state of world population

From The

A transformative agenda
for women and girls in a
crisis-prone world

We live in a world where humanitarian crises extract mounting costs from economies, communities and individuals. Wars and natural disasters make the headlines, at least initially. Less visible but also costly are the crises of fragility, vulnerability and growing inequality, confining millions of people to the most tenuous hopes for peace and development.

More than 100 million people are in need of humanitarian assistance. An estimated 26 million of them are women and adolescent girls of reproductive age


While sexual and reproductive health services are increasingly provided in humanitarian responses, striking gaps remain.

The world has repeatedly affirmed the sexual and reproductive rights of women and girls. Now it needs to deliver in all cases, including humanitarian crises.

Conflicts and disasters do not exempt any government or humanitarian actor from obligations, embodied in the Programme of Action of the 1994 International Conference on Population and Development, to uphold the right of the individual to sexual and reproductive health, including the right to decide freely and responsibly whether, when or how often to become pregnant.

A time of burgeoning crisis has demanded a ballooning humanitarian response. While humanitarian “fires” will always need to be fought, particularly as natural disasters accelerate in a time of climate change, much more could be done to cut root causes of crises and reduce underlying vulnerabilities.

All crises, whether those that strike in the hours of a ferocious storm, or that keep peace at bay for decades, destroy prospects for development, often profoundly. People lose their lives and livelihoods, their homes and communities, sustain profound injuries and may become disabled. Education and health services disappear, depriving people of their rights to them, and setting in motion long-term consequences that make eventual recovery ever more difficult. 

Foremost among the losses are those to sexual and reproductive health. While sexual and reproductive health services are increasingly provided in humanitarian responses, striking gaps remain. For the woman giving birth or the girl who has been raped in the chaos of fleeing the bombs falling on her city, the consequences, including death and disability in the worst cases, can multiply harms many times over.




Women and girls are

Featured Stories


When time won’t wait: meeting basic health needs for pregnant women on the move

  • Leyla Ashur and family. © UNFPA/Nake Batev
  • Ashur and her family plan the next leg of their journey north. © UNFPA/Nake Batev
  • Families wait near the train station in Gevgelija, the former Yugoslav Republic of Macedonia. © UNFPA/Nake Batev
  • Families wait near the train station in Gevgelija, the former Yugoslav Republic of Macedonia. © UNFPA/Nake Batev
  • Lidija Jovcevska. © UNFPA/Nake Batev
  • Lence Zdravkin. © UNFPA/Nake Batev
  • Ashur and family leaving Gevgalija, the former Yugoslav Republic of Macedonia. © UNFPA/Nake Batev

“I was three months pregnant and worried about what this trip would do to my baby, but I didn’t have a choice. We had to go,” says Leyla Ashur, one of the few hundred Syrians allowed to cross into the former Yugoslav Republic of Macedonia from Greece one day in August.

Ashur, 35, says she, her husband and their four sons had fled fighting in their home town of Dayr Az-Zawr, Syria, in 2012 and lived for about a year in Iraq. But the fear of violence from the self-proclaimed Islamic State in Iraq and the Levant, or ISIL, drove them across yet another border, into Turkey, where they stayed for three years until even that situation became untenable. She says not only were they afraid of escalating violence along the border, but they also felt exploited and unwelcome in her host community.

“When they saw we were Syrians, we had to pay three times the rent everyone else was paying,” she says. “And everyone kept telling us, ‘Go away, go away.’”

And so the family of six left with a few belongings crammed into backpacks. The journey across Turkey took 10 days, with little rest and very little to eat along the way. “We didn’t receive help from anyone,” Ashur says.

When she and her family reached the Turkish coastal city of Bodrum, they and about 20 others together paid a smuggler €10,000 to carry the group in a rubber raft across the Aegean Sea to the Greek island of Ios. From there, they made their way to the former Yugoslav Republic of Macedonia.

From the southern city of Gevgelija, Ashur and her family began the next leg of their journey north, with the aim of crossing through Serbia and Hungary and then on to Belgium, where her husband’s sister lives.

“We will reach our destination or die on the way.”

While hundreds piled onto overcrowded trains and buses, or simply walked the 178 kilometres to the northern frontier city of Kumanovo, Ashur and her family found a taxi to take them for €100. Her two younger sons waved goodbye from the back window.

Syrians like Ashur and her family account for about 80 per cent of the people transiting through the country. Afghans and Iraqis each account for about 5 per cent. The others are from Pakistan, Somalia, Palestine and five countries in sub-Saharan Africa.

Between June and August 2015, an average of 700 refugees and migrants followed the same path to northern Europe through the former Yugoslav Republic of Macedonia every day. Of that number, about one in four is a woman, and on average, 6 per cent of those women are pregnant.

Many of the pregnant women have health concerns stemming from walking long distances in the heat, poor nutrition, dehydration and the absence of sanitation, all of which can lead to pregnancy complications or even miscarriage. And many are traumatized, says Suzana Paunovska of the Red Cross in the capital, Skopje. “You see it immediately in their faces.”

The Government in June declared that refugees and migrants could access health care, including obstetric and gynaecological services, for free from public health centres and hospitals, including the one in Gevgelija.

But because refugees and migrants are in a hurry to reach the border with Serbia within the 72 hours the Government allows for transiting through the country, most choose not to take advantage of free services rather than risk missing one of the few trains or buses traveling north.

Pregnant women will only use services that are fast and within easy reach of transit hubs near border crossings, says Bojan Jovanovski, who heads the Association for Health Education and Research, or HERA, in the capital, Skopje.

HERA deploys its only mobile health clinic to the border with Greece, a few hundred metres from Gevgelijia one day a week to provide free, quick, basic gynaecological services for refugees and migrants. UNFPA, the United Nations Population Fund, helps cover the clinic’s operating expenses.

Lidija Jovcevska is an obstetrician-gynaecologist based in Kumanovo. She volunteers one day a week for the mobile clinic. The five or six women she sees in a day mostly want to know whether their foetuses are healthy. She uses an ultrasound machine to reassure most expectant mothers but also lets them know about any potential for complications. Some women who have traveled for days and sometimes months also ask for vitamin supplements to increase the chances they will deliver healthy babies. Vaginal and urinary tract infections are common. Jovcevska prescribes antibiotics and other medications.

On occasion, there is a serious problem requiring attention at a hospital. Jovcevska refers these cases to the nearby hospital, which can handle emergencies as well as deliveries.

Jovcevska says the risks of traveling under such extreme conditions while pregnant are high. “It is unclear to me, as a mother of two myself, how they can even contemplate such a trip,” she says, but acknowledging the desperation that many of these women feel. “One woman I saw today told me, ‘It’s all right if I die on the way.’”

The mobile clinic also offers contraception, though few take advantage of it, says Vesna Matevska, a programme coordinator for HERA. The refugees and migrants she sees tend to be very private people who are reluctant to ask for or accept condoms or the pill, even though they are free and available from non-judgmental service providers. She says this sense of privacy, along with language barriers, also make it difficult for many women to talk about or report gender-based violence.

In addition to services provided by non-governmental organizations and the country’s ministry of health, there are those offered informally by individuals like Lence Zdravkin, 48, a self-described activist, who says she has helped hundreds of pregnant women as they walked north across the country to reach the Serbian border.

