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Contraception in humanitarian crises

  • Page updated onMarch 10, 2025
Contraception in humanitarian crises
Photo: Bruno Abarca

Historically, access to contraception in humanitarian crises has been pushed to the background. Decision-makers long considered this not to be a need on the same priority level as others. However, time and the voices of women affected by complex humanitarian crises have revealed otherwise: in a humanitarian context, the need for family planning and contraception is more urgent than ever. Moreover, we also know that contraception is one of the most cost-effective investments in public health.

Access to contraception in humanitarian crises is also essential to respect the reproductive rights of girls and women. They must be able to freely decide if they want to have children, how many, when, and how. Therefore, humanitarian action in emergencies and complex crises must meet a minimum standard in service provision to prevent unwanted pregnancies.

Preventing unwanted pregnancies is a global priority

Millions of women of reproductive age wish not to become pregnant

Many women spend most of their reproductive years trying to avoid becoming pregnant. In low- and middle-income countries, an estimated 56% of women of reproductive age face this challenge. This need becomes even more pressing in humanitarian settings, where women are exposed to violence, forced displacement, hunger, and vulnerability. In fact, studies from conflict zones in Africa have found that between 43% and 71% of women wanted to delay their next pregnancy or did not want more children. This aligns with findings from other regions, such as the Middle East, where surveys show that 50% to 66% of displaced Syrian women in Lebanon or Iraq neither wanted nor planned their last pregnancy, and about 75% did not want any more pregnancies.

There are many reasons why so many women do not wish to become pregnant during the most challenging times of their lives. Among these are concerns for their own safety, health, and well-being, as well as that of their children. After all, in a humanitarian crisis, the risk of serious complications and maternal death during pregnancy and childbirth doubles. Furthermore, in a complex crisis, the risks of illness, malnutrition, and child mortality multiply. Some of these women may desire a pregnancy, but at a different time—when they feel they have the stability and capability to face it, or when they feel ready for it.

However, it is precisely during complex humanitarian crises that many women and girls are most vulnerable to unwanted pregnancies. The risk of violence and sexual exploitation multiplies as social support networks and protection mechanisms become more fragile, making access to essential services increasingly difficult.

There is a huge gap in access to contraception, especially in low- and middle-income countries.

It is estimated that over 923 million women of reproductive age in low- and middle-income countries do not wish to become pregnant. However, 24% of them (218 million) do not use modern contraception. When considering only adolescent women (ages 15 to 19) or solely low-income countries, this percentage rises to 43% or 46%, respectively. Furthermore, another 35% of these women only use short-term methods, such as pills, injectables, or condoms.

The most immediate consequence of this gap in the use of modern contraception in middle and low-income countries is well known: unwanted pregnancies. It is estimated that 77% of all unwanted pregnancies occur in that 24% of the population that wants to avoid pregnancy but does not use contraception. The outcome of these pregnancies, moreover, results in a live birth only 27% of the time. The other 73% end in abortion or fetal death. Furthermore, it is estimated that half of those abortions would be unsafe, either due to the use of inappropriate methods or because they are performed without the support of a trained person.

Ensuring access to modern contraceptives would not only significantly reduce the number of unintended pregnancies. It would also decrease unsafe abortions by nearly 75%, one of the leading causes of maternal death. Overall, for this and other reasons, it is estimated that around 70,000 maternal deaths could be prevented among women in middle- and low-income countries.

Methods for contraception in humanitarian crises

The Minimum Initial Service Package for Sexual and Reproductive Health (MISP) includes a dedicated objective to prevent unintended pregnancies. This objective is one of the most expanded in the 2018 update of this document compared to its previous version from 2010. According to the MISP, health services in response to a humanitarian emergency must include long-acting reversible contraceptive methods and short-acting methods.

Availability of a wide range of contraceptives allows freedom of choice

The MISP does not specify exactly which products should be guaranteed, but it does determine that there must be a sufficiently wide range to cover short-acting contraception (including emergency contraception) and long-acting reversible methods. This allows for addressing the needs and priorities of different subgroups of people based on their age, gender, contraceptive intention, breastfeeding practices, time since the last childbirth, health status, and economic capacity, among other factors.

For some individuals, certain contraceptives may be more suitable than others. Having multiple options allows users the freedom to choose. This, in turn, is a key factor that enables them to try, accept, and continue using a method that fits their needs and preferences. Additionally, there may be contraindicated methods for certain women due to current and past infections and comorbidities, among other factors. For example, the use of an IUD may be contraindicated with certain infections, while the use of combined oral contraceptives (estrogen and progesterone) may be contraindicated in cases of hypertension.

