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Status of Women and Infants in ComplexHumanitarian EmergenciesNaeema Al Gasseer, RN, PhD, Elissa Dresden, RN, ND,Gwen Brumbaugh Keeney, CNM, PhD, and Nicole Warren, CNM, PhD(c)

Women and children bear the greatest burden in the midst of war and long-term disasters. Complexhumanitarian emergencies are characterized by social disruption, armed conflict, population displacement,collapse of public health infrastructure, and food shortages. Humanitarian assistance for refugees andinternally displaced populations requires particular attention to the common issues affecting morbidity andmortality in women and infants. Gender-based violence and reproductive health concerns are discussedwithin the context of populations affected by conflict and forced migration. Recommendations for midwivesand women’s health care providers engaging in care for women and children in complex humanitarianemergencies are discussed. J Midwifery Womens Health 2004;49(suppl 1):7–13 © 2004 by the AmericanCollege of Nurse-Midwives.keywords: disasters, refugee health, international health problems, public health policy, safe motherhood,

maternal care, infant care, war, violence

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omen face difficult challenges during times of conflictnd disaster. Midwives and other specialists in women’sealth are particularly needed to provide culturally compe-ent and essential care for these populations. In this article,ssues confronting women, children, and health care work-rs are reviewed, and recommendations for care of womenffected by war and disasters are presented.

OMPLEX HUMANITARIAN EMERGENCIES

omplex humanitarian emergencies is a relatively newerm and is used to describe “humanitarian crises charac-erized by political instability, armed conflict, large popu-ation displacement, food shortages, social disruption andollapse of public health infrastructure” (p. 147).1 Mortalityates can increase to extremely high levels in complexumanitarian emergencies, mainly due to disease, malnu-rition, and trauma. Health professionals working in com-lex humanitarian emergencies must understand the linksetween the health needs and the larger political, social,conomic, and historical contexts. These conflicts are oftenivil conflicts in which civilians are targeted and majoropulation displacement occurs. Human rights abuses areampant, and humanitarian aid workers themselves may beargeted.

AR, WOMEN, AND HEALTH

he horrors of war are well known. Although it is difficulto quantify morbidity and mortality from armed conflicts, its widely accepted that with the end of the Cold War, theature of war has shifted.2 Increasingly, current conflicts 1)re based on identity or sectarian politics; 2) use techniques

ddress correspondence to Gwen Brumbaugh Keeney, CNM, PhD, Univer-ity of Illinois at Chicago, UIH Rm. 404, M/C 550, 1740 W. Taylor, Chicago,

AL 60612. E-mail: gbkeeney@uic.edu

ournal of Midwifery & Women’s Health • www.jmwh.org2004 by the American College of Nurse-Midwives

ssued by Elsevier Inc.

o commit eradication of a population through forcedesettlement, mass killings and intimidation; and 3) connectocal conflicts with global war economies, using people,rocesses, and ideologies that may be geographically re-ote.3 Civilians are often the targets of these armed

onflicts as non-state combatants use indiscriminate weap-nry and terror.War and other armed conflicts adversely affect individual

nd public health due to 1) physical injury, 2) psychologicalrauma, 3) decreased sanitation and hygiene, and 4) deteri-ration of health infrastructure. A goal of the World Healthrganization (WHO) is to “reduce avoidable loss of life,urden of disease and disability in emergencies and post-risis transitions” (p. 1).4 Emergency and postcrisis situa-ions have a profoundly negative impact on the health ofomen and their infants. The WHO goal for the care ofomen and infants can be achieved by prioritizing services

uch as reproductive health services and ensuring theresence and operational capacity of health agents in theeld who can immediately and effectively strengthen suchervices. These efforts should ensure collaboration andharing of lessons learned among key agencies and con-erned populations to maintain the health sector’s account-bility. In times of war and conflict, specialized knowledge,raining, and experience are required to implement anffective and appropriate response to improve the health ofomen and infants. Midwives and other reproductiveealth care providers can effect profound and positivemprovements in these settings.