Until June 2015, it was illegal for refugees and migrants to use trains, buses or taxis, so most simply walked the distance, usually along the main railway tracks, which pass 10 metres from Zdravkin’s home.

Zdravkin began offering refugees and migrants food and water and opened her home to people who simply needed a rest. She brought pregnant women to a local clinic for checkups or to treat the injuries that are inevitable when walking for days in the summer heat.

“Everything was happening right in front of me,” Zdravkin says. “I couldn’t just close my eyes.”

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Vicious cycle of conflict, poverty and isolation undermines health and rights of women and girls in Colombia

  • Neida Waitotó, left, and Maria-Estela Ibargüen, Docordó. © UNFPA/Daniel Baldotto
  • Neida Waitotó. © UNFPA/Daniel Baldotto
  • Waitotó, left. with mother whose child she helped deliver. with former client and her son, which she helped deliver. © UNFPA/Daniel Baldotto
  • Nimia Teresa Vargas. © UNFPA/Daniel Baldotto
  • Wounaan woman, Union Balsalito, Colombia. © UNFPA/Daniel Baldotto
  • Residents of Docordó, Colombia. © UNFPA/Daniel Baldotto

“I started working as a midwife 37 years ago,” says Neida Waitotó, one of four midwives in Docordó, a river community with about 1,200 residents, mostly Afro-descendants, in a remote jungle area of Colombia two hours by boat from the nearest city.

“In 1978, the nuns came and taught us how to deliver babies and gave us supplies.” Since then, she says, the midwives of Docordó have had some additional training but no new equipment. Still, they have managed to safely deliver hundreds of babies over the years. “And no mothers have died,” says Waitotó, who, a week earlier, helped deliver twins.

Midwives are critical to the survival of women and babies in Docordó and dozens more remote Colombian communities that have been effectively cut off from government health services not only because of geography but also because of armed conflict and violence, which have plagued large swaths of the country for more than 50 years. Conflict has so far displaced about 7 million people. Nine in 10 displaced of them are from indigenous groups.

Non-state actors including the Revolutionary Armed Forces of Colombia, or FARC, the National Liberation Army, or ELN, paramilitaries, groups involved in organized crime and the Colombian military have clashed for decades, leaving many communities literally caught in the crossfire and many more vulnerable to coercion, exploitation, intimidation and abuse.

Fighting and violence have taken a heavy economic toll on communities in a number of provinces, or “departments,” including Chocó, where Docordó is situated, causing and exacerbating poverty and underdevelopment in the region. Four of five people in Chocó live in extreme poverty.

Maternal deaths higher in conflict-affected zones

Conflict and violence—and the isolation stemming from them—have also taken a heavy toll on the health of women. Maternal deaths are almost eight times higher in communities where armed groups are present. Other health indicators also illustrate the negative impact security problems have on the sexual and reproductive health of those who live there: deaths from HIV and AIDS are three times higher than the national rate, and pregnancies among adolescent girls under age 15 are twice that in other parts of the country.

Waitotó says there are some births in Docordó that are too complicated for her to handle on her own; a doctor’s intervention is needed to save lives. But because of the security situation in the area and the extreme isolation, the community routinely lacks access to a doctor. “When doctors do come, they never stay for long,” she says. Recently, the community went four months with no physician or other medical professional.

So that means some women have to travel hours by boat to a hospital in Buenaventura, at a cost prohibitively high for most. And if the complications arise at night, travel to a hospital is not even an option because of the threat of violence after dark. Medicines that can help save a mother and baby are mostly unavailable, even before the local health station closed because of a lack of resources.

Maria-Estela Ibargüen is another Docordó midwife. She and Waitotó delivered each other’s babies. She worries that the community’s midwives are growing old, with no young people stepping forward to take their places. “What will the future look like once the old generation is gone?”

Health conditions for women are even more troubling directly across the river in Union Balsalito, an indigenous Wounaan community with about 360 residents. There, midwives use traditional birthing methods but lack the most basic supplies, such as rubber gloves.

For women in Union Balsalito, accessing services, even in Buenaventura, is particularly difficult: most do not speak Spanish and have even fewer resources than their neighbours across the river. And some who have managed to travel to cities in search of services have faced discrimination from providers.

The government deploys roving health brigades throughout the country to provide basic services to the poor and marginalized in places like Docordó. But the security situation in many parts of the country makes it impossible to reach many of the communities most in need.

Access to supplies, medicines and services, including emergency obstetric care and family planning, is routinely blocked by conflict and violence as well as natural disasters, especially floods and landslides in this area, which receives an average of 400 inches of rain annually.

In the first six months of 2015 alone, an estimated 2 million people “suffered limitations on access or mobility” as a result of “122 events related to armed actions, natural disasters or mass protests,” according to the United Nations.

Wielding the weapon of sexual violence

While conflict has impeded access to health services, it has also taken a direct toll on the health, lives and survival of thousands of women and girls.

A study by Oxfam and House of Women estimates that 500,000 women and girls have been raped or suffered other forms of sexual violence in the course of the country’s decades-long conflict. Sometimes rape has been deployed as a weapon of war. Other times, it has been used to intimidate whole communities, with perpetrators threatening to attack others in a community that refuses to pledge its allegiance to one armed group over another. And, available data suggests that one in 10 survivors of sexual violence in conflict-affected areas is male.

Nimia Teresa Vargas runs the Departmental Network of Chocoan Women, headquartered in Quibdó. The network, which receives technical and financial assistance and supplies, such as clean birth kits, from UNFPA and other parts of the United Nations, began in 1991 as a women’s empowerment group but has since evolved into a human rights advocacy organization that also provides services to survivors of sexual violence.

“As women began learning about their rights in our discussion groups, more of them started talking about having survived sexual violence,” Vargas says. “Cases started coming to light about armed actors trying to take control over communities, using sexual violence as a strategy to show they had power.”

She says often a perpetrator would rape a woman in front of her husband or a girl in front of her father to assert control and to show what might happen to others if the community did not acquiesce to the demands of whichever armed group was threatening them.

In response, Vargas’ organization started organizing support groups for survivors, but also began systematically reporting incidents to government authorities and making sure Chocoan women gained access to not only to quality health care and psychological support, but also to justice.

Armed groups responsible for the sexual violence have repeatedly threatened Vargas’ life and, in one instance, killed a woman who participated in one of her network’s training programmes and later became an outspoken activist.

New support for survivors

In 2011, Colombia enacted the Victims and Land Restitution Law 1448, which aimed to support the country’s estimated 7.3 million victims of armed conflict. This law also led to the establishment of a government Unit for Attention and Integral Reparation to Victims, or UARIV, which targets support to victims of armed conflict, including survivors of sexual violence.

Survivors who report their cases to UARIV are entitled to cash restitution, but also to integrated health, psychological, rehabilitation and other support services, all provided in ways that respect privacy. Those who come forward also learn, usually for the first time in their lives, about their rights.

