/ 21 June 2005

Contraceptives — both needed and scorned

As the international community marked World Refugee Day on Monday, a Somali woman’s tale of how she helped fellow refugees terminate pregnancies has highlighted the shortcomings of reproductive health care in refugee camps.

Mariam*, who lived at the Dadaab camp in northern Kenya from 1992 to 1998, discreetly performed abortions on girls and women.

“I did not like doing this but the women would come to me crying, some saying that they already had ten children or more, and that they could not care for additional children,” she said. “One even threatened that if I refused, she would hang herself in my hut.”

In all, Mariam performed more than 20 procedures, generally without payment.

“I used wooden gadgets, iron rods — including hangers and others — to carry out my duty. Some pregnancies were four months old and sometimes not easy to bring out, but luckily none of the women died.” She left the camp at the beginning of 1999 and found her way to the Kenyan capital, Nairobi, where she now works as a hawker.

According to statistics issued last month by the United Nations High Commissioner for Refugees (UNHCR), Dadaab houses over 140 000 refugees, of which about 69 000 are women.

Humanitarian assistance to people in this and other camps has understandably focused on providing food, water, shelter and sanitation. In the scramble to ensure that refugees stay alive, however, the contraceptive needs of women sometimes fall by the wayside — despite the fact that women may be more vulnerable to sexual abuse and disease, and unwanted pregnancies, in a refugee setting.

Florence Machio, coordinator of AfricaWoman Communications, a regional media service that champions women’s rights, says female refugees need to be provided with a “comprehensive reproductive health kit”. This should include contraceptives to prevent unwanted pregnancies, which often present women with insurmountable difficulties.

“In the case of expectant mothers, they may find themselves with little or no access to antenatal care as well as a lack of safe delivery assistance. This, without doubt, makes childbearing a life-threatening affair,” Machio notes.

The vast number of refugees in Africa (over 4,2-million, according to the UNHCR’s latest figures) suggests that meeting the needs of female refugees will be essential if the continent is to meet the fifth Millennium Development Goal (MDG). This goal stipulates that maternal mortality should be reduced by three quarters, by 2015.

Eight MDGs were adopted by world leaders at the United Nations Millennium Summit in 2000, in a bid to overcome under-development. The remaining goals deal with issues such hunger, poverty, education and environmental sustainability.

As 20-year-old Abraham Wol points out, the campaign to improve contraceptive use in refugee camps will also have to include men.

The Sudanese national lived in Kakuma refugee camp ‒ in north-western Kenya, near the border with Sudan — for seven years until 1999. The UNHCR puts Kakuma’s population at over 90 000. Women make up less than half of the refugees in the camp, numbering almost 37 000.

“By the time I left Kakuma, we were being given condoms … For example, we would get five after every one or two months. Surely this was not enough?” Wol asks.

He now works for GTZ (Deutsche Gesellschaft für Technische Zusammenarbeit), a development agency owned by the German government, which also provides services to the World Bank and other organisations.

Speaking at the GTZ office in Nairobi, Wol emphasised that condom distribution had to be accompanied with education initiatives.

“Men are given condoms but they do not use them; instead they throw them away. Because of this, they need to be told why they are being given the condoms in the first place and how these should be used,” he noted.

In instances where modern notions of birth control clash with tradition, this message will probably have to be repeated a good many times before it takes root.

“When you tell the refugees of the advantages of family planning, many of them resist. They will tell you that they ran away from war having lost children, and therefore they need to replace them,” says Dr Burton Wagacha, a medical coordinator with GTZ who assists refugees in Dadaab.

“To these refugees, the number of children really counts.”

Similar words come from Firdoso Salad Aden, a Somali refugee who has been at Dadaab since 1998. At the age of 21, she is already a mother of four.

“I do not believe in family planning methods and neither does my husband. He does not use condoms either. We have these children out of choice and we will add more,” she said.

Beyond conflicting ideas of family planning and birth control lies the spectre of Aids, however.

In an interview ahead of World Refugee Day, Wagacha said the HIV prevalence rate amongst refugees in Dadaab was steadily inching upwards. In 2002, the rate was between 0,5 and 0,7%; in April 2005, it stood between 0,8 and 1,1%

As refugees are discovering, the decision on whether or not to use that rare condom may soon be less about preventing unwanted pregnancy, and more about preventing premature death.

* Not her real name –IPS