War ravages the lives of women and children. Over theast decade, conflicts have left more than 2 million childrenead, another 4 million physically mutilated, and another 1illion orphaned or separated from their families.5 Follow-

ng the Rwandan genocide, 70% of the remaining Rwan-ans were females, more than half of which were widowed.

survey in Sierra Leone reported that 94% of displaced

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amilies surveyed had experienced sexual violence, includ-ng rape, torture, and sexual slavery.6

The burdens of conflict weigh most heavily on Africa,ast Mediterranean, and South-East Asia. Table 1 illus-

rates these staggering human costs, particularly on thefrican continent where more than half of all conflictsccur and the number of deaths exceeds all other regionsombined.7 As an example, a recent study conducted in theastern region of the Democratic Republic of Congostimated that 1.7 million excess deaths occurred over 22onths due to war.8 The vast majority of these deaths

more than 80%) were due to preventable diseases such asalaria, diarrhea, and malnutrition, with 11% due to violent

rauma.

MPACT OF COMPLEX HUMANITARIAN EMERGENCIES ON THEEALTH OF WOMEN AND INFANTS

n analyzing data on the health effects of conflict, it ismportant to examine data by gender and separate out thevulnerable groups” into their distinct categories. Theealth and well-being of women and infants are dispropor-ionately and adversely affected during complex humani-arian emergencies, yet only recently has public policyocused on gender issues in complex humanitarian emer-encies. Save the Children created a data-based Mothers’ndex that ranks the status of mothers’ well-being in morehan 100 countries. The criteria used in the rankings include

aeema Al Gasseer, RN, PhD, is the WHO Representative to Iraq aftererving as the Chief Nursing and Midwifery Scientist at the WHO Genevaeadquarters.

lissa Dresden, RN, ND, recently completed a 2-year Post Doctoral Researchraining program at the University of Illinois at Chicago with an emphasis onrimary health care research and evaluation as applied to humanitarian policynd practice.

wen Brumbaugh Keeney, CNM, PhD, is clinical faculty and a staff midwifet the University of Illinois at Chicago and currently serves as a short-termonsultant for ACNM Global Outreach’s Home Based Life Saving Skillsrogram.

icole Warren, CNM, PhD(c), MPH, is currently working on her dissertationesearch with midwives in Mali where she previously served as a Peace Corps

Table 1. Burden of Conflict Reported in World Health Report 2002

WHO Region

Number of Deaths Attributed Directlyto War 2002 (1000s)

N (%)

Africa 91 (51.4)Eastern Mediterranean 35 (19.8)Southeast Asia 21 (11.9)Europe 19 (10.7)Americas 8 (4.5)Western Pacific 3 (1.7)World Total 177 (100)

Source: WHO 2003.7

folunteer working with maternal-child health education programs.

ix factors related to women’s health (lifetime risk ofaternal mortality, percent using modern contraception,

ercent of births attended by trained personnel, percent ofnemic pregnant women, adult female literacy rate, andarticipation in national government) and four indicators ofhildren’s health (infant mortality rate, primary schoolnrollment, percent of population with access to safe water,nd percent under 5 years suffering from nutritional wast-ng).9

The Mothers’ Index reveals that 16 of the 25 (64%)ottom ranking countries are experiencing conflict (Table).9 Regions of war and conflict consistently rank poorly inerms of children’s and mother’s well-being. The reportirectly links the health status of the mother with that of herhildren. Therefore, it is imperative that effective andppropriate care for women includes care for children inonflict settings.

International humanitarian agencies, such as WHO, theorld Food Program, the United Nations High Commis-

ioner for Refugees (UNHCR), and the United Nationshildren’s Fund (UNICEF), are integrating issues of gen-er into their programs, policies, and trainings. In October000, the United Nations Security Council passed Resolu-ion 1325 on Women and Peace and Security.10 Thisatershed document places women and a gender perspec-

ive into activities such as negotiating peace agreements,lanning refugee camps, and reconstructing societies. Rapes a weapon of war has been acknowledged recently,ringing to light the multitude of adverse consequences ofex and gender-based violence in times of conflict and war.

