Reproductive Health Services for Syrian Refugees in Zaatri Refugee Camp and Irbid City, Jordan

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1 Reprductive Health Services fr Syrian Refugees in Zaatri Refugee Camp and Irbid City, Jrdan * * * An Evaluatin f the Minimum Initial Service Package March 17-22, 2013 Bstn University Schl f Public Health, United Natins High Cmmissiner fr Refugees, United Natins Ppulatin Fund, US Centers fr Disease Cntrl and Preventin, Wmen s Refugee Cmmissin i

2 Reprductive Health Services fr Syrian Refugees in Zaatri Refugee Camp and Irbid City, Jrdan * * * An Evaluatin f the Minimum Initial Service Package March 17-22, 2013 Reprt Authrs: Dr. Wilma Dedens 2 Ms. Nreen Giga 4 Ms. Sandra Krause 4 Dr. Mnica A. Onyang 1 Ms. Samira Sami 3 Ms. Erin Stne 4 Dr. Basia Tmczyk 3 Dr. Hlly Williams 3 A cllabratin amng: 1 Bstn University Schl f Public Health 2 United Natins Ppulatin Fund 3 US Centers fr Disease Cntrl and Preventin 4 Wmen s Refugee Cmmissin With funding prvided by the: US Department f State, Bureau f Ppulatin, Refugees and Migratin, Jhn D. and Catherine T. MacArthur Fundatin, and Internatinal Planned Parenthd/Australian Agency fr Internatinal Develpment Acknwledgements: The Interagency Wrking Grup n Reprductive Health in Humanitarian Crises (IAWG) MISP study team is grateful t the United Natins High Cmmissiner fr Refugees, UN Ppulatin Fund and the Internatinal Rescue Cmmittee and in particular Drs. Ann Burtn and Shible Sahbani, Ana Calv, Heather Lrenzen, Rbert Warwick and Firas Dabbas fr agreeing t hst this missin recgnizing the imprtance f reprductive health even at the height f demands t their time n the grund. We wuld als like t thank the interpreters and nte takers Dia Al Hayek, Rsanna Petr, Mai Hussein, Ahmad Ababneh, Ibtisam Darwish, Amal Rizqallah and Tariq Saleh. The reprt was edited by Diana Quick f the Wmen's Refugee Cmmissin. Finally, we very much appreciate agency representatives wrking n the grund in Syria and Syrian wmen themselves fr taking the time t meet with us. Cntacts: Sandra Krause, Basia Tmczyk Wilma Dedens, ii

3 Cntents List f Acrnyms...i Executive Summary Intrductin Overview f reprductive health in Jrdan Maternal and newbrn health Family planning HIV/ AIDS Gender-based vilence Syrian refugee ppulatin in Jrdan Reprductive health cntext Disaster risk reductin Minimum Initial Service Package Purpse f the evaluatin... 9 