According to Licet Ciénfuegos, in UARIV’s women’s and gender group, survivors accessing UARIV’s services “recognize that they aren’t alone, that they are citizens with rights and that they are change agents.” She said many have gone on to create their own advocacy or support groups. “We are trying to help women see themselves as actors of change and capable of shaping the futures of their own communities.”

As of September 2015, 9,892 women, 863 men and 53 people who identified themselves as lesbian, gay, bisexual or transgender have reported acts of sexual violence against them. Some of these acts occurred in the past two years but many occurred years ago.

UNFPA collaborated with UARIV in developing training for first responders to deliver culturally sensitive psychosocial support. “We teach them how to speak to victims in a way that doesn’t revictimize them,” Ciénfuegos says.

The conflict has also had an indirect but perhaps more insidious impact on the health—and rights—of women and girls in Chocó.

Conflict-driven poverty’s impact on health

Violence or the threat of it has choked off local economies in the region, leaving many individuals and families with few or no opportunities for jobs or livelihoods. Poverty multiplies vulnerabilities, especially for women and adolescent girls.

In some instances, women and girls engage in transactional sex with armed groups to obtain food or other survival items. In other instances, women and girls are forced into prostitution.

There have also been cases where an armed group will engage in what seem like goodwill gestures with a community by providing food or other goods. But after a while, favours are expected to be repaid, sometimes by giving away daughters, who may end up as sex slaves or as armed combatants.

Poverty stemming from conflict also drives men from remote communities to cities to look for work. When they return home, some also return with sexually transmitted infections, which they in turn transmit to their spouses. The dearth of health care in most of these communities means that sexually transmitted infections may go undiagnosed and untreated.

“Conflict has affected everyone in some way,” says UNFPA Representative Jorge Parra. “But it has disproportionately affected women and girls and denied them their basic rights to health, to security, and to have the power and the means to decide whether, when or how often to have children,” he adds. “The task ahead is monumental, but with the right resources and political will, we can reach the most vulnerable women and girls across the country.”

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Natural Disasters

The number of natural disasters tripled between 1980 and 2000, followed by a slight decline, but still double the number today than what was recorded 25 years ago.

On average, more than three times as many people died per disaster in low-income countries (332 deaths) than in high-income nations (105 deaths). A similar pattern is evident when low- and lower-middle-income countries are grouped together and compared to high- and upper-middle-income countries. Taken together, higher-income countries experienced 56 per cent of disasters but lost 32 per cent of lives, while lower-income countries experienced 44 per cent of disasters but suffered 68 per cent of deaths.

For each person who dies in a disaster, there are hundreds more who are affected by it and require immediate basic survival needs, such as food, water, shelter, sanitation or immediate medical assistance. Those affected by a disaster often lose their homes and livelihoods, become separated from families, face a lifetime of illness, disability or restricted opportunities, and are displaced from their communities.

While disasters have been recorded more frequently during the past 20 years, the average number of people affected has actually fallen from one in 23 between 1994 and 2003, to about one in 39 between 2004 and 2014.

Controlling for population growth, the likelihood of being displaced by a disaster today is 60 per cent higher than it was four decades ago. Over the last 20 years, there have been an average of 340 disasters per year, affecting 200 million people annually, taking an average of 67,500 lives a year.

Rajina Tamang with her baby amid the rubble of what remains of Kuni village, which was destroyed when a 7.8 earthquake struck central Nepal.
Photo © Panos Pictures/Brian Sokol


Recorded Natural Disasters, Worldwide, By Type - 1994 to 2014

*Figures include disasters such as insect infestation, extreme temperature, landslide, volcanic activity and wildfire. (CRED, 2015a)

Estimated Number of People Affected By Natural Disasters, By Type - 1994 to 2014

*Figures include disasters such as insect infestation, extreme temperature, landslide, volcanic activity and wildfire. (CRED, 2015a)

Recorded Natural Disasters, By Region - 1994 to 2014

(CRED, 2015a)

Estimated Number of People Affected By Natural Disasters, By Region - 1994 to 2014

(CRED, 2015a)


The Second World War, the largest conflict in the modern world, remains humanity’s reference point for mass harm. About 3 per cent of the world’s people died as a direct result of that conflict or its prelude and aftermath. Meanwhile, more than one third of the world’s people were affected by it. For each death, therefore, 10 other lives were radically disrupted.

In 2014, the total number of refugees and internally displaced people worldwide reached 59.5 million, the highest number since the Second World War. The number of internally displaced people doubled from 2010 to 2015.

More than half of all new refugees in 2014 came from Syria, Afghanistan, Somalia and Sudan. More than half of all internally displaced people reside in Syria, Colombia, Iraq and Sudan.

Today, about one in four people in Lebanon and one in 10 in Jordan is a refugee. Today, only about one in three refugees resides in a camp. Two in three today live in urban areas.

About two-thirds of the world’s refugees are in situations of seemingly unending exile, with the average time spent that way reaching 20 years. The 25 countries most affected by a prolonged refugee presence are all in the developing world.

Men are much more likely to die directly and during conflicts, whereas women die or are otherwise harmed more often of indirect causes after a conflict. Every estimate of direct conflict deaths suggests that more than 90 per cent of all casualties occur among young adult males.


Fragility and Vulnerability

Fragile States are home to one third of the world’s poor. More than 1 billion people, or about 15 per cent of the world’s population, are in extreme poverty, according to estimates from the World Bank. Extreme poverty, previously concentrated in East Asia, has shifted to sub-Saharan Africa and South Asia, which today accounts for 80 per cent of the world’s poor, the majority of whom are women and children.

The poor are especially vulnerable to the effects of conflict, and various measurements of fragility suggest that high levels of poverty and income inequality can contribute to instability. The poor have fewer economic, social and other resources to help them withstand or recover from conflicts, which can in turn exacerbate poverty.

There are many explanations of fragility and its causes. But regardless of the definition, fragility is closely linked to forces such as poverty, inequality and exclusion, which disproportionately affect women and girls.

When States’ fragility is matched against key reproductive health indicators, correlations emerge, showing that extremely fragile countries are likely to have fewer births assisted by skilled attendants, higher rates of adolescent pregnancy and more unmet need for family planning.

Close to half the people in low-income countries in 2010 were in States that are fragile, in conflict, or recovering from conflict. These same areas accounted for 60 per cent of the world’s people who are undernourished, 77 per cent of the children not attending primary school, 70 per cent of infant deaths and 64 per cent of unattended births.

Conflict, violence, instability, extreme poverty and vulnerability to disasters are deeply interrelated conditions, which today prevent more than 1 billion people from enjoying the massive social and economic gains since the end of the Second World War.

A complex mix of overlapping hazards contributes to displacement and determines patterns of movement and needs in fragile and conflict-affected countries. Other additional aspects of vulnerability—gender, ethnicity, income and residence—appear to be associated with heightened chances for long-term harm and complicate recovery. And overlaying all aspects of social exclusion, poverty and low educational achievement create profound vulnerability.