The negative impact of complex humanitarian emergen-ies on women and infants is profound. The addition of aomplex humanitarian emergency to an area with a preex-sting high rate of common maternal health complicationsreates a lethal combination. For example, in 1995, mater-al mortality in Afghanistan was estimated at 820 deathser 100,000 live births.11 With prenatal care coverageelow 10%, alarmingly elevated rates of infant and mater-al mortality persisted into 2001 (Table 3).12 By 2003,

Table 2. Mothers’ Index of Countries With Recent Large-Scale Conflict

Countries With Conflict in Bottom 25 Mother’s Index Ranking*

Country Ranking Country Ranking

Nigeria 94 Liberia 106Burundi 95 Angola 108Haiti 95 Chad 109Mozambique 95 Guinea 111Pakistan 99 Sierra Leone 111Nepal 100 Yemen 111Central African Republic 103 Guinea-Bissau 114Eritrea 103 Ethiopia 115

*Rank is based on total of 117 Countries.

Source: Save the Children 2003.9

ollowing the war in that country, the maternal mortality

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stimate had risen to 1600.13 Overall, Africa, along withuffering the highest burden from conflict, has the highestates of maternal death in the world.14

During complex humanitarian emergencies, women andnfants face multiple health risks. Although the health statusf the population as a whole deteriorates during complexumanitarian emergencies, women and infants may bearticularly affected due to both biological and sociocul-ural factors. For example, biology is responsible foromen’s higher risk of reproductive tract infections and

nfants’ unique dietary needs. Sociocultural norms mayictate that women have little control over financial re-ources and transport. This may jeopardize both her and herhildren’s access to health care resources. Moreover,omen tend to shoulder the burden of being their family’s

are provider, especially for children and those who areick or traumatized. This responsibility can in and of itselfontribute to deteriorating health outcomes.

Protecting and promoting the health of women andnfants in times of conflict can be very difficult. Wardncludes nurses and midwives as key actors in facing thishallenge.15 Even after a conflict is over and women andnfants have been removed from the conflict zone, signifi-ant challenges remain. For example, Table 4 demonstratesn alarming number of rape cases in refugee settlementscross Africa.16 Rape is only one example of gender-basediolence that women experience.During crisis and displacement, women face a myriad of

ssues that impact their health and well-being. Although theollowing list of health issues is not exhaustive, it highlights

Table 3. Safe Motherhood Indicators in Afghanistan

Coverage of antenatal care (%) 8%Births attended by skilled attendant (%) 8%Crude birth rate (per 1000 population) 51.3Maternal mortality ratio (per 100,000 live births) (estimated

range of regions within country: 300–1700) 820Lifetime risk of maternal death 1 in 15Low birth weight (%) 20%Stillbirth rate (per 1000 live births) 70Early neonatal mortality rate (�7 days) (per 1000 live births) 70.2Neonatal mortality rate (0–4 weeks) (per 1000 live births) 121

Source: WHO, 2001.12

Table 4. Rape Cases Reported in Stable African Refugee Settings

Situation Population Year Reported

Kibondo, Tanzania 76,740 1998Dadaab, Kenya 109,000 1998Goma, Congo (Zaire) 740,000 1996Ngara, Tanzania 110,000 1998

16

Source: Sexual and gender-based violence 1999.

ournal of Midwifery & Women’s Health • www.jmwh.org

ajor concerns that health care providers need to address inomplex humanitarian emergency contexts.

Displacement causes mass population movement, expos-ing individuals and families to environmental, social, andphysical dangers. If women travel across internationalborders, they may receive protection as legally recog-nized refugees. However, the vast majority flee within astate border and are classified as internally displacedpersons and thus do not receive the protection andservices provided for refugees.Loss of extended family and community support due todisplacement and community disruption places addi-tional burdens on the woman. Women are often forced toflee and find themselves in strange environments wherethey may not speak the language, know the culture, or beable to call on others for support.Increases in female-headed households can place womenin new, unfamiliar roles, and they may be forced to offersex in exchange for food, shelter, or protection. This canbe exacerbated by social customs and norms that neglectto recognize women as heads of households, therebydenying them decision-making authority and reinforcingdisempowerment.17

Sex and gender-based violence is becoming an increas-ingly apparent feature of war and conflict. A recentsurvey in Iraq by the United Nations Population Fundreported an increase in sexual violence and noted thathealth providers are not trained in how to respond to thevictims.18 The social, cultural, psychological, and phys-ical effects of rape and other forms of sexual violenceoften last for generations, causing overwhelming painand suffering for individuals, families, and communities.The health impact of this violence can result in physicalinjuries, unwanted pregnancies, sexual dysfunction, andsexually transmitted infections (STIs), including HIV/AIDS. The mental impact can include posttraumaticstress disorder, depression, anxiety, and suicide. Thesocial or cultural impact can bring about social ostracismand isolation for the victims.Communicable diseases, including HIV/AIDS, can rap-idly spread in complex humanitarian emergency settingswhere social instability, massive population movement,poverty, sexual violence and exploitation of women,increasing military presence, and conflict occur. A study

