Refugee reproductive and sexual heath
Why should reproductive and sexual health services be specifically targeted to forcibly displaced populations?
Anyone who has been forcibly displaced from their home due to conflict, natural disaster, and/or political reasons may be exposed to a myriad of risk factors that affect their reproductive health and status. For example, exposure to sexual violence, health status during the flight, health conditions in the host country/region, stress, economic and social breakdown, and pre-flight RSH services are all contributing factors to an individual’s RSH status.
Women and girls face increased chances of reproductive health risks during migration. Violence, including sexual violence from armed forces, increases exposure to the transmission of STIs, HIV/AIDS, and unwanted and/or high-risk pregnancies. Poverty is exacerbated, and thus individuals may submit to sexual exploitation in order to meet basic survival needs. Many become separated from their families and lose traditional cultural and legal supports and protection that affect reproductive health and status. If the destinations of fleeing migrant populations do not provide adequate reproductive healthcare services, this can result in high rates of unwanted pregnancy, unsafe abortion, and preventable death and injury as a result of pregnancy and childbirth ( UNFPA 2000 ). Poor nutrition, overcrowding, unsanitary conditions, untreated illness, violence against women, and stress all take a steep toll on women's physical and mental health, well-being, and social participation.
Taken globally, reproductive morbidity and mortality are major problems that disproportionately affect men and women. Sex or biological differences between women and men, such as childbearing, breast cancer, and menopause, create unique health issues for women. The WHO’s World Health Report 2002 found that reproductive ill-health
Compiled from Burden of Disease in DALYs (Disability-Adjusted Life Year) and recalculated solely for STDs excluding HIV, maternal conditions, and peri-natal deficiencies including nutrition-related deficiencies. This list does not take into consideration other related communicable diseases.accounts for approximately 20 per cent of the total disease burden among women compared to an estimated 6.5 per cent in men. Comparably, in Africa, where a large proportion of the world’s forcibly displaced populations are found, the total disease burden due to reproductive morbidity is 44.5 per cent. Poor reproductive health related to sex and reproduction is due to key causal factors found within risky sexual behaviours, pregnancy, abortion, and childbirth ( WHO 2002 ).
Reproductive and sexual health services in emergency versus longer-term settings
Populations who undergo forced migration are not a homogeneous group, and this fact impacts upon service delivery, as do the length of time a camp has been established and the range of services provided. For example, services provided during the acute emergency phase will be somewhat different from those services required in stable refugee/IDP camp settings. While a standard set of services has been developed for emergency settings, as the situation stabilizes, comprehensive RSH services must be established. However, unlike emergency settings, where a standard of care is specified for RSH service providers, in long-term settings comprehensive RSH services need to be tailored to the specific context. Pre-migration contexts will result in differences in the need and demand for services. This means that previous service provision, access to services, and acceptability of services all impact upon demand and uptake, as do issues of female literacy and empowerment, and religious and cultural values ( Palmer 1998 ).
- CARE (2002) Moving from Emergency Response to Comprehensive Reproductive Health Programs. A modular training series2 - http://www.rhrc.org/mod_training.html
- WHO (2000) Reproductive Health During Conflict and Displacement: a guide for programme managers, Chapter 9 - http://www.who.int/reproductive-health/publications/RHR_00_13_RH_conflict_and_displacement/RH_conflict_chapter9.en.html
- Reproductive Health Outlook: Refugee Reproductive Health Section - http://www.rho.org/html/refugee_keyissues.
Emergency RSH services
Policy on reproductive health has been the last to come on board in emergency settings. Traditionally, food, shelter, sanitation and basic health care were first priorities. Where RSH services were seen as a priority, the emphasis was on maternal and child health care (MCH) or STI services as part of general health care ( Palmer 1998 ). However, RSH needs of displaced populations were recognized in the early 1990s (Wulf 1994). In particular, the Inter-agency Field Manual highlighted the fact that specific RSH services needed to be delivered in acute emergency settings until full RSH services could be implemented once the situation stabilized. It was recognized that not providing emergency RSH services resulted in severe adverse consequences such as preventable maternal and infant deaths, unwanted pregnancies that could lead to unsafe abortion, and the transmission of STIs or HIV. In immediate emergencies, it is known that forcibly displaced populations have worse health outcomes than others in both their host country and country of origin ( Hynes et al. 2002 ; McGinn 2000; Toole and Waldman 1997 ). However, it has been documented that in most post-emergency camps, the reproductive health outcomes are better than in their respective host country and country of origin ( Hynes et al. 2002 ). This evidence demonstrates that quality RSH services can be provided in difficult settings with positive outcomes. Yet, despite improved awareness and mounting research, RSH service delivery has been and to a large extent remains inconsistent, which is a reflection of donor and/or head office commitments ( RHRC 2003 ).