Sapana Suwal, 25, with her children in shelter for earthquake survivors, Bhaktapur, Nepal. Photos © Panos Pictures/Brian Sokol


The Fund For Peace's Fragile States Index 2015

This index looks at 12 dimensions of vulnerability, including whether economic development is uneven or equitable, whether there is respect for human rights and liberties, the extent of poverty and economic decline, frequency of disasters, and whether key services, particularly education and health are available to all. According to this index, four countries are on "very high alert", with South Sudan at the top of the list, followed by Somalia, Central African Republic and Sudan. Between 2013 and 2014, measures of fragility on this index worsened to some degree in 67 countries (FFP, 2015).
The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations.

Risks to Women and Adolescents

Humanitarian crises disproportionately impact women and adolescent girls.

Whether sudden or protracted, crises expose women and girls—and their sexual and reproductive health and rights—to layers of disproportionate risk.

Conflicts and disasters can make a bad situation worse. For women and adolescent girls, the advent of a crisis can lead to an even greater risk of sexually transmitted infections, including HIV, unintended and unwanted pregnancy, maternal morbidity and maternal mortality, as well as other risks to the health of mothers and newborns. Women and adolescent girls are also at greater risk of sexual and gender-based violence, including intimate partner violence, rape, early marriage and trafficking.

Women and young people do not all have the same story to tell. Their experiences are influenced by a complex intersection of factors, such as age, sex, marital status, economic status or place of residence. Other vulnerabilities depend on whether they are members of an ethnic minority, living with HIV or disability, refugees or internally displaced persons or poor, or have the support of family or have dependents.

The intersection of these factors, often in complex and multiple combinations, influence the risks and vulnerabilities faced by individuals.

Boat in the Strait of Sicily,
40 miles from the Libyan coast.
Photo © Franco Pagetti/VII

Women do not stop getting pregnant or having babies when a crisis hits

Sierra Leone

An estimated 123,000 women were pregnant in Ebola-affected Sierra Leone in 2015.


UNFPA estimated that there were approximately 126,000 pregnant women at the time of the April earthquake, including 21,000 of whom would need obstetric care in the coming months.


An estimated 250,000 women were pregnant when Typhoon Haiyan hit in November 2013 and approximately 70,000 were due in the first quarter of 2014.


At the time of Tropical Cyclone Pam (2015), there were an estimated 8,500 pregnant and lactating women in the affected provinces.


Although there are important differences among women and young people in any given crisis, there are two common overarching factors that contribute to heightened risk: The first is gender inequality, which not only continues during humanitarian crises but often increases.

Inequality manifests itself in less access to education, economic and political resources and social networks. It can also be fatal—when parents facing food shortages direct most or all nutrition to boys.

The second overarching factor leading to heightened risk is the breakdown or disruption of critical sexual and reproductive health infrastructure and services that occur in crisis settings, and the difficulties in accessing these services, where they still exist, as a result of chaos or insecurity.



Essential actions and services
from the onset of a crisis

Featured Stories


Saving the lives of Syrian women and adolescent girls in Jordan

  • Family health clinic, Deir Allah, Jordan. © UNFPA/Salah Malkawi
  • Reema Diab with Client. © UNFPA/Salah Malkawi
  • Newborns Za’atari Camp. © UNFPA/Salah Malkawi
  • Malak, Deir Alla, Jordan. © UNFPA/Salah Malkawi
  • Family health centre, Sweileh, Jordan. © UNFPA/Salah Malkawi

On one August morning at the Za’atari camp in Jordan, thousands of Syrian refugees began their routines before the peak of the midday heat.

By 11 a.m., the temperature outside was already 30°C. But inside one of UNFPA’s four reproductive health clinics in the camp, air conditioning was keeping five expectant mothers cool as their contractions intensified.

On an average day, 10 babies are born in Za’atari’s labour and delivery centre, according to obstetrician-gynaecologist Reema Diab. The centres are designed, managed and monitored by UNFPA, the United Nations Population Fund, working with a local non-governmental organization, the Jordan Health Aid Society, and with donor funding from the European Commission and the United States.

Diab is one of five doctors who, with the help of 17 midwives, deliver hundreds of babies every month despite the challenging conditions of a refugee camp. So far, no mother has died in pregnancy or while giving birth in Za’atari.

But there have been plenty of close calls.

Diab says that one of the five women in labour that August morning had pre-eclampsia, a potentially life-threatening condition, and had to be transferred to a hospital equipped with an operating room, anaesthesia and other essentials for complicated deliveries and caesarian sections. Sometimes cases are referred to a nearby Jordanian hospital. But in most instances, women are transferred within the camp to a hospital run by the Moroccan military. The Moroccan hospital performs an average of three Caesarean sections a day, and the surgeons are also trained to repair cervical tears and obstetric fistulas.

Sajah, 25, is one of many who have benefited from the specialized care available at the Moroccan hospital. She was recently referred there for a high risk delivery, after experiencing five miscarriages. A Caesarean section resulted in a safe, healthy, delivery.

Integrated, comprehensive care

The labour and delivery centres are just one aspect of the comprehensive sexual and reproductive health services available to the residents of Za’atari, where one in four is a woman or adolescent girl of reproductive age.

Women in the camp are also able to receive antenatal care and post-partum follow-up services. Women, men and young people can obtain information about family planning and free modern contraception. The centres’ health-care staff have been trained to identify and provide clinical management of sexual and gender-based violence and to make referrals to the camp’s counselling and case-management centres.

Still, life in the camp is a struggle. Even with readily available services, refugee women and girls face a host of barriers to good physical and psychological health, from the lingering trauma of their displacement to the impact of negative coping mechanisms, to forced child marriage.

Heaping loss upon loss

That morning at the labour and delivery centre, two 16-year-old girls gave birth. Adolescent pregnancies are tragically commonplace in Za’atari. Omar Laghzaoui, the lead obstetric surgeon at the Moroccan hospital, says that about one in three of the births he assists are to girls 15 years or younger. “The youngest I’ve seen was 12,” he says. With early pregnancies come heightened risks of complications and, often, the need for Caesarean sections.

Special challenges for adolescents and young people

These early pregnancies are usually linked to child marriages in the camp, says Asma Nemrawi, a psychologist serving the camp’s young people. Parents often arrange marriages for their young daughters to eliminate the financial burden of caring for them, or out of the misguided notion that a husband will better protect them from sexual violence. Nemrawi routinely sees girls who are, or are about to be, married. Some are as young as 14. “Some want to learn how to have children,” she says. “Others are already pregnant and want psychological support.”

Nemrawi says that some girls tell her they want to have children to make up for the losses they’ve experienced in their lives. Some also say they fear their husbands will become violent or divorce them if they don’t have children. For these difficult situations, she tries to meet with both the girl and her husband at the same time to talk about the health, psychological and economic benefits of delaying pregnancies until later in life, drawing attention to the challenges of raising a child in a refugee camp.

Nemrawi also talks to the camp’s youth about family planning. “At the beginning, they didn’t want to hear about family planning,” she says. But her efforts to explain how it works and how it is good for the health of the mother are paying off. About 60 per cent of the young people who came to one of her sessions leave convinced they should use it.

Reaching those not in the camps

Za’atari is home to about 80,000 Syrian refugees; four other camps house another 30,000. But these camp residents combined account for only about 18 per cent of all Syrian refugees in Jordan. The other 82 per cent live in cities, towns and rural areas throughout the country, where many of them struggle to obtain access to sexual and reproductive health care.