Actual Rape Cases Reported(No. of months)

Rate of Rape per10,000 Population/Year

129 (12) 17.08128 (12) 11.74140 (7) 3.2424 (12) 2.16

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of Rwandan women attending antenatal clinics in Tan-zanian refugee camps found that more than 50% of themwere infected with some form of STIs.19 Women andgirls’ risk of exposure to STIs is aggravated by the lowstatus of women and girls in some settings where they areunable to negotiate sexual activities.Mental health problems due to physical and/or mentaltrauma are real dangers for women in complex humani-tarian emergencies. Due to the combined effects ofdisplacement, poor nutrition, lack of access to care, anddecreased support systems, increased caregiving burdenand exposure to trauma make it likely that women willexperience short- or long-term deleterious mental healtheffects.Lack of access to family planning and reproductivehealth services results in an increased number of un-wanted pregnancies and unsafe abortions. In addition,there may be pressure on women to replenish the popu-lation that was lost during the conflict. This can result inhigh fertility rates and pregnancies at close intervals,often negatively affecting the health of the mother andcontribute to low birth weight.Malnutrition may be a problem during and followingdisasters for several reasons. The family may havemissed their harvest, lost stores of food, or no longer havefreedom to scavenge for seasonal sources of nutrition. Inaddition, poor logistical management or corruption offood distribution may contribute to the problem. Ingeneral, women are vulnerable to vitamin and irondeficiencies. However, pregnant and lactating womenand small infants have unique needs that may be partic-ularly difficult to meet. A study of Somali refugeesreports that up to 70% of women of reproductive age areanemic, probably due to lack of iron in the diet and/ormalaria, which decreases the body’s stores of iron.20

Maternal morbidity and mortality are high during com-plex humanitarian emergencies. In countries experienc-ing conflict, women often cannot obtain prenatal supportor emergency obstetric care. Destruction of health infra-structure can mean that women have little or no access tocare, remaining health workers may have limited train-ing, referral and supply systems are disrupted, andunstable environments may make it unsafe to seektreatment. Pregnant and lactating women are particularlyvulnerable to poor water and sanitation.Exposure to chemical, biological, and nuclear weapons isof particular concern for the pregnant or lactatingwoman. Often women are not aware of what weapons arebeing used and what effects they have on the populationor reproduction.

The health status of infants is closely linked with theother’s health and well-being. It has been reported that

he morale and mental well-being of mothers can be21

mportant determinants of infant health during wartime.

0

ssues of concern for infant care providers include theollowing:

Low birth weight is associated with poor infant out-comes. Production, distribution, and availability of foodall impact nutritional outcomes.22 Because conflicts neg-atively impact these aspects of the food system, providersshould be alert for poor nutritional status among affectedpopulations. Infant outcomes may be poor because poornutritional status of the mother contributes to low birthweight.23 Unfortunately, screening and growth monitor-ing cannot occur when women lack access to adequateprenatal care, thereby increasing the likelihood thatperinatal risk factors like malnutrition will not be de-tected. Therefore, it is essential that reproductive healthservices are a priority in these settings. Malnutrition maybegin in utero when maternal intake is inadequate forfetal growth and development. Severe maternal anemiacan prevent adequate iron stores in the newborn as well.Although breastfeeding is the optimal nutrition for in-fants, infant feeding is often a challenge if maternalbreastmilk is insufficient due to maternal malnutrition orunavailable due to maternal death. In addition, the HIVepidemic in many regions of the world has resulted inincreased formula feeding among some populations.Infant formula presents ongoing challenges among pop-ulations where clean water is not readily available andcontributes to incorrect practices for preparing formula,including harmful proportions of water and substitutemilk powder.Decreased access to clean water and sanitation oftencauses frequent and severe diarrhea. Giardia and amebicdysentery are common in areas with unsafe watersources. Diarrheal diseases exacerbate infant malnutri-tion and are a major factor in high infant mortality ratesamong refugee populations. Breastfeeding is the bestprotection from diarrheal diseases.Hypothermia is common among preterm and low birthweight infants, as well as malnourished infants. Insuffi-cient fat stores provide diminished ability to maintainbody temperature. Lack of shelter, clothing, or blanketscan contribute to increased infant exposure. Continuousskin-to-skin care provides an appropriate environmentfor maintaining infant temperature. However, maternalworkload to carry water or firewood and lack of access tofamily support may make it difficult to provide continu-ous skin-to-skin contact.Poor maternal health due to maternal morbidity, malaria,or other health conditions decreases the ability to provideadequate infant care. As the traditional caretakers fortheir families, women generally have the responsibility toprovide the meals, wash household items and clothing,and care for the children. When a mother is incapacitated,feeding and hygiene of her infant will be compromisedunless alternative care providers are available. However,

