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The MISP: sexual and reproductive health standards in humanitarian response

  • Page updated onApril 12, 2026
Reproductive health in emergencies
Text and photo: Bruno Abarca

In humanitarian crises, not only do gender systemic inequalities and discrimination against girls and women increase, but their freedom, rights, and health regarding sexuality and reproduction are also directly threatened. For this reason, it is essential to include essential sexual and reproductive health actions and services in emergencies that allow for the reduction of risks of gender-based violence, unintended pregnancies, sexually transmitted infections, and maternal health problems.

Advances in reproductive rights and health in the 90s

The Cairo Conference of 1994 and Reproductive Rights

In 1994, the International Conference on Population and Development was held in Cairo. This event and the resulting program of action marked a turning point by defining reproductive health and rights and placing them among the priorities of public health and human rights.

Thanks to this and other successive advances, today we understand that in order to achieve the right to health, it is essential to advance towards reproductive health, gender equality and women's empowerment, and that for this it is essential to defend and respect the rights and freedoms of all people a:

  • That their personal autonomy, bodily integrity and privacy be respected.
  • To be able to define their sexuality, sexual orientation, gender identity and how to express it.
  • Choose their partners.
  • Have safe and pleasurable sexual experiences.
  • Decide whether or not, when and with whom they want to get married.
  • Decide whether or not, when and how to have one or more children.
  • To have access to information, resources, services and the support necessary to exercise all other rights, free from discrimination, coercion, exploitation and violence.

The Shift from Maternal Health to Reproductive Health in Humanitarian Contexts

At the same time as the Cairo conference was taking place, reproductive health was also beginning to be seen as a priority in humanitarian contexts and complex emergencies. The use of sexual and gender-based violence, for example, as a weapon of war, was widely denounced in the humanitarian emergencies of this period. In Rwanda, between 100,000 and 250,000 women were raped during three months of genocide in 1994. During the Bosnian war (1992-1995), similarly, between 10,000 and 50,000 women were raped, sometimes repeatedly for years in civilian concentration camps. In those years, the world witnessed the fragility of the sexual and reproductive health and rights of millions of women affected by humanitarian crises.

The report "Refugee Women and Reproductive Health Care: Reassessing Priorities" published in 1994 by the (now) Women's Refugee Commission analyzed the reproductive health and rights situation among displaced and refugee women in Côte d'Ivoire, Rwanda, Kenya, Pakistan, Belize, Thailand, Cambodia and Hong Kong. This critical analysis of reproductive health needs also prompted the development of new international coalitions. These included the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) in 1995, or the Reproductive Health Response in Conflict Consortium.

MISP, a minimum standard for sexual and reproductive health in emergencies

An inter-agency field manual and a minimum initial service package

The 20th century still saw one last major milestone for reproductive health in humanitarian settings. This was the development, between 1996 and 1999, of the Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings. This document and its successive updates in 2010 and 2018 (the current one) have laid the foundation and consensus around the sexual and reproductive health services that are most important in humanitarian settings, particularly among girls and women, while protecting their lives with dignity.

Within the Field Manual, a minimum set of reproductive and sexual health actions for response to humanitarian emergencies was also defined. It is the Minimum Initial Service Package for Sexual and Reproductive Health in Crisis Situations (simply MISP). This set of priority actions was born between 1996 and 1999, and has been significantly updated twice: in 2004 and in 2018. In addition, in 2010 it was included as a standard of the Sphere Handbook. Today, it is a powerful tool for advocacy, coordination and programming of these actions.

The MISP sets out a series of objectives. These include prevention of sexual and gender-based violence and mitigation of its consequences, prevention and treatment of HIV/AIDS and other sexually transmitted infections, prevention of unintended pregnancies through information, counselling and contraceptives, emergency obstetric and neonatal care to reduce morbidity and mortality, and ensuring access to safe abortion care to the extent permitted by law (the latter mentioned only as an "additional priority"). The MISP also proposes that the "minimum package" should be expanded as soon as possible to cover a wider range of needs.