Providing services to refugees outside the camps is complicated. The populations are dispersed, and many are beyond the reach of the institutions serving Jordanian citizens.

In addition, services in Jordan’s public hospitals and Government-run clinics are free only to insured citizens. Syrians and refugees from other countries have to pay a fee, which is not high compared to the cost of private services, but is still often unaffordable for most. One alternative is to access services from non-profit providers, such as the Institute for Family Health, or IFH, which has a nationwide network of clinics offering sexual and reproductive health services to Syrians and Jordanians alike. IFH implements programmes supported by UNFPA.

Hanin Zoubi is the IFH-UNFPA programme manager. “We take an integrated approach,” offering free antenatal and postnatal care, family planning counselling and services, treatment of sexual transmitted infections and psychosocial support for survivors of gender-based violence and trauma, all under one roof, she says.

But not everyone is able to come to the clinic, so IFH also provides community outreach.“We go to where the people are,” Zoubi says. They go, for example, to schools to provide information to adolescents, or to community-based organizations to offer life-skills training to young people.

People welcome the information, she says, noting that vulnerable populations in the country often lack access to the Internet and are unable to find out on their own about how to prevent a pregnancy or a sexually transmitted infection.

The refugee population living outside the camps is different in key ways. Their demand for family planning is greater, according to Zoubi, and there are fewer adolescent pregnancies.

Haya Badri, the IFH clinics coordinator, says up to 65 Syrians and Jordanians patients come to the facility in Amman for services every day. Most of the clients come for check-ups, including ultrasound examinations, but some also receive treatment for anaemia or request contraception. Many also come in to report or receive treatment and counselling for sexual and gender-based violence. One-to-one counselling sessions and support groups are also available for traumatized adults and children and even for torture survivors.

Confidentiality and respect

Whatever the service being provided, privacy is critical. All staff have been trained and have signed a code of conduct, committing to provide confidential services to all without judgment. The guarantee of confidentiality helps clients overcome fear and maintain dignity in seeking help.

At another centre, in Deir Alla in the Jordan Valley, Nadia om-Hassan, 35, comes for family planning, to see counsellors and participate in social support groups. Three years ago, when she was still in Syria, she had just given birth to her fifth child by Caesarean section and was still groggy from anaesthesia when bombs struck the hospital, forcing an emergency evacuation. In the following days, her surgical incision became infected. Despite her condition, she, her husband, their newborn and four other children all fled to Jordan.

Afterward, om-Hassan’s husband pressured her to become pregnant again. “He wanted more boys, to help support the family,” she says. “I did get pregnant after three months, [but] had a miscarriage.” IFH staff in Deir Alla told her about family planning and explained how it was important to her health. “Now I explain to my husband that it’s also good for the health of the whole family.”

“When I come to the clinic and have a chance to talk about my problems, I feel so happy and relieved,” om-Hassan says.

The Deir Alla centre also supports adolescents. Malak, 15, came to Jordan from Damascus four years ago with her parents, grandparents and three siblings. She attends secondary school, where science is her favorite subject, but says she wants to become a police officer one day. Earlier this year, her aunt approached her parents to arrange a marriage with her 20-year-old son. “I wasn’t happy, but I couldn’t refuse. I didn’t want to give up my education,” Malak says.

Then one day Malak accompanied her mother to the centre and found out about information sessions on child marriage, which they both attended. Her mother, and later her father, came to accept that it would be better for Malak to stay in school and finish her education. The engagement ended after a month.

According to Daniel Baker, who coordinates the UNFPA effort to support Syrian refugees in Jordan, Egypt, Iraq, Lebanon and Turkey as well as Syrians who have not yet fled the country, “The situation of Syrian refugees is dire in spite of the generosity of the neighboring host countries. As the war in Syria goes on with no end in sight, their situation is becoming even more desperate as they deplete all of their resources. The provision of basic services, like maternal health care, is the responsibility of the international humanitarian community so that life can be sustained and that there is some hope for a better future when the war ends.”

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The collateral damage of Liberia’s Ebola crisis: women and girls of reproductive age

  • Comfort Fayiyah and children. © Abbas Dulleh/AP Images for UNFPA
  • Woseh Gobeh. © Abbas Dulleh/AP Images for UNFPA
  • Dr. Wilhelmina Jallah at hospital in Paynesville, Liberia. © Abbas Dulleh/AP Images for UNFPA
  • Dr. Wilhelmina Jallah at hospital in Paynesville, Liberia. © Abbas Dulleh/AP Images for UNFPA
  • Comfort and family at home. © Abbas Dulleh/AP Images for UNFPA

Comfort Fayiah is one of the lucky ones.

As the late-September 2014 due date for her twin babies approached, the Ebola crisis in Comfort’s native Liberia was reaching a fever pitch. Since the first Ebola patient presented in Monrovia in June 2014, the number of new cases was growing every day: By August, it was topping 400 per week. The Ministry of Health and Social Welfare was forced to suspend virtually all non-Ebola-related activities to focus on managing the crisis. The unintended result was that women of reproductive age in Liberia experienced some of the worst fallout from Ebola, regardless of their own infection status.

“The national health supply chain abruptly ceased all its routine operations, preventing health facilities from accessing essential medical supplies and commodities,” says Woseh Gobeh, national programme officer for reproductive health for UNFPA, the United Nations Population Fund. “Even in counties considered less affected by the outbreak, health facilities suffered massive stock out of drugs and medical supplies.”

It was not just a supply issue: Liberia’s already-scarce medical personnel (at the start of the crisis, there were only 45 physicians practicing in the public sector in the entire country, according to a Ministry of Health estimate) were being crippled by Ebola. By May 2015, an astounding 8.07 per cent of Liberia’s doctors, nurses and midwives would die from Ebola, compared to 0.11 per cent of the general population. Fear of becoming infected—particularly because it is difficult to determine whether a patient has Ebola without a lab test—led many health workers to turn people away.

“Health-care workers started getting afraid and started refusing patients,” says Dr. Wilhelmina Jallah, the chief executive officer and medical director of Hope for Women International, a medical non-governmental organization, and a practicing physician based in Paynesville, Liberia. “No healthcare worker wanted to touch a pregnant woman even with personal protective gear.”

For pregnant women like Comfort, now 29, that meant prenatal care was scarce—while one common indicator of positive maternal outcomes, completion of four antenatal care visits, had been on the rise in Liberia, it declined from 65 per cent in 2013 to 40 per cent in August 2014. And delivering in an appropriately appointed medical facility became impossible. When Comfort’s time for delivery came, she went from place to place but was unable to find a hospital or clinic that would admit her. “They refused me; they said they could not help me,” Comfort says. “I cannot blame the health workers who refused to assist me, because everyone was afraid of the disease.”

And while expecting mothers without Ebola (like Comfort) had trouble finding care, those who were infected had almost no chance of a good outcome. “It is more dangerous to treat pregnant women with Ebola because the effect of Ebola in pregnancy is not understood and there are no set guidelines to follow. Pregnant women have blood and body fluids that could expose health workers to the virus,” Jallah says.