the social disruption of migration and displacement often

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separates family and communities, leading to lack ofaccess to needed social support.Disruption in immunization during displacement in-creases the risks of acquiring preventable childhoodillnesses. Epidemics can move rapidly through refugeepopulations with high morbidity and mortality.

ECOMMENDATIONS

n 1994, The Women’s Commission for Refugee Womennd Children characterized most maternal-child health ser-ices in refugee programs as large, well-run programs.24

hat can midwives and women’s health professionals do tonsure that this remains true, not only in refugee settingsut in other settings where complex humanitarian emergen-ies have occurred? Strategies for engaging in comprehen-ive approaches to address the issues of refugees orisplaced women and their infants include the following.

evelop Programs and Policies

uring conflict and civil strife, a diminished capacity toespond to growing health needs exists, which sometimesesults in inappropriate responses. For example, someeproductive health programs in refugee settings wereiscouraged out of fear they would offend the population orake the refugee setting too appealing and discourage

uture resettlement.25,26 Since then, it has been acknowl-dged that reproductive health services are indeed critical.24

owever, as recently as 2003, reproductive health servicesere still not adequate due to a combination of factors

ncluding a lack of appropriate resource allocation toeproductive health services. Therefore, it is imperative thatidwives and other providers, whether they operate at the

onor, policy, or field level, advocate that reproductiveealth services become or remain a priority. Local staffho are knowledgeable in how to care for women and

nfants in complex humanitarian emergencies should beecruited if possible. Not only can they help ensure the cares culturally appropriate, but they can also readily identifypecific needs that may be difficult for outsiders to discern.

Numerous technical guidelines, manuals, and reports arevailable via Web pages of United Nations agencies andumanitarian assistance organizations that provide insightnd expertise on how to integrate the needs of women andnfants into a general health sector response to complexumanitarian emergencies. It is important that programsddressing specialized areas, such as reproductive healthnd gender-based violence, be flexible enough to be inte-rated into wider, more comprehensive programs to meethe different needs of regions, populations, and communi-ies.

Programs implemented in complex humanitarian emer-encies need to emphasize low tech and essential packagesf services. Programs should include a mix of prevention

nd treatment strategies, such as tetanus toxoid vaccination, W

ournal of Midwifery & Women’s Health • www.jmwh.org

alaria prevention and treatment, curative interventions forTIs, and breastfeeding education.

onduct Assessments and Report Findings Carefully

t should be noted that data on war-related health conse-uences is a political issue. Because each party has annterest in either conflating or minimizing the harm, figuresre highly biased and demand critical assessment.27 Zwiuggests that different types of data from a variety ofources be triangulated to build a more accurate sense of thexperience.27 A combination of quantitative and qualitativepproaches to needs assessments and program evaluationan help to represent a variety of voices, strengths, andeeds.

nvolve the Participation of Affected Women Whereverossible

articipatory approaches have been shown to enhance theuality of data on women in complex humanitarian emer-encies.28 Although involving affected communities duringonflict presents incredible barriers, because people mayust simply be inaccessible, it is important to make theffort to build bridges to reach women. Through theirarticipation, positive indigenous coping strategies can beromoted and culturally congruent approaches designednd implemented. Moreover, in these unstable settings inhich women are often left powerless, participation in suchrograms can provide sources of empowerment and hope.