The (limited?) scope of MISP for sexual and reproductive health in humanitarian emergencies

At the same time that, for many people, the MISP is too brief and insufficient, for others it is too ambitious and far removed from reality. 

Some argue that key elements are missing to cover all sexual and reproductive health needs in humanitarian settings. What about sexual education? And antenatal care and prenatal visits? Or menstrual health and menstrual hygiene management? And cervical cancer or fertility problems? Others, however, criticise that the MISP has covered so many objectives that it is no longer minimum or realistic for certain contexts. They argue that amid the insecurity and chaos of a humanitarian emergency, prioritisation is essential. They also point out that this must be done based on scientific evidence, people's rights, and what is acceptable and feasible as action in the first days of a crisis response. They further criticise that the voices of some key actors were not taken into account in the latest MISP update.

The MISP today falls short of what a comprehensive sexual and reproductive health services package should look like in stable settings. However, there is also no consensus that it represents what is feasible or truly prioritised to reduce the excess of avoidable morbidity and mortality related to sexual and reproductive health in the initial response to any humanitarian emergency. Despite being proposed as an indivisible "minimum package", this remains more an aspirational goal than a reality, in which adaptation to each humanitarian crisis and each phase of its evolution continues to prevail.

The 2025 humanitarian crisis threatens reproductive health and rights

Before humanitarian funding was drastically reduced, much remained to be done in the area of reproductive rights.

Before the humanitarian funding crisis of 2025, there had already been a significant slowdown in progress in maternal and reproductive health. Annually, there were still 300,000 maternal deaths. Of these, approximately 200,000 were in humanitarian settings. This stagnation was related to the impact of the COVID-19 pandemic, the global economic crisis brought on by the conflict in Ukraine and the growing debt burden in Africa, as well as a chronic lack of political will and gender inequality.

In this context, funding for sexual and reproductive health was already insufficient and inadequate. Concentrated on some programs, such as those aimed at fighting HIV/AIDS, funding left in the background aspects such as family planning, gender violence or the empowerment of local organizations led by women. Serious gaps also persisted in the availability of emergency obstetric and neonatal care and in access to safe abortion, as well as a huge information gap regarding the impact of the crises on LGBTQIA+ individuals.

U.S. administration's decisions threaten the health of millions of women

In early 2025, a drastic shift in United States foreign and health policy dismantled much of its international aid. Following an initial funding freeze, 80% of USAID grants were terminated. This effectively dismantled the agency that channelled 30% of all global health financing and 40% of family planning funding. Among the consequences of this upheaval, it is estimated that more than 11 million women and girls will lose access to contraceptives, potentially resulting in more than 4.2 million unintended pregnancies and more than 8,000 additional maternal deaths in just one year.

This is not only a matter of reduced funding for sexual and reproductive health and rights, but also of enormous ideological and political pressure. This is reflected, for example, in the reinstatement and expansion of the global gag rule, which prohibits international organisations receiving US funding from providing information on legal abortion services. Furthermore, the Geneva Consensus Declaration was signed again, an anti-abortion coalition that repudiates reproductive rights widely recognised internationally, while seeking the support and endorsement of more countries. At the same time, the donor has ended its contributions to agencies such as UNFPA, WHO, UNAIDS and UN Women, and introduced great uncertainty over the funding of other key international programmes and initiatives.

The full global impact of these measures will take time to assess. Among their potential consequences are the loss of lives and increased suffering for millions of women, girls and their families, but also the rollback and collapse of many of the advances made over the years, and with great effort, in human and reproductive rights. 

🧠 Let's pause and reflect

In a context of drastically reduced humanitarian funding and increasing political pressure on reproductive rights, how should humanitarian organizations defend and sustain the gains made in sexual and reproductive health?

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How to cite this page

Abarca, B. (April 12, 2026). The MISP: sexual and reproductive health standards in humanitarian response. Salud Everywhere. https://saludeverywhere.com/en/health-in-humanitarian-crises/reproductive-health-and-rights-in-emergencies/

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