offer them “a place that men and boys feel comfortable accessing.”
The new MISP materials are due to be released in spring 2018.
Read more Devex coverage on reproductive health.