Short-acting (and emergency) contraceptives should be available in the community.

Short-acting contraceptives include barrier methods such as male and female condoms (wherever they are already in use). They also include oral and injectable hormonal contraceptives of various types. All of these are intended for community health and primary care settings, including small health posts.

Included in this group are emergency contraceptives, which allow individuals to prevent pregnancy after having unprotected sexual intercourse. This may occur in cases of rape, contraceptive failure, or the absence of a contraceptive method. Emergency contraception methods are most effective the sooner they are used (preferably within the first three days after intercourse), preventing fertilization. The lack of availability can have a serious impact on the physical and mental health of women and girls who are survivors of sexual and gender-based violence, especially if safe abortion care is not available or is illegal.

Long-acting contraceptives meet women's essential needs

Recommended long-acting contraceptives to consider in humanitarian contexts include the intrauterine device (IUD) and implants. These methods are included in the Inter-Agency Emergency Reproductive Health standards, but only for their provision in supplementary kits to be used in specific circumstances. For example, it is important to consider whether they were already registered and in use in the country affected by the crisis.

These methods are safe, reversible, highly effective, and minimize the risk of user error. Additionally, they have a significant advantage over short-acting methods: their effect lasts from 3 to 12 years depending on the method, without the need for repeat visits to health centers. However, they require that health personnel have appropriate training and equipment. Their removal can also be an issue if the woman does not have access to health services where it can be done when needed.

The quality of family planning services is crucial

To prevent unwanted pregnancies or to enable women to decide which children to have, how, and when, the availability of various contraceptive methods is not enough. The MISP, in fact, emphasizes the importance of providing information and advice for the informed choice of an adequate and effective method. For this to be possible, family planning services must have sufficient quality across several dimensions:

Contraceptive information in humanitarian crises

Family planning services must provide information about the different contraceptive methods available and their contraindications. This information must also cover their advantages and disadvantages, how to use the selected method, possible side effects, and what users can expect from family planning services.

Technical competencies of healthcare personnel

Healthcare personnel must be well-trained, knowledgeable about contraceptive usage techniques, protocols, and recommendations, and adhere to hygiene standards. This aspect, however, may be the most challenging to critically evaluate by users. Additionally, the actors supporting the services should not limit themselves to theoretical training, but must also ensure and evaluate the skills and technical competencies of the staff.

In some humanitarian contexts, trained and experienced local personnel can be used to train the rest of the staff, including community health workers. Often, employing community volunteers can be extremely helpful in increasing contraceptive use among women who, due to sociocultural constraints, lack the autonomy to access health centers. The use of peer educators has also proven very valuable, as they can further promote the prevention of unwanted pregnancies among adolescents, for example.

Interpersonal relations and treatment in family planning services

The relationships between users of reproductive health services and their providers are often marked by personal interactions. This includes prejudice-free attitudes, active listening, and tactful dialogue, as well as demonstrating sensitivity to the issues and needs of different groups (such as adolescents, LGBTQI+ individuals, people with disabilities, or those in prostitution, for example).

The emotional dimension and the dialogue established in health services can greatly influence users' trust in their decisions and abilities, as well as their willingness to overcome obstacles. However, these relationships can also be influenced by the organization of services, the time available for each consultation, the privacy guaranteed, or the ideology of the organizations and their staff.

Continuity of contraceptive use

This refers to the ways in which well-informed individuals can continue using contraceptives on their own. Many programs, however, place more emphasis on starting contraception than on maintaining its use. Some services, for example, may actively follow up with contraceptive users to know their satisfaction or their possible need to change methods.

Family planning service constellation

Family planning services must be acceptable to the population and can be linked to other health services. These may include care for sexually transmitted infections or postnatal care, among many others. Of course, there should also be a connection to care and referral in cases of sexual and gender-based violence.

Other considerations: voluntariness and involvement of men

Clearly, all actions aimed at defending reproductive rights and universal access to family planning rely on voluntariness. Attempting to coerce individuals into using a contraceptive method is not family planning. Moreover, it is a violation of their rights. Just as access to contraceptives must be free of barriers, it must also be free of incentives, payments, and rewards that could condition free choice, especially for the most vulnerable individuals.

Finally, there must be family planning health services specifically aimed at men. This is important to engage them in responsibilities for preventing unwanted pregnancies, thus addressing changes in gender roles. In many cases, this can be facilitated or driven by local and traditional leaders.

Contraception before and after the humanitarian emergency

In an emergency context, it may be completely unfeasible to introduce new contraceptive methods that were not already known locally. If women or healthcare personnel are not familiar with them, there may be issues with their use or with healthcare provision during a very difficult time. In an emergency, there may also be shortages of healthcare staff and interruptions in the supply channels for contraceptives. For this and other reasons, it is strategic to include elements related to contraception in humanitarian emergencies during the disaster preparedness phase and in post-emergency recovery actions.