With no other choice, Comfort took shelter from the pouring rain, lying down in the dirt to labor under a corrugated tin roof. “I suffered a lot and was afraid I was going to die. The only thing I hoped for was for a miracle to happen,” she says. One did: Comfort gave birth to two healthy baby girls with the assistance of a nurse aid who happened to pass by at the right time.

Other women have not been so lucky. Across the region, doctors reported an increase in pregnant women dying from preventable causes, including hemorrhage, ruptured uterus and hypertensive disease. And because healthcare workers cannot be instantly replaced (consider the many years it takes to educate and train a surgeon), the impact will only expand: According to a recent World Bank report, the loss of health workers in Guinea, Liberia and Sierra Leone may result in an additional 4,022 deaths of women each year from complications of pregnancy and childbirth. Maternal mortality could increase by 38 per cent in Guinea, 74 per cent in Sierra Leone, and 111 per cent in Liberia.

That’s not to mention the impact on women’s ability to determine whether, when or how often to become pregnant. According to UNFPA estimates, nearly half the health facilities in Liberia were completely out of stock of injectable contraceptives during the height of the Ebola crisis. Little more than a third of health facilities were providing family planning services, according to the Ministry of Health. Noticeable pre-crisis gains in contraceptive use have all but been wiped out.

“The number of women and girls who continue to die from preventable health conditions is unacceptably high,” Gobeh says. “It’s a human rights issue to deny a woman or girl access to quality reproductive health services.”

Efforts to improve the situation have had some impact, however. UNFPA and others are working to add workers to the healthcare ranks by, for example, encouraging retired midwives to return to the workforce. “With this effort, health facility-based deliveries have increased from an average of six to 10 monthly to between 30 and 40 monthly in only two months,” Gobeh says. UNFPA also launched a nationwide condom promotion and distribution campaign to help educate young people about the importance of preventing sexually transmitted infections including Ebola. And the dwindling numbers of new Ebola cases in the region (the last laboratory-confirmed case in Liberia was buried in March 2015) can only spell relief for women of reproductive age.

“I give credit to Liberia and the international community for winning against Ebola in a relatively short period of time,” Gobeh says. But now, “the most important responsibility and appeal to the government of Liberia, the donor community and all partners is that the need to rebuild the health care delivery system is now greater than ever.”

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Until only 20 years ago, sexual and reproductive health took a back seat to priorities such as water, food and shelter in humanitarian response. But a wealth of research and evidence since the early 1990s has helped make the health of women and girls far more visible. Many humanitarian interventions now meet needs associated with pregnancy and childbirth, and seek to prevent and address vulnerabilities to sexual or gender-based violence and sexually transmitted infections, including HIV.

Not only is it more widely accepted that meeting these needs is a humanitarian imperative and a matter of upholding and respecting human rights, but it is also clear that ensuring access to sexual and reproductive health is a pathway to recovery, risk reduction and resilience. The benefits extend to women and girls—and beyond. When they can obtain sexual and reproductive health care, along with a variety of humanitarian programmes that deliberately tackle inequalities, positive effects ripple throughout all aspects of humanitarian action.

Family planning

In humanitarian crises where funding for life-saving interventions is limited, family planning is a sound investment. In general, each $1 spent on contraceptive services saves between $1.70 and $4 in maternal and newborn health care costs.

Last year, UNFPA provided contraceptives and other family planning supplies in emergency reproductive health kits, which targeted the delivery of services to 20,780,000 women, men and adolescents of reproductive age in humanitarian settings worldwide.

Family planning is an indispensable element of response, as well as rebuilding and recovery, and directly benefits women and girls through increased family savings and productivity, as well as better prospects for education and employment. It also improves health outcomes as fewer unintended pregnancies result in fewer complications during childbirth and fewer maternal deaths.


United Nations humanitarian response, 2007-2014

Disasters Conflicts

Healthy mothers

UNFPA’s role in any humanitarian situation is to ensure that women have access to safe delivery services, no matter what the circumstances, in order to protect the lives and health of both mothers and babies.

The 10 countries with the highest maternal mortality ratios in the world are affected by, or emerging from, war (World Health Organization et al., 2014).

Creative means have sometimes been used to ensure access to maternal and newborn health services to women who are distant or dispersed.

Community health workers responding to Ebola in Guinea, for example, used smartphones to register people exposed to the virus and relay critical information to health officials.

In Somalia, nurses used global positioning systems to facilitate the delivery of health services to internally displaced persons in remote areas (Shaikh, 2008).

Also in Somalia, UNFPA is supporting 34 maternity waiting homes for pregnant women with complications to provide care and protection until it is time for delivery at a health facility.


UNFPA Supports Access to Services By Women And Girls

Image Map Chad Niger Nigeria Cameroon

Services and supplies provided January to September 2015 in Lake Chad Basin countries affected by Boko Haram crisis


4,075 kits for safe delivery distributed to health posts in camp and centres

5,400 dignity kits delivered to pregnant and vulnerable women and girls

10,000 male condoms distributed

110 women accessed contraception

11 case of rape clinically managed

30 district health staff and 40 community health agents trained and deployed

22 newly trained midwives deployed

5 youth centres equipped for skills development and adolescent counselling

4 public health facilities serving refugees equipped to provide quality reproductive health services

4 youth-and women-friendly spaces created in Minawao camp


53,312 condoms distributed

10,913 women and adolescent girls accessed family planning

1,458 women assisted for safe deliveries

1,407 dignity kits were distributed to refugees

906 women received antenatal care

118 adolescents and youth received training as reproductive health educators for refugees

40 health providers were trained

22 women survivors of gender-based violence received psychological support


28,000 condoms distributed

2,500 women, men, young people attended awareness-raising about gender-based violence

1,500 women received antenatal care

1,500 women received gender-based violence services

510 women assisted for safe deliveries

500 women accessed contraception


2,108,441 people’s awareness raised about preventing and responding to gender-based violence

27,293 women assisted for safe deliveries

22,000 women and adolescent girls received dignity kits

214 reproductive health kits (1,759 cartons) distributed, containing a range of life-saving medical equipment, drugs and other supplies

213 health workers and programme managers were trained in providing reproductive health services in humanitarian settings

56 midwives and nurses were trained in administering long-acting reversible contraception


Preventing and treating HIV

HIV has received progressively greater attention in humanitarian settings during the last two decades and receives greater funding and targeted assistance than other sexual and reproductive health topics. Many countries have made notable progress in increasing access to antiretroviral therapy and prevention of mother-to-child transmission.

Response to gender-based violence in humanitarian settings requires services and support to prevent and protect affected populations, to reduce harmful consequences and prevent further injury, trauma, harm and suffering. United Nations guidelines for addressing the problem emphasize that all “humanitarian personnel ought to assume gender-based violence is occurring and threatening affected populations; treat it as a serious and life-threatening problem; and take actions…regardless of the presence or absence of concrete evidence” (IASC, 2005).

Gender-based violence includes sexual violence, including rape, sexual abuse, sexual exploitation and forced prostitution; domestic violence; forced and early marriage; harmful traditional practices such as female genital mutilation, honour crimes and widow inheritance; and trafficking (IAWG, 2010). Thus, in humanitarian settings, response to gender-based violence requires a multi-sectoral approach.