raw From the Experiences of Other Professionalrganizations and Communities

ollowing a disaster, experts from a wide range of disci-lines converge quickly to provide aid. It is essential thatomen and infant health providers communicate effec-

ively with the rest of the relief team. For example,anitation and engineering experts can provide criticalesources to reproductive health programs such as latrineccess and adequate lighting for safety. This type ofollaboration allows for public health and primary healthare experts to learn best practices, coordinate approaches,nd share lessons learned. Although each setting is unique,here are cross-cutting lessons and issues that need to behared among different sectors, organizational types, andultures. For example, in the area of reproductive health, aroup of non-governmental organizations (NGOs), UNgencies and governmental donors worked together toevelop the standards to be applied for reproductive healthnd created a Minimum Initial Service Package (MISP) ofupplies and interventions to be provided in emergencyettings.29

How can donor agencies and their partners be betterrepared to tackle issues related to complex humanitarianisasters and, in particular, their effect on women? The

ar-torn Societies Project, jointly initiated by United

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ations Research Institute for Social DevelopmentUNRISD) and the Program for Strategic and Internationalecurity Studies (PSIS), aims to assist groups to understandnd respond better to the complex challenges of postconflictettings.30 Macrae et al. stressed that in consideration ofonor agencies’ base of support and concomitant influence,gencies must play a major role in postconflict policyormation.31 And these groups should be held responsibleor the success or weaknesses of the policies they influence.

dvocate to Policy Makers on Behalf of Women and Infantsffected by Complex Humanitarian Emergencies

he spotlight must be kept on the realities that women andnfants face in complex humanitarian emergencies. Individ-als and groups can work to educate representatives, writeetters, and raise public awareness. In 2003, U.S. Senatoroe Biden (D-DE) introduced the bill Women and Childrenn Armed Conflict Protection Act of 2003.32 This bill isesigned to protect women and children during times ofrmed conflict and to ensure that the U.S. governmentakes the protection of women and children a priority in all

tages of conflict through an integrated strategy, a code ofonduct, and a $45 million annual Women and Children’srotection Fund for relevant initiatives. Intraagency advo-acy is also important so that reproductive health resourcesre protected and distributed appropriately during the exe-ution of an assistance program.

hare Your Experience

ealth professionals working in complex humanitarianmergency settings have written up descriptions of theirxperiences in professional journals. These contributionsrovide invaluable exposure and insight into different roleshat professionals play. Heymann relates her experiences asnurse-midwife working for an international humanitarian

id agency in Kosovo.33 She presents background andistory to the conflict, as well as an orientation to the healthare system and women’s health issues. Hammes presentsxcerpts from her diary while working as a nurse-midwifen Kosovo for an international humanitarian aid agency.34

hrough this personal narrative, the readers learn about thearious roles that midwives play and challenges they face inomplex humanitarian emergencies. Recent commentariesn the Lancet describe some of the daily struggles andealities of refugee women and outline the work of somerganizations fighting for positive change.35,36

ONCLUSION

oving forward toward peace is the optimum strategy forddressing many of the issues raised above. The Alma Ataeclaration from the International Conference on Primaryealth Care provided a foundation for governments andealth professionals to connect policies for disarmament

nd maintenance of peaceful societies with goals for

2

mproving global health indicators.37 A clear priority forhe respect for human rights of women and children canuide concrete efforts aimed at providing and improvingealth policies and services in the context of complexumanitarian emergencies. Midwives and care providersor women and infants can use the educational resourcesvailable for humanitarian health workers to build on theirxisting skills to play a key role in these efforts.

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2. Murray CJL, King G, Lopez AD, Tomijima N, Krug EG.rmed conflict as a public health problem. BMJ 2002;324:346–9.

3. Garfield R, Dresden E, Rafferty AM. Commentary: The evolv-ng role of nurses in terrorism and war. Am J Infect Control 2003;1:163–7.

4. World Health Organization. Essentials for emergencies [Inter-et]. Geneva: World Health Organization [cited March 28, 2004].vailable from: http://www.who.int/disasters/repo/8078.doc.

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ates developed by WHO, UNICEF and UNFPA [Internet]. Geneva:orld Health Organization, 2001 [cited February 9, 2004]. Available

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