Barriers to Reproductive Healthcare in Conflict Zones: What's a Priority?
By Margo Cohen
The following contains a discussion of sensitive topics, including assault and violence against women, which may be disturbing to some readers.
Introduction
Reproductive health is a human security concern that exists at all points in time, not just during conflict situations. A perhaps disproportionate section of security studies literature focuses on the weaponization of reproduction through wartime rape. A quick JSTOR database search for “”Rape” AND “War” AND “Security”” yields 59,725 results [1]; “"reproductive health" AND "war"” yields 8,602 [2]- less than 15% of the prior search results.
The association of sex with violence in war zones is warranted (as evidenced by the all-too-common use of rape as a weapon of war), but absolute focus to the point of neglect may be the product of viewing reproduction as an extension of hegemonic masculinity alone. This occurrence pushes narratives of female autonomy to the sidelines and takes power over the body away from women. It is absolutely essential to recognize that healthcare provision as a form of security does occur, many times, after consensual sex. Women who need pregnancy services after consent are as entitled to optimal healthcare as women who are also survivors of assault. By continuing the expansion of the field to include reproductive services outside of rape as a security concern, we recognize the importance of self-determination for people with uteruses, and reiterate the universality of healthcare as a human right.
There are several crucial variables to track in analyses of access to reproductive care. These encompass both concrete factors and more fluid ideas, including quality of pre-existing infrastructure, concentration of combat in the region, and legal status of women before conflict, and social structures and norms.
Much of the previous scholarship regarding reproductive healthcare access emphasizes the role of education. The well-known causal relationship between educational attainment and fertility [3] is often highlighted as evidence that investment in women as long-term social and economic players pays off for their communities. However, during conflict, educational infrastructure may be destroyed or occupied, leading to long-term setbacks in the status of women. How, then, should community leaders and policymakers prioritize for reproductive healthcare stability in a human security framework? And, what more immediate factors impact women’s access to reproductive health services in conflict zones?
With these questions in mind, this work will examine access to reproductive healthcare as a right actively violated in warzones and post-conflict scenarios through poor quality of care. After thorough analysis, I will come to the conclusion that during conflict, and after it, one of the biggest barriers to access to reproductive care is quality of care.
Examining the Issue
Armed conflict is notoriously dangerous for people giving birth. A study of maternal mortality from 2000-2019 in conflict zones by Jawad et al. found that “approximate[ly]... 300,000 avoidable maternal deaths and 2 million avoidable infant deaths” [4] occurred in the surveyed areas. These deaths were caused by a combination of systemic healthcare failures and larger ecosystemic breakdown.
One of the largest factors that continued through literature reviewed for this piece was the need for higher-quality care. A critically under equipped hospital won’t be much help for the mother or child needing specific or rare treatment(s). [5] In Northern Uganda, for example, nurses would be kidnapped, and supplies stolen, in order to provide
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broad health services to rebels- leaving communities unable to care for themselves. Nurses who were left would give priority care to members of their personal ethnic groups [6], an especially dangerous phenomenon given the group-based nature of the conflict.
In conflict zones where proper infrastructure does exist, women and people with uteruses are often blocked from receiving proper care by high costs of medication. Economic insecurity, as demonstrated by the Human Rights Watch video linked above, thus becomes a potentially fatal factor. As one compares the Council on Foreign Relations’ Global Conflict Tracker map [7] and Slate/Harvard’s [8] map of global access to subsidized birth control pills, this reality becomes even more evident. Of the 26 nation-states represented on the CFR’s conflict map [9], 10 had no subsidized access, 6 had partial access, and 5
had free access [10] to contraceptives. 7 out of the 26 countries are off track to meet UN Sustainable Development Goal(SDG) 1- the elimination of extreme poverty [11] or actually have rising poverty rates. [12] This may translate to needing subsidized or free birth control, as higher relative costs for birth control can translate into a barrier for access. From this, it may be possible to deduce that women in states with active conflict are at an elevated risk of having difficulty gaining access to birth control due to financial reasons.