Protecting adolescents’ right to health

Humanitarian settings are accompanied by inherent risks that increase adolescents’ vulnerability to violence, poverty, separation from families, sexual abuse and exploitation. Moreover, childbearing risks are compounded for adolescents, due to increased exposure to forced sex, increased risk-taking and reduced availability of, and sensitivity to, adolescent sexual and reproductive health services.

Young people can be agents of positive change, capable of advancing reconstruction and development in their communities. But to be engaged in the process, they need access to an array of programmes including formal and non-formal education, life skills, literacy, numeracy, vocational training and innovative strategies to address insecurity and staff shortages.

  • Haya,18, Deir Alla, Jordan, was married to her cousin at 15 years of age. Haya’s full name is concealed to protect her privacy. © UNFPA/Sharron Ward
  • Haya stands in her tent on the outskirts of the urban town of Deir Alla in the Jordan Valley.Haya’s full name is concealed to protect her privacy. © UNFPA/Sharron Ward
  • Dr. Ruba al Kayed with Haya. Haya’s full name is concealed to protect her privacy. © UNFPA/Sharron Ward
  • At age 15 Noor ended her engagement, Deir Alla, Jordan. Noor’s full name is concealed to protect her privacy. © UNFPA/Sharron Ward
  • Dr. Ruba al Kayed with Noor. Noor’s full name is concealed to protect her privacy. © UNFPA/Sharron Ward
  • UNFPA-supported Noor Hussein clinic conducts early marriage awareness sessions, Deir Alla, Jordan. © UNFPA/Sharron Ward

Preventing and addressing gender-based violence

The attention to gender-based violence has grown from a focus primarily on rape to include early and forced marriage, domestic violence, female genital mutilation, and trafficking.

Local women are usually the first to respond and the first to find solutions, sometimes simple ones that can make the difference between life and death. When an earthquake rocked Haiti in 2010, the incidence of rape increased markedly, as the institutions that might normally protect them collapsed, women mobilized within displacement camps to protect each other and support survivors. The non-governmental organizations MADRE and KOFAVIV distributed whistles to women in displacement camps, which helped reduce the incidence of rape by 80 per cent in one camp. The installation of lights powered by solar batteries also contributed to a reduction in gender-based violence in the camps.

Women themselves also took the lead in the Philippines after Typhoon Haiyan by forming watch groups and “women-friendly spaces” to protect themselves from gender-based violence. In July 2014, when another typhoon was forecast to strike the country, women dispatched watch groups to evacuation centres in coordination with female police officers and local authorities.

Ayan, 16, Minkaman Camp, South Sudan:
"I feel unsafe when I go to the bush because there are often men who rape women."
Photo © Panos Pictures/Chris de Bode


Prevention, preparedness
and empowerment

Featured Stories


Protecting the health of South Sudanese mothers and adolescents

  • Mothers and children at Tierkidi health centre. © UNFPA/A. Haileselassie
  • Mother and newborn, Tierkidi Camp, Ethiopia. © UNFPA/A. Haileselassie
  • Peter Lam Gony. © UNFPA/A. Haileselassie
  • A midwife attends to a mother and newborn. © UNFPA/A. Haileselassie

An average of 45 women give birth each week at the health centre in the Tierkidi refugee camp in Ethiopia.

The number wasn’t always so high, according to health centre manager Yonas Zewdu. Until recently, most women were delivering in their own living quarters, without the help of a skilled birth attendant.

Zewdu says the centre has deployed outreach staff to visit women where they live, encourage them to come for antenatal care and make arrangements for them to give birth in the centre, where two midwives manage all deliveries.

One of the midwives, Lelisa Bekele, says whenever a pregnant woman who has come in for one antenatal care does not turn up for a follow-up visit, outreach staff check on her to make sure she is all right.

To pregnant women who live far from health centres, UNFPA, the United Nations Population Fund, distributes clean delivery kits, consisting of a towel, blade, gloves, plastic sheets, cord ties and soap.

UNFPA stocks the centre with emergency reproductive health kits, which include everything from equipment and medicines for safe deliveries, surgical repair of cervical and vaginal tears, as well as treatments for sexually transmitted infections, and a variety of contraceptive methods.

According to Peter Lam Gony, who oversees community outreach for sexual and reproductive health, more and more women are learning about and choosing to use family planning, often against the wishes of their partners.

“Their husbands think that their wives will be seeing other men if they use family planning,” Gony says.

An increasing number of adolescents are also choosing to use contraception in the camp. Those who avail themselves of the confidential services also learn that aside from condoms, contraceptives only prevent a pregnancy, not a sexually transmitted infection, such as HIV.

The centre also makes free condoms available through free dispensers available throughout the camp.

Tierkidi camp houses about 52,000 refugees from South Sudan.

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From despair to hope in Nepal

  • Ishwori Dangol (centre). © UNFPA/Santosh Chhetri
  • Ishwori Dangol. © UNFPA/Santosh Chhetri
  • A UNFPA staff member with Dangol. © UNFPA/Santosh Chhetri
  • UNFPA Staff member with Ishwori Dangol. © UNFPA/Santosh Chhetri
  • Ishwori Dangol with her baby. © UNFPA/Santosh Chhetri

When Nepal’s worst earthquake in almost a century struck on April 25, Ishwori Dangol’s life changed forever.

Seven months pregnant at the time, the 30-year-old woman frantically searched for her seven-year-old son who was playing in her neighbour’s home in Betrawati village in Nuwakot district, only to realize that he was among the almost 9,000 people who lost their lives in the disaster that day.

Consumed by grief, Ishwori also worried about the health of her foetus and whether she would have to deliver on her own, since the 7.8 magnitude earthquake damaged or destroyed 70 per cent of the birthing centres in Nepal’s 14 most affected districts, including Nuwakot.

Thousands of pregnant women like Ishwori were left with little or no access to crucial health services to ensure safe deliveries.

Sushila, a local female community health volunteer, told Ishwori about a reproductive health camp supported by UNFPA, the United Nations Population Fund, and run by Manamohan Memorial Community Hospital and the Adventist Development and Relief Agency in coordination with the Ministry of Health and Population.

The camp provided Ishwori and more than 400 others lifesaving information and services in the first three days of operation. UNFPA supported and secured funds for 109 such camps and distributed reproductive health supplies to 124 health facilities, reaching an estimated 1.8 million people in the first five months after the earthquake.

Camp services included antenatal to postnatal care, safe delivery, family planning, testing and treatment for sexually transmitted infections, including HIV, psychosocial support and health care for survivors of gender-based violence.

Dr. Suman Panta, the camp doctor who examined Ishwori said her foetus was in an abnormal position in her womb. Ishwori was referred to the nearby Trishuli Hospital, which continued providing services despite damage to the facility. Ten weeks after losing her first child in the earthquake, Ishwori gave birth via Caesarean section to a healthy baby boy.

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A conflict or disaster can erase in a moment a generation of economic and social gains.

It can also permanently undermine an individual’s prospects for a better life, shattering opportunities and limiting choices.

And it can exacerbate existing inequalities in society, resulting in even greater hardship for the poor and marginalized, exacting a disproportionate toll on women and young people, particularly under the age of 20, who constitute about half the population in many conflict and post-conflict settings.

