Reproductive health background
The concept of reproductive health arose in the 1980s with a growing movement away from population control and demographic targets towards a more holistic approach to women’s health
For example, see Sen, A., ‘Population: delusion and reality’ New York Review of Books XLI(15), 1994; Bongaarts, J., ‘Population Policy Options in the Developing World.’ Science 263:771-6, 1994; and Hartmann, B., Reproductive rights and wrong: the global politics of population control and contraceptive choice. New York: Harper and Row, 1987.. It was not until the ICPD in 1994 and the Fourth World Conference on Women (FWCW) in 1995 that the concept gained international acceptance and was heralded as a turning point for women’s health. The ICDP brought to international recognition two important guiding principles of RSH: 1) that empowering women and improving their status are important ends in themselves and essential for achieving sustainable development; and 2) reproductive rights are inextricable from basic human rights, rather than something belonging to the realm of family planning. The FWCW reaffirmed and strengthened the consensus that had emerged at the ICPD.
The ICPD conference was instrumental in formalizing the paradigmatic shift in how women’s health was conceptualized and how services were delivered. The way in which reproductive health was viewed began to change: the focus became the promotion of healthy reproductive lives, rather than the prevention of sexual morbidity. Not only were there changes in the kinds of programmes that were delivered, but also in the intended recipients and manner of delivery of programmes. For example, men were recognized as having an important role to play; child survival was emphasized; the integration of RSH services into primary health care rather than their being offered as a separate service in separate facilities was advocated; and the need for reproductive health services specifically designed for refugees and internally displaced persons (IDPs) was recognized. Overall, it called for a fundamental rethink of health service provision.
- International Conference for Population and Development - http://www.iisd.ca/linkages/Cairo/program/p07000.html
- The Fourth World Conference on Women - http://www.un.org/womenwatch/daw/beijing/index.html
Refugee reproductive health background
In 1989, the Women’s Commission for Refugee Women and Children was founded as one of the first advocacy organizations monitoring the care and protection of refugee women and children. This group was instrumental in raising awareness of the paucity of RSH information and services for refugees and other forcibly displaced populations (e.g. IDPs). Early in the 1990s, a document by the Women’s Commission, Refugee Women and Reproductive Health Care: Reassessing Priorities, published results of an eight-country, year-long study of availability and feasibility of reproductive health services for refugee women. It highlighted the fact that little if any priority was given to reproductive health in emergency situations. It stated that general health care was prioritized with marginal provision of maternal and child healthcare services. No emphasis was given to family planning, sexually transmitted infections (STIs) and HIV/AIDS, sexual and gender-based violence, or other obstetric needs. It was one of the first comprehensive studies to document the importance of and need for reproductive health in emergencies.
Following the ICDP and FWCW conferences highlighting the need for refugee RSH to be regarded as a distinct need within the human rights framework, various non-governmental organizations (NGOs) and United Nation (UN) bodies used this as a platform to push RSH research and policy forward, and to advocate for better service provision for refugees and IDPs. Two instrumental organizations were formed. The first, The Reproductive Health Response in Conflict Consortium (RHRC), originally established as the Reproductive Health for Refugees Consortium, brought together RSH expertise from seven organizations committed to improving RSH services and standards to populations forcibly displaced. The RHRC changed its name to reflect that the work undertaken is not only for refugees, but all people affected by conflict.