The Minimal Initial Service Package (MISP) provides the basic standard of reproductive health care that must be delivered together with all other basic services during the initial days of an emergency setting. The priority is to reduce both short- and long-term RSH ill-health and mortality, with the aim that additional funding will be provided for continued services once the situation has stabilized ( Krause, Jones, and Purdin 2000 ). Implementation of MISP does not require the additional assessments that longer-term services do, since documented evidence has already justified the use of MISP. MISP is a package of kits and supplies together with activities to be put in place by trained staff. The reproductive health kit is designed for the basic emergency phase and is made up of twelve different sub-kits to be ordered and used according to the level of care provided. Depending on the setting, some components of the MISP kits will be more relevant to the particular situation, and assessment must be made to determine the capacity of the organizations to implement them as well as the needs within the community. One obstacle to providing MISP in emergencies is that like any other service, all components must be planned for, together with having trained staff from the onset; otherwise, fragmented and less robust service provision can occur as the situation develops ( RHRC 2003 ).
In emergency settings, the core components of MISP to be planned for and delivered include:
The co-ordination and implementation of MISP by identifying a lead agency and a reproductive health co-ordinator.
Prevention and management of the consequences of sexual violence by: enhancing physical security in the camps; ensuring availability of female protection and health staff, incorporating issues of sexual violence into health meetings, making information available and widely delivered to refugees, and ensuring medical response including the availability of emergency contraception.
Reduction in transmission of HIV that includes both in terms of safety procedures for medical staff as well as the availability of free condoms.
Prevention of excess neonatal and maternal morbidity and mortality through the provision of clean delivery kits for mothers or birth attendants; midwife delivery kits to assist with basic obstetric emergencies (but not surgical); and get a referral system in place to provide essential obstetric care that can only be managed at hospital level.
Plans for comprehensive RSH services to be integrated into affect the power balance in the relationship primary health care as soon as possible.
( UNHCR 1999 )
One of the more controversial components of MISP is the provision of emergency contraception (EC). EC is one method used to prevent unwanted pregnancy as a result of sexual violence, which often accompanies conflict and displacement. It is available either in the form of a pill or a copper intrauterine device (IUD). The pill can prevent unwanted pregnancy if used within seventy-two hours, and should under no circumstances be regarded as a method of contraception. Technically, it is an easier method to administer than the copper IUD. However, EC pills are a contentious, as they have been (inappropriately) linked with the abortion debate
The EC pills do not interrupt or damage a pregnancy, and thus the WHO does not consider them a method of abortion. Rather the EC pills work by interrupting the woman’s reproductive cycle ( WHO 2002 ).. Some view it as an abortive method rather than a preventative measure against unsafe abortion. The key problems hindering effective implementation of EC pills are: 1) the lack of appropriate training for staff on how to administer the pill and attitudes towards the pill; 2) the lack of women’s awareness of EC; and 3) funding (e.g. the United States Office of Foreign Disaster Assistance does not supply contraception and thus EC cannot be funded [ Goodyear and McGinn 1998 ]). Due to the fact that sexual violence in emergencies now plays a major role in RSH, it is imperative that EC can be provided in a timely manner, and that health staff and women are aware of its existence.
Longer-term reproductive and sexual health services
Once an emergency situation has stabilized, there are some specific RSH concerns that must be taken into consideration and tailored for according to the population’s needs. Long-term planning includes planning RSH services for a camp setting, as well as integrating them into the services of the host country/region. Longer-term RSH services in a camp setting must evolve to meet the changing RSH needs of the population including psychological and chronic problems ( Hynes et al. 2002 ). However, there comes a point when it is not financially or politically sound to continue providing parallel services for refugees/IDPs ( WHO 2000 ). Planning must take into consideration the comparability of services within the camp versus those of the host community or community of origin, and what this means for returning populations. The challenge not only becomes transferring standards of RSH services and care to local NGOs and/or service providers in the host area or area of return, but ensuring women can maintain access to family planning methods (condoms, the pill, IUDs, etc.).