Reproductive Health and Migration
Women who leave conflict zones often face equally perilous levels of care. A 2017 academic article in Reproductive Health Matters journal by Yasmine and Moughalian noted that Syrian refugees fleeing violence who fled to Lebanon consistently faced exosystemic security threats produced by a healthcare system that did not have the ability or desire to treat them:
“Many women stated that, during delivery, healthcare workers ignored them for hours, while others said they felt obliged to have [a] C-section because doctors did not want to wait on them and labor and three quarters of their bill would… be covered by UNHCR. C-section rates among Syrian refugees (35%) are triple the recommended WHO rate, and more than double the rate in pre-conflict Syria(15%).”[13]
Although it is true that the rate of C-section procedures is increasing worldwide [14], the rate for Syrian refugees is still 167% higher than the global average- enough to warrant serious international concern about neglect and quality of care in Lebanon. By neglecting to actively provide timely and appropriate healthcare in the given circumstances, these hospitals may violate Article 12 of the International Covenant on Economic Social and Cultural Rights(ICESCR) [15], an international agreement that includes as a right the entitlement to “the enjoyment of a variety of facilities, goods, services, and conditions necessary for the realization of the highest attainable standard of health.”[16]
These Syrian refugees often face undue pressure to avoid locations that provide reproductive and sexual health care services. Described bluntly in previous academic work as “a lack of dignity” [17], the issue disproportionately affects groups that are further marginalized among refugee groups- namely, people with disabilities and members of the LGBTQ+ community.
Mistreatment, mismanagement, and blatant discrimination against women in conflict zones often serve as major barriers for women to even attempt to access care. If negative experiences with treatment at a healthcare center are frequent narratives, women in these communities may come to the conclusion that bad healthcare has a similar or more optimal impact as no healthcare.
Healthcare as a Human Right
Following the ICESCR is an inherently murky task. Previous scholarship on the Covenant has noted that “influence derives mainly from the obligation…to ‘take steps’ (legislative and other measures) to the maximum of available resources…the ratification of international human rights treaties is meaningful if the rights guaranteed in relevant treaties have an effect upon [domestic treatment of] human rights, and effective remedies for violations of the protected rights are available and accessible”[18], meaning that enforcement and fulfillment of Covenant requirements is largely up to the states. Thus, violation of refugee
womens’ rights to dignified and unabridged healthcare may be against the Covenant, but unless the Lebanese government actively decides to take action against these hospitals, there are few, if any, repercussions for the healthcare providers. [19]
Regardless, lack of an enforcement mechanism or existing, enforced protections does not diminish the gross violation of provider trust and patient dignity seen in Lebanon. Healthcare as a good and service is provided, but healthcare in conditions that are to the best of the facility’s ability is clearly not. In future policymaking, the Lebanese government must follow up on these reports of purposefully subpar healthcare, and adjust policy and ICESCR enforcement measures to reflect their findings.
Conclusion
Conflict zones are known for being some of the most dangerous places in the world for anyone, regardless of sex. However, recent scholarship emphasizes that oftentimes the ones most in danger are women[20]. In this deliverable, I emphasized the need for higher-quality care for women in, and fleeing from, areas of civil conflict. Through analyses of examples from Ukraine, Uganda, and Syria in in- and post-conflict environments, this paper rests on the conclusion that during conflict, and after it, the biggest unaddressed barrier to access to reproductive care is quality of care.
Security studies, as a field, is long overdue for a reckoning with our neglect of reproductive healthcare provision as a security concern. By focusing primarily on violence, academics in security focus only on immediate impacts of conflict and hegemonic masculinity as an extension, when the reality for people living in insecure areas is much more complicated. Future work to improve the human security status of women in conflict zones around the world must shift emphasis away from narratives centered on hegemonic masculinity and the idea of too few hospitals. Instead, policy must shift towards improving the quality and safety of existing healthcare infrastructure while continuing current work to supplement existing scholarly deficiency.
1. “JSTOR Query- ’Rape’ AND ‘War’ AND ‘Security.’” JSTOR, https://www.jstor.org/action/doBasicSearch?Query=%E2%80%9DRape%E2%80%9D+AND+%E2%80%9CWar%E2%80%9D+AND+%E2%80%9CSecurity%E2%80%9D.
2. “JSTOR Query- ‘Reproductive Health’ and ‘War.’” JSTOR, https://www.jstor.org/action/doBasicSearch?Query=%22reproductive+health%22+AND+%22war%22.