Development of family planning services and disaster preparedness.

Preparation work can increase the baseline level of access to a wide range of modern contraceptives and minimize the risk of interruption of these services. Moreover, efforts can also be made to extend family planning training to local humanitarian and development actors so they can participate in a potential response. It is equally important to have a contingency plan to prevent contraceptive shortages or to allow for the mobilization of trained personnel. For the latter, strategies can be developed to share tasks in multidisciplinary teams, or to include contraception in the programs of community health workers.

Recovery of post-emergency family planning services.

Once the acute phase of the emergency is over, it may also be necessary to consider a transition to the recovery of routine family planning services. At these stages, it is important to recover a sustainable supply chain. It is also important to accurately estimate the quantities of contraceptives to be provided, based on the new needs of the population.

Barriers to contraceptive access in humanitarian crises

Despite the importance of contraception and family planning in complex crises, its availability is much lower than desirable. Numerous studies show that a large proportion of health centers in humanitarian contexts lack a sufficient range of methods or quality services. Furthermore, humanitarian action often fails to cover the minimum standard packages to prevent unwanted pregnancies. Even when services are available, many people face significant sociocultural barriers to accessing and utilizing them.

Users of contraceptives must overcome many barriers to access

In humanitarian contexts, barriers that also exist in stable contexts are exacerbated. These include, among others, the limited power of many women in decision-making about their lives, the stigma, and negative attitudes towards the use of contraceptives. These attitudes, both personal and from partners and the community, are often conditioned by gender dynamics, religion, and the lack of information. For example, many people still believe that contraceptives can cause infertility.

Access to quality reproductive health services is also a problem, as it has been a low-priority area in many health systems. Many centers lack spaces or an organization that allows for adequate privacy. They also do not make the availability of contraceptives visible. In some cases, these services are not even included in the essential basic package of primary care. Additionally, it is common to find healthcare personnel without proper training to provide information and advice, with prejudices against users (especially regarding emergency contraceptives), or with misconceptions about these products. This personnel may also have fear of crossing sociocultural boundaries (which do not always exist) and of promoting promiscuity if they suggest contraception.

At times, there is even healthcare personnel who oppose offering these services to single women and adolescents. These two groups of women are often ignored by many reproductive health programs that, in an attempt to avoid challenging local sociocultural norms, only address the reproductive rights of married women or those who already have children. Unmarried women, particularly young and adolescent women, often find their reproductive rights overlooked. This can have especially serious consequences regarding barriers to accessing emergency contraception, which is still perceived with many prejudices.

Lack of institutional commitment to family planning

Despite the advances with the FP2020 and FP2030 alliances, global funding for family planning has practically stagnated since 2012. Several reasons are believed to be behind this. One of them is the introduction, at the 1994 International Conference on Population and Development in Cairo, of the prioritization of sexual and reproductive rights. Some believe that this had an unintended adverse effect: family planning ceased to be a global imperative for stabilizing the world population and became a desirable (but not essential) public health service.

In addition to the above, efforts to prevent unwanted pregnancies have been strongly opposed by many anti-abortion movements and conservative populism. Certain policies (such as the "Global Gag Rule"The U.S. government has also limited funding for organizations that work for reproductive rights and family planning by also offering reproductive health services, including family planning. safe abortion care (adapted to the laws of each territory).

At the national level, there are also numerous legal and policy barriers to contraception in humanitarian crises. In fact, there are countries that exclude single women or minors without parental consent from accessing contraceptives.

Many humanitarian organizations do not meet minimum standards

Part of the limitations of humanitarian support for family planning is due to internal factors within organizations. Many organizations still do not view the humanitarian standards for preventing unwanted pregnancies as life-saving interventions, or with the same level of priority as other more traditional actions. In some contexts, the humanitarian response is carried out under the umbrella of a national health policy that barely addresses reproductive rights, without humanitarian actors adopting or proposing a transformative approach. It is also common for humanitarian actors to prioritize the procurement and promotion of short-acting contraceptives, giving less priority to long-acting methods such as implants.

There are also obstacles beyond the control of organizations. One example of this relates to the lack of multi-year funding in emergency contexts. This clashes with the reality that establishing quality family planning services may take longer than other types of actions. On the one hand, these are complex services that often require training staff and developing the supply chain for contraceptives. On the other hand, these programs require addressing and challenging sociocultural and gender norms in many cases. This cannot be achieved in an intervention lasting several months.

Sexual and reproductive health

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