Safe motherhood includes ante-natal care, safe delivery, and post-natal care. It is a pinnacle service into which other services can be integrated, such as family planning, STI and HIV/AIDS prevention and management, female genital cutting (FGC) and other RSH concerns. Averting maternal death and maternal morbidity is paramount to safe motherhood. However, statistics reveal that much work still needs to be done in this area. Globally, 600,000 women die from pregnancy-related causes each year ( UNHCR 1999 ) and for each woman who dies, 30-100 other women will suffer from maternal morbidity ( UNFPA Fast Facts ).
Precautions to avert maternal death and disability are known, however they are not always available to women in developing countries and forcibly displaced populations. It is known that approximately 15 per cent of all pregnant women including refugees will develop unforeseen complications that require essential obstetric care. However, obstacles prevent women from accessing this care. For example, displaced populations have little access to transportation giving access to hospitals, in addition to the fact that timely referrals are difficult to make if traditional midwives are unskilled and referral facilities are unavailable. Therefore, in order to avert maternal death and disability the following minimum services are required: ante-natal services, minimally skilled assistance for proper delivery care (both traditional birth attendants and midwives), established referral systems and timely accessibility to these facilities, and post-partum care for the assessment of mother and child health, particularly if the woman is alone as head of family.
Other related issues that may increase in unstable migrant settings and thus need to be targeted include:
Miscarriage (spontaneous abortions). These can be due to poor nutrition, malaria complications, fatigue and inadequate ante-natal services. Post-abortion care services must be in place to deal with these complications.
Peri-natal and neo-natal mortality (Peri-natal deaths include deaths of infants from twenty-two weeks’ gestation to one week of life. Neo-natal mortality is the death of a newborn within twenty-eight days of birth.). An estimated 3.4 million out of 8 million infant deaths per year result from poor maternal health and inadequate delivery care ( UNFPA Fast Facts ). Both poor health and inadequate delivery care are characteristic of displaced environments. The most important factors leading to mortality are infections, birth asphyxia, and low birth weight resulting in difficulties keeping these babies alive. Key contributors (which are typical to a forcibly displaced person) are a change in lifestyle including maternal deficiency in specific nutrients, the lack of ante-natal care, improper care during delivery, failure to provide immediate care for the baby and appropriate post-partum care (Save the Children).
Family planning (FP) services are necessary both to persons not wanting a pregnancy and to those who desire pregnancy, but want to ensure adequate spacing. There is no conclusive evidence to specify whether fertility rates increase or decrease during displacement ( Palmer 1998 ; McGinn 2000 ; John Hopkins University 1996 ). There have been arguments for both, but the most convincing is that fertility rates resemble those of pre-migration settings in stable or longer-term refugee/displaced conditions ( McGinn 2000 ). However, it is imperative that migrant populations are provided with access to contraception, and as situations stabilize, that they are provided with effective, safe, and culturally appropriate methods of family planning. The most basic form of FP should be condoms, not only to assist with family planning decisions, but also to protect against STIs and HIV/AIDS.
Gender-sensitive programming is essential to address the dynamics of knowledge, power, and decision-making in sexual relationships, between service providers and clients, and between community leaders and citizens. Men must be recognized as having reproductive health needs together with the fact that the involvement of men is an essential part of protecting women's reproductive health.
The other related issue that may increase in unstable migrant settings and must be targeted is unsafe abortions. They are an outcome of unwanted pregnancies (often the result of sexual violence, especially in conflict situations). There are an estimated 20 million unsafe abortions each year, and 19 million of these occur in developing countries, of which many do not legally allow abortion for rape cases. Approximately one-third of women undergoing unsafe abortions experience serious complications, and approximately one in eight women who die each year from pregnancy-related causes do so due to abortion complications ( The Alan Guttmacher Institute 1999).
While ‘in no cases should abortion be promoted as a method of family planning’ ( ICPD para. 8.25 ), post-abortion care (PAC) services are necessary to mitigate maternal mortality and morbidity due to incomplete or septic abortions. This means that referral systems must be established, and existing facilities must be able manage minimum complications and take prompt referrals when required. To be effective, PAC services must be linked to other FP and RSH services, rather than exist as stand-alone services, in order to avoid repeat abortions ( Postabortion Care Consortium 2002 ). Whether or not abortion is legal in the host country, PAC must be included in comprehensive RSH services ( see section 5.2 for a case study on PAC).