The profound human impact of disasters and conflicts on people, communities, institutions and nations highlights the critical importance of building resilience so all may better withstand the effects of crises and recover from them more quickly. Building resilience can also help mitigate the potential negative effects on the sexual and reproductive health of women and adolescent girls.

Who lives, dies and recovers during or after a conflict or disaster depends in part on the policies, programmes and social, economic and political contexts prior to the crisis.

Pre-empting poverty and inequality

The socioeconomic and structural factors that determine the capacity of communities to be resilient are critical preconditions to the effect of a disaster or conflict and require unwavering attention by governments.

While resilience may be seen as an end state, it is also an ongoing process, requiring continuous efforts to address the socioeconomic and structural factors—poverty, harmful gender norms and even food insecurity—that can influence whether communities may withstand or recover from a crisis or shock. Resilience-building as a process must be prioritized at every level and guided by local adaptation strategies, culture, heritage and knowledge. This requires the involvement of actors across the humanitarian and development continuum, but the process must be owned by the community.

Humanitarian emergencies, such as natural disasters and conflicts, can lead to a broadening and deepening of poverty and inequality. Resilience can mitigate those effects.

Building resilience involves addressing underlying causes of vulnerability, such as poverty and inequity, and initiating pre-emptive measures to build positive adaptation before a crisis strikes. Investments in reproductive, maternal, newborn, child and adolescent health, and reproductive rights will protect those most affected by disasters.

Susila Bora, 19, Saurpani-4 village,
which was destroyed when a 7.8 magnitude earthquake struck Nepal in April 2015.
Photo © Panos Pictures/Vlad Sokhin

Lack of Coping Capacity, 2015

This dimension measures the lack of resources available that can help people cope withhazardous events. It is made up of two categories—institutions and infrastructure. This map shows details for the 12 countries with the highest values in the lack of coping capacity dimension.

The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations.

Disaster risk reduction

Disaster risk reduction is a critical element in resilience. While humanitarian response is a short-term intervention, disaster risk reduction is a long-term undertaking that addresses the root causes of vulnerability during a crisis. Though some crises, such as earthquakes and tsunamis, cannot be prevented, their impact can be mitigated by pre-crisis investment in the building of sexual and reproductive health systems that are resilient and focused on the needs of the most vulnerable segments of the community.

Women, girls and resilience

One of the weakest areas of resilience currently is among women and girls, and the institutions that serve them. As long as inequality and inequitable access short-circuit their rights, abilities and opportunities, women and girls will remain among those most in need of humanitarian assistance and least equipped to contribute to recovery or resilience.

Sexual and reproductive health and rights are a cornerstone of young people’s transition to adulthood. When governments take steps to ensure the transition is safe and healthy, they are also taking steps to boost the “shock-absorbing” capacities of communities and nations, thereby creating environments where individuals can also become resilient.

People displaced by Typhoon Haiyan, Tacloban, the Philippines.
Photo © Panos Pictures/Andrew McConnell


Inclusive, equitable development

Development that is inclusive, equitable and that respects and protects everyone’s human rights, including reproductive rights and the right to health, including sexual and reproductive health, is central to resilience. The principles of inclusiveness, equity and rights are also the foundation for the new generation of United Nations Sustainable Development Goals, which will guide the international community in navigating the economic and social challenges of the coming 15 years.

Guaranteeing the sexual and reproductive health and rights of women and adolescent girls will go a long way towards achieving the goal of inclusive, equitable development, and can lead to more resilient societies, more capable of withstanding crises and rebuilding in ways that lead to even greater resilience.

But the new vision for sustainable development for the coming 15 years may only be realized if all of the world’s people are engaged and have a stake in its success. This means that women and adolescent girls must play a central role in leading and contributing to efforts to improve health and sustainable development at all levels—household, community, institutional and government—and not be left behind or relegated to a secondary role.


Moving Forward

A new vision for
humanitarian action

Tip the balance from reaction to preparedness and resilience

We must aim for a more resilient, less vulnerable world. Such a world would be one where development, within and across countries, is fully inclusive and equitable, and upholds all rights for all people. Where women and girls are no longer disadvantaged in multiple ways but are equally empowered to realize their full potential, and contribute to the development and stability of their communities and nations.

It would be a world where every country can manage its economy and its polity to guarantee everyone’s access to decent work and high quality essential services, including sexual and reproductive health care. Among those who set the course of public policies, there would be a sound understanding that investment in equitable, inclusive development is about the best and certainly the fairest and most humane investment that can be made. Far-reaching benefits include reducing the risks and impacts of crisis.

Better management of risk

Transformation to a more resilient, less vulnerable world also depends on better management of risks and institutions with sufficient capacities in place long before a crisis strikes. Risks first need to be comprehensively understood; only then can effective investments be made in measures to reduce them.

For those risks not fully avoidable, proactive preparation is critical to limit the worst consequences. One of the most central strategies in reducing risks in all countries is making sure people are resilient in the face of them. Those who are healthy, educated, have adequate income and enjoy all human rights have far better prospects when risks become reality.

Dr. Babatunde Osotimehin,
UNFPA Executive Director
  • Mother and daughters outside new home built after tsunami inundated her community in Lhoknga, Indonesia, in 2004. © Panos Pictures/Abbie Trayler-Smith
  • Girls dance at the Za'atari Camp, Jordan. © Panos Pictures/Mads Nissen
  • Birth attendant Christine Yakoundou examines client at Centre de Santé, Central African Republic. © Panos Pictures/Jenny Matthews
  • © Ali Arkady/VII Mentor Program
  • © Panos Pictures/Mads Nissen/Berlingske
  • Syrians leaving Gevgalija, the former Yugoslav Republic of Macedonia. © UNFPA/Nake Batev
  • At a camp in Dohuk, Iraq. © Ali Arkady/VII Mentor Program

Promote equality

Transformation can begin, in part, in the aftermath of a crisis, but that largely depends on the response. If it mainly replicates existing discriminatory patterns, such as by failing to provide quality sexual and reproductive health services from the first moments, it is not transformative. It will fail as well on all scores of effectiveness and human rights. All humanitarian issues involve some kind of gender perspective, because men and women, girls and boys experience the world in markedly different ways. All types of humanitarian action therefore need to recognize and respond to these differences, and actively correct any disparities.

Wherever feasible, humanitarian assistance can challenge existing forms of discrimination, such as through providing comprehensive services for survivors of gender-based violence. It can enlist men and boys in building acceptance of new social norms, such as around women’s inherent rights and the peaceful resolution of differences.


A new vision for humanitarian action

Sexual and
health and
Prevention and
At the core of the interrelated elements of humanitarian action, from response to resilience and development, are sexual and reproductive health and rights

Tear down the divide between humanitarian action and development

The distinction between humanitarian response and development today is a false one. Humanitarian action can lay the foundations for long-term development. Development that benefits all, enabling everyone to enjoy their rights, including reproductive rights, can help individuals, institutions and communities withstand crisis. It can also help accelerate recovery.

Equitable, inclusive and rights-based development, and the resilience fostered by it, can in many cases obviate the need for humanitarian interventions.



State of World Population 2015

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