3. Cornett, A. (2020). Analyzing the Relationship Between Female Education and Fertility Rate. Drake Undergraduate Social Science Journal- Spring 2020 Edition. Retrieved April 23, 2023, from https://www.drake.edu/media/departmentsoffices/dussj/2020documents/Cornett%20DUSSJ%202020.pdf
4. Article Source: Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000–2019
Jawad M, Hone T, Vamos EP, Cetorelli V, Millett C (2021) Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000–2019. PLOS Medicine 18(9): e1003810. https://doi.org/10.1371/journal.pmed.1003810
5. Image description: two soldiers walk through the remains of a Mariupol, Ukraine maternity hospital, left. In the right foreground, it appears that a crib and incubator sit among the debris. Image Credit: The Associated Press, Maloletka, E. (2022). Ukrainian servicemen work inside of a maternity hospital that was damaged by shelling in Mariupol, Ukraine, March 9, 2022. . AP News. Retrieved from https://apnews.com/article/russia-ukraine-war-maternity-hospital-pregnant-woman-dead-c0f2f859296f9f02be24fc9edfca1085.
6. Chi, P.C., Bulage, P., Urdal, H. et al. Perceptions of the effects of armed conflict on maternal and reproductive health services and outcomes in Burundi and Northern Uganda: a qualitative study. BMC Int Health Hum Rights 15, 7 (2015). https://doi.org/10.1186/s12914-015-0045-z
7. Council on Foreign Relations. (n.d.). Global conflict tracker council on foreign relations. Council on Foreign Relations. Retrieved April 23, 2023, from https://www.cfr.org/global-conflict-tracker/
8. Beauchamp, Zack. “Here's a Map of the Countries Where the Pill Is Fully Subsidized (It Includes Iran).” Vox, Vox, 30 June 2014, https://www.vox.com/2014/6/30/5857904/where-the-pill-is-free. and Kirk, Chris, et al. “The Complete Global Map of Abortion and Birth Control Laws.” Slate Magazine, 30 May 2013, https://www.slate.com/articles/news_and_politics/map_of_the_week/2013/05/abortion_and_birth_control_a_global_map.html.
9. As of April 18, 2023
10. Note: 5 nations[Yemen, Myanmar, Taiwan, North Korea], had no inputted data. No data for South Sudan, only Sudan.
11. United Nations. (n.d.). Goal 1 | Department of Economic and Social Affairs. United Nations. Retrieved April 23, 2023, from https://sdgs.un.org/goals/goal1
12. World Poverty Clock. (n.d.). Retrieved April 23, 2023, from https://worldpoverty.io/map
13. Yasmine, Rola, and Catherine Moughalian. “Systemic Violence against Syrian Refugee Women and the Myth of Effective Intrapersonal Interventions.” Reproductive Health Matters, vol. 24, no. 47, 2016, pp. 27–35. JSTOR, https://www.jstor.org/stable/26495888. Accessed 11 Apr. 2023.
14. “Caesarean Section Rates Continue to Rise, amid Growing Inequalities in Access.” World Health Organization, World Health Organization, https://www.who.int/news/item/16-06-2021-caesarean-section-rates-continue-to-rise-amid-growing-inequalities-in-access.
15. Health and Human Rights: Basic International Documents; Second Edition. Page 80; 84; 86
16. Health and Human Rights: Basic International Documents; Second Edition. Page 84
17. Endler, M., Al Haidari, T., Chowdhury, S., Christilaw, J., El Kak, F., Galimberti, D., Gutierrez, M., Ramirez-Negrin, A., Senanayake, H., Sohail, R., Temmerman, M., Danielsson, K.G. and (2020), Sexual and reproductive health and rights of refugee and migrant women: gynecologists’ and obstetricians’ responsibilities. Int J Gynecol Obstet, 149: 113-119. https://doi.org/10.1002/ijgo.13111
18. Ssenyonjo, M. The Influence of the International Covenant on Economic, Social and Cultural Rights in Africa. Neth Int Law Rev 64, 259–289 (2017). https://doi.org/10.1007/s40802-017-0091-4
20. Image Description: A woman, in a flower-patterned veil, talks to a woman with a stethoscope, white medical vest, and light pink hijab. Image Credit: Middleton, Marjie. “Syrian Refugees in Lebanon: ‘Pregnant Women Often Have No Idea Where to Go’: MSF.” Médecins Sans Frontières (MSF) International, 5 Aug. 2013, https://www.msf.org/syrian-refugees-lebanon-pregnant-women-often-have-no-idea-where-go%E2%80%9D.
21. Mlaba, Khanyi. “How Do Women and Girls Experience the Worst of War?” Global Citizen, https://www.globalcitizen.org/en/content/women-and-girls-impacts-war-conflict/.