STIs including HIV/AIDS
War and displacement, with their roots in poverty, powerlessness, and social instability, increase the transmission of STIs and HIV/AIDS (WHO/UNAIDS in Krause et al. 2000 ). The disintegration of family, stable relationships, and governing norms regarding sexual behaviours accelerate transmission of STIs and HIV/AIDS. This makes refugees and IDPs vulnerable groups, especially women and adolescents, due to their disadvantaged socio-economic status. Often sex is used as a form of currency in exchange for goods/services such as food, security, shelter, and other basic needs ( UNHCR 2001 ), and condoms are not always used, thus increasing possible transmission of STIs and HIV.
A controversial view is that refugee HIV rates are higher than a host population’s. Perpetuation of this view only further marginalizes a displaced population and can lead to discrimination and stigmatization. A recent study by the UNHCR and partners has revealed that the prevalence of HIV in three out of four refugee populations was lower than in the host country ( UNHCR 2003 ). A study of Rwandan refugees in Tanzania revealed that HIV rates remained lower and more stable in official camp settings than rates among Rwandans living outside of camps within the host population ( Mayaud 2001 ). There is certain to be some mixing between the host and displaced groups, and the mixing of these low- and high-prevalence populations (of both migrant and host populations) can increase transmission of STIs and HIV through increased sexual networks and risky behaviours. In instances of military presence, STIs and HIV transmission is accelerated due to the fact that the military often has a higher prevalence of these diseases than civilians, and the soldiers’ movements contribute to the spread ( Healthlink Worldwide 2002 ).
Controlling the transmission of STIs not only helps to reduce long-term reproductive morbidities such as ectopic pregnancy and infertility, but also reduces the likelihood of HIV transmission; thus, it is an important strategy for preventing the spread of HIV/AIDS. The syndromic approach endorsed by WHO/UNAIDS has become the standard of care in many countries for management of the most common STIs. By directing treatment against the common causes of easily identified STIs, primary healthcare workers can achieve high rates of cure without the delay and cost involved with laboratories, which is not always feasible in camp settings. Contact tracing of partners should always be part of the STI treatment; however, in an unstable environment it may not always be possible.
Another main mode of transmission is mother-to-child transmission (MTCT) or vertical transmission. Integrating HIV services into general RSH care can reduce transmission to children since the spread of HIV from an infected mother can occur during pregnancy, during labour, or after delivery through breast milk. Therefore, attempts to reduce chances of vertical transmission must be tackled at multiple points.
Integrating HIV management into RSH care is an important way to avoid MTCT. The addition of voluntary HIV testing into ante-natal care can help reduce the spread of disease to the child at birth through antiretrovirals (ARVs). The WHO estimates that 15–30 per cent of HIV-infected mothers transmit HIV during pregnancy and delivery without ARVs (WHO). Post-natal care targeting breast-feeding is an extremely important part of general RSH care, but especially with HIV-positive women. The WHO estimates that 10–20 percent of mothers with HIV will transmit it through breast milk.For forcibly displaced populations, the Inter-agency Field Manual advocates standards on HIV and infant feeding established by UNAIDS, UNICEF, and WHO. These include the possibilities of avoiding breast-feeding and using formula or an HIV-negative wet nurse, or exclusive breast-feeding for a short period of time. However, in unstable situations some or all of these may be impractical. Especially if formula cannot be correctly stored and prepared, the infant may be at greater risk of illness and death than the transmission of HIV ( UNHCR 1999 ). Healthcare providers must be properly trained in post-natal care to provide the best possible counselling to all mothers, especially HIV-positive mothers. Constant research is being conducted, and UNICEF/WHO should be contacted for any updates.
For forcibly displaced populations, the Inter-agency Field Manual advocates standards on HIV and infant feeding established by UNAIDS, UNICEF, and WHO. These include the possibilities of avoiding breast-feeding and using formula or an HIV-negative wet nurse, or exclusive breast-feeding for a short period of time. However, in unstable situations some or all of these may be impractical. Especially if formula cannot be correctly stored and prepared, the infant may be at greater risk of illness and death than the transmission of HIV ( UNHCR 1999 ). Healthcare providers must be properly trained in post-natal care to provide the best possible counselling to all mothers, especially HIV-positive mothers. Constant research is being conducted, and UNICEF/WHO should be contacted for any updates.
Sexual and gender-based violence
Gender is a prescribed role assigned to men and women that is defined and upheld by learned societal norms and constructs. Gender roles can vary according to different cultures, and fundamentally define status, identity, and power relations in society. Gender differences between women and men can place burdens on women's health. The roles, rights, responsibilities, and status assigned to women by society leave women vulnerable to unwanted and unprotected sexual intercourse, poor nutrition, and physical and mental abuse. They can also limit women's access to health care and attaining good RSH.