The second key group formed was the Inter-agency Working Group on Refugee Reproductive Health (IAWG). The IAWG is made up of various NGOs, UN bodies, and governments. One instrumental work put together by IAWG has been the development of RSH guidelines and a field manual specifically for refugee and conflict settings. This manual, Reproductive Health in Refugee Situations: an Inter-agency Field Manual, was first developed in 1997 and tested in the field for two years before the current (1999) version was finalized. The purposes of the field manual are: to advocate for providing and/or strengthening refugee RSH services using a multi-sectoral approach; to be used as a guide for field staff in refugee situations; and to be used as a tool for decision-making in all aspects of the programme cycle. The manual includes technical standards for quality RSH services as outlined by the World Health Organization. The key components include:
Minimum Initial Service Package (MISP)
Other Reproductive Health Concerns
Reproductive Health of Young People
Sexually Transmitted Diseases including HIV/AIDS
- Reproductive Health Response in Conflict Consortium (formerly Reproductive Health for Refugees Consortium) - http://www.rhrc.org/
- The Women’s Commission for Refugee Women and Children - http://www.womenscommission.org/index.html
- Reproductive Health in Refugee Situations: an Inter-Agency Field Manual - http://www.who.int/disasters/tg.cfm?doctypeID=20
Reproductive health as a human right
A healthy reproductive and sexual life is now considered to be a basic human right for all, including refugees and other forcibly displaced persons, and is protected by three bodies of law: human rights law, refugee law, and humanitarian law. The foundations for reproductive rights were first established in the two fundamental human rights treaties, the United Nations Charter, adopted in 1945, and the Universal Declaration of Human Rights, adopted in 1948, which ensured an individual’s right to health. In 1951, refugee law came into effect with the United Nations Convention Relating to the Status of Refugees; its 1967 Protocol specified refugee rights to be granted by all signing states. This means that all signing parties must grant refugees who are lawfully staying in the country the same rights as its citizens, including rights to the provision of social security, maternity, and sickness. But it also means that those refugees who are non-Convention refugees, or those illegally within the county, are not often given the same rights; and these people may have difficulty accessing health and reproductive health care and services ( Girard and Waldman 2000 ). In 1949, the Geneva Convention Relative to the Protection of Civilians in Times of War provided the basis from which reproductive health was addressed under humanitarian law. Although not addressing reproductive health specifically, it made reference for protection and special assistance to ‘maternity cases’ as well as protecting women ‘against rape, enforced prostitution, or any form of indecent assault’ ( UNHCHR 1949 ).
In 1976, the international community agreed on an additional covenant that provided more detail to the rights embodied in the Human Rights Declaration and the Convention of the Status of Refugees, with implications upon issues of gender, reproductive health, and refugees, including those individuals not lawfully within a host county. The International Covenant on Economic, Social and Cultural Rights (ICESC), Article 12, goes beyond the Universal Declaration’s right to health. Rather, Article 12 states ‘the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ and then outlines steps to the realization of this goal. While there is no specific mention of reproductive health rights, some of its provisions, such as Articles 10(2) and 12(2a), address reproductive health issues ( UNHCHR 1976 ). However, the subsequent UN General Comment No. 14 on Article 12 ( UN 2000 ) states: ‘The right to the highest attainable standard of health, it specifically addresses reproductive health rights of all individuals with specific reference to women and adolescents, the inclusion of refugees, asylum-seekers, illegal immigrants, and internally displaced persons, as well as state responsibilities to uphold these reproductive rights’.
In 1979, The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) set clearer definitions and standards than the earlier covenants with respect to gender equality. It expanded the protections against discrimination and called for increased attention to vulnerable groups including refugees and migrants. CEDAW is the only human rights treaty that addresses women’s reproductive health rights through acknowledgement of pervasive social, cultural, and economic discrimination against women. In particular, Article 12 of the Convention requires states to ‘eliminate discrimination in access to health services throughout the life cycle, particularly in the areas of family planning, pregnancy and confinement, and the post-natal period’ ( CEDAW 1979 ). In 1999, CEDAW General Recommendations 24 on Women and Health (Article 12) made further recommendations according to the fact that ‘access to health care, including reproductive health, is a basic right under the Convention on the Elimination of All Forms of Discrimination against Women’ ( CEDAW 1999 ). It comprehensively addresses violence against women, STIs and HIV/AIDS, female genital mutilation (FGM), unwanted pregnancies, safe motherhood, provision and access to services, and quality of services provided, and declares that all of these are to be addressed by the participating states as provision of basic human rights.
The 1989 Convention on the Rights of the Child (CRC), equally guarantees children have access to basic human rights including health and access to RSH information and services. The 2002 Optional Protocol of the CRC was extended to mention the sale of children for prostitution, which endangers their RSH status.
Framed within human rights and refugee law, a Humanitarian Charter and Minimum Standards of Care in Disaster Assistance was developed by a large group of agencies in 1997. This Charter describes core principles of humanitarian actions in order to reaffirm the rights of affected populations, as well as pointing out responsibilities of warring parties or states. The Charter formed the basis of the Sphere Handbook, which sets out minimum standards of care for multi-sectoral disaster responses. In 2004, an updated version came into effect, which, in addition to other crosscutting themes, addresses RSH-related issues of protection, gender, children, HIV/AIDS, and people living with HIV/AIDS. Chapter Five of the Sphere Handbook outlines the minimal standards in health provision with a specific section addressing issues of RSH.
Finally, the most detailed documents and powerful agents of change, which draw on previous human rights treaties and various conventions, but do not have any legally binding recourse, are the ICPD and FWCW documents. These documents are based on international consensus decisions supporting gender equality, rights, and women’s empowerment, and clearly set out the concepts of sexual and reproductive rights including refugee reproductive rights.