Imagine making the journey as a refugee from Syria into Lebanon. It may be a long distance and often involves travelling through areas of fighting. On arrival, your first priorities are food and shelter, and protecting your loved ones; family planning is probably the last thing on your mind.
But pregnancy happens in every community, and war zones are no exception. Sadly, however, access to family planning may be rare.
No two conflicts or natural disasters are the same, but difficult pregnancies are seen time and again when communities are forced to flee their homes. Some women are forced to give birth alone; others make it to clinics, but urgently need blood transfusions and are miles from the nearest hospital with a blood bank. Pregnancy can also carry a risk of death and disability for mothers and newborns, especially in fragile states.
This is especially true for refugees. Some 15% of deliveries are likely to result in life-threatening complications (pdf) and require emergency obstetric care, which only a doctor or midwife can provide. Delivery is more likely to be complicated if you have been through the trauma of fleeing a conflict or natural disaster, and medical assistance, such as antenatal care, is less likely to be available. But even though the risks associated with pregnancy are greater, reproductive health is often put to one side in emergency relief situations.
Before Syria descended into civil war, it had a working health system. Family planning was free and used relatively widely by 58% of women (pdf). Yet the last time an extensive survey was carried out among Syrian refugees in Lebanon, only 37% of non-pregnant married women were using contraception (pdf). According to the UN Population Fund, 250,000 women in Syria and refugee settings will become pregnant by the end of this year. Syrian refugees frequently tell aid workers they are terrified of becoming pregnant, so why is family planning such a rarity?
Part of the answer is rooted in the same reasons that women lack healthcare in general. Lebanon, whose population has grown by nearly 25% since the war in Syria began, is struggling to meet demand for basic healthcare. Many refugees live in unofficial settlements far from cities, and simply do not know where to get healthcare. Cost is also an issue. Most clinics are privately run and prohibitively expensive: a prescription for the pill and a consultation fee may be only a few dollars, but most Syrian refugees are entirely reliant on savings, which dwindle quickly.
Fundamentally, however, there are simply more immediate needs. In refugee communities, people will, understandably, be concerned first and foremost about medical care for those who are already ill, or finding food and shelter. Colleagues from other NGOs have told stories about setting up focus groups to determine family planning needs, where refugees have interjected and asked to discuss food and jobs instead.
The solution lies in adapting to the specific needs of refugees, whether they are living in camps, host communities or informal settlements. For example, Merlin uses mobile clinics to take healthcare to remote communities around the world. We are prioritising such clinics in Lebanon to provide healthcare, including family planning, to unregistered refugees.
Family planning remains a low-cost way of reducing pregnancy-related deaths, and one that women have told us they need time and again. But conflict-affected settings receive 50% less funding for reproductive health than stable settings.
Addressing this different and often complex set of challenges means that pregnancy can be the natural and life-affirming process it should be for women who have already endured conflict and disaster.
• Lizzy Berryman is head of emergencies for the medical charity Merlin