Gender-based violence is violence against a particular group based on their gender or sex, rather than indiscriminate violence ( UNHCR 2003 ). It includes physical, mental, sexual, verbal, and psychological abuse. While rape and sexual assault are most commonly known, it also includes marital rape, domestic violence, sexual exploitation, sexual harassment, physical assault, verbal abuse, confinement, female genital mutilation, forced marriage, early marriage, infanticide, socio-economic discrimination, and social exclusion ( UNHCR 2003 ). Violence against girls and women throughout the world causes more death and disability among women aged 15–44 than cancer, malaria, traffic accidents, and even war, according to The World Bank ( UNFPA Fast Facts ). It fundamentally stems from unequal power relations, and most often the powerless are the women and children.
Sexual and gender-based violence (SGBV) can happen in all settings; however, displacement and its associated stressors can exacerbate the frequency or magnitude with which it happens. This includes the breakdown of social structures, poverty, socio-economic discrimination, psychological strains of refugee life, and powerlessness. It can happen at any stage of displacement, and thus, prevention and responses must be tailored to the different circumstances of each phase, from initial conflict, to flight, to place of asylum, through to reintegration ( UNHCR 1999 and 2003 ). There can be fatal results of SGBV, including homicide, suicide, and infant mortality. More common are non-fatal consequences including reproductive ill-health, physical disabilities, emotional and psychosocial disorders, and negative social outcomes ( UNHCR 2003 ). Stigma, shame, and silence are inextricably linked to this issue, which can lead to under-reporting of the crime. Therefore, preventive measures should be set up on the assumption that it is a problem, together with co-ordinated medical, psychosocial, and legal responses ( UNHCR 1999 ; Ward 2002 ), as one is not an effective response without the others.
Commitment to SGBV is improving, but it is not widely implemented as a core feature of humanitarian interventions yet, despite standards and protocols ( Ward 2002 ). A multi-sectoral intervention including the health sector, social workers, law enforcers, and legal/policy systems must work in a co-ordinated effort.
Adolescent reproductive and sexual health
Adolescence and youth is defined as the period between approximately 10–24 years of age. It is a time of continuous change physically, mentally, and socially. This age group faces social pressures and expectations that can affect their reproductive health status; therefore, young people require information about these changes in order to make decisions that can prevent sexual ill-health. Parents can be sources of information and counselling to their children, as can other adults in and out of the family, especially political and religious leaders, who have a great deal of influence on changing social attitudes ( UNFPA 2000 ). However, while intending to protect young people, some adults may limit young people’s access to information and health services in fear that information will promote sexual behaviour. Information is the greatest tool young people have to protect themselves against reproductive and sexual ill-health.
Displacement accentuates the turmoil typical of this period. The breakdown of family, community, social norms, loss of parental supervision, lack of schooling and recreational activities, frustration, boredom, insecurity of refugee life, and uncertainty about the future may lead adolescents to experiment with risky behaviours, including violence, drug abuse, and unprotected sex ( UNHCR 1999 and 2000 ). Some may have gone through traumatic experiences such as armed conflict, sexual abuse, violence, and/or loss of family members, and many have to deal with these issues alone. Therefore, young displaced people are more at risk of developing sexual ill-health than settled adolescents ( UNHCR 1999 and 2000 ), and RSH services must target the unique needs and circumstances of this group.
Working with young people to address their reproductive and sexual health requires the special skills of service providers. An understanding of the cultural sensitivities around providing information and services to young people, confidentiality, a non-judgemental environment, easy accessibility, and a service provider of the same sex are all extremely important to getting young people to accept services ( UNHCR 1999 ). Integrating adolescent RSH services into mainstream health care may ostracize young people from seeking services due to fear of reprisal, shame, or embarrassment.
Disseminating information to young people can be difficult. In stable settings, education systems are a popular means of providing information to a large number of young people. Because education services can be limited within displaced settings, or many young people may leave school during this time, displaced young people are less likely to access health-related information through schools. Other means must be devised to ensure messages are being delivered. One common method to ensure participation of young people is to work through peers. Young people often have a culture of their own, with their own norms. Working with peer educators helps to break down the adult–young person barriers, and allows young people access to information, ranging from the basic changes in their bodies and emotions; to avoiding pregnancy, STIs and HIV/AIDS; as well as issues that may be especially pertinent to their circumstances, such as forced sex or selling sex for survival. All of this information must be accompanied with instructions on how and where to access services (see Case studies for examples of adolescent reproductive and sexual health matters).
Other reproductive and sexual health needs
In the past, the principle objection to male participation in sexual and reproductive health has been that adding male services will damage the quality of women's services and create additional competition for already scarce resources. However, we know now that neglecting to provide information and services for men can detract from women's overall health, but they must be integrated in a way that is beneficial to both men and women ( Wegner 1998; RHO ). For example, men who are educated about reproductive health issues are more likely to support their partners in decisions on contraceptive use and family planning; be supportive during pregnancy; and if obstetric complications arise, they will know not to delay in getting appropriate assistance. Men’s education on the protection, testing, and treatment of STIs, as well as stressing partner notification, can assist in reducing HIV transmission. Getting men to share the responsibility of good reproductive and sexual health can help to prevent disease, as well as to share the benefits of contraception decisions and avoid the risks otherwise present.
At the same time, service providers must be aware of the gender dynamic within a couple. A woman may be fearful of losing her partner or be threatened with violence if he knows she is positive for a STI or HIV. Women may feel their husband is not supportive of birth spacing or longer-term contraception and may want use it without the partner’s knowledge ( Ringheim 2002 ). Programmes that support a couple approach must be careful not to jeopardize a woman’s right to decision-making. Gender-sensitive programming is essential to address the dynamics of knowledge, power, and decision-making in sexual relationships.
Harmful traditional practices: FGC and early marriage
Harmful traditional practices are those that are endorsed and practised by various cultures, but may cause lasting adverse biological and/or psychosocial effects on the individual ( Toubia 1995 ). Included in these practices are female genital cutting (FGC) and early marriage. Reproductive and sexual health services seek to eliminate these practices while at the same time approaching them with sensitivity. Despite the fact that FGC is now on the international agenda, and is condemned by most governments, it is still common in twenty-eight countries, and it is sanctioned unofficially in many communities despite what the law may say ( UNFPA Fast Facts ). These are cultural practices that are ingrained into the psyche of the individuals within that society: wishes to go against these practices can lead to abuse and ostracization. Therefore, addressing issues dealing with fundamental social change may be better achieved in stable situations than in refugee/displacement settings. Changing values and challenging beliefs require long-term, ongoing support.
Each year, 2 million girls are at risk of FGC, and it is estimated that 130 million women worldwide have undergone some form of the procedure ( UNFPA Fast Facts ). Women with FGC need special care, and in refugee settings service providers must be aware of the cultural practices in order to appropriately address RSH needs. Care must be taken of pregnant women during delivery. The rigid scar tissue around the vaginal opening resulting from the cutting may lead to a delay in the second stage of labor, which may endanger the lives of the mother and/or the baby. Family planning options may be somewhat limited, as special care must be taken with contraceptive forms such as the IUD, and the management of unsafe and spontaneous abortion will need special attention ( UNHCR 1999 ). While these issues can be addressed medically, the sexual and psychological negative effects can be lifelong ( Toubia 1995 ).
Early marriage is another cultural issue that can result in severe, and sometimes fatal, biological and psychological effects. The UNFPA estimates that 82 million girls between the ages of 10-18 in developing countries will be married before their eighteenth birthday (UNFPA 2003). In cultures supporting early marriage, the power balance in the relationship is unequal. Men are generally married later than girls, and girls are expected to defer to their husband. This can leave a girl in a subservient position within the relationship that affects her ability to make decisions in the relationship including those that impact her reproductive and sexual health status, for example negotiating condom use. Early marriage leads to the discontinuation of education, which can affect her ability to make better decisions about her own health and that of her present and future children, and can reduce future employment opportunities ( UNFPA 2003 ).
At times, the physical effects of early marriage can be fatal. Young girls who bear children before they are physically mature can suffer obstructed labour, obstetric fistulas and in some cases death of the child or mother ( UNFPA 2003 ). Worldwide, approximately 14 million women and girls between the ages of 15-19—both married and unmarried—give birth each year, and pregnancy is a leading cause of death for young women in this age group, with complications of childbirth and unsafe abortions being the major contributing factors ( UNFPA 2003 ).
In these circumstances, RSH service providers must be aware of the special needs facing this group. While the girls are still adolescents, they may require information relevant to their age group, but at the same time they also require access to information about specific reproductive issues pertinent to their marital status such as family planning, birth spacing, and delaying their first birth. It is not uncommon that these young girls receive little or no education from elder females upon their entrance into marriage. If elder females have died or become separated from them during displacement, it is important that these young girls receive the necessary RSH education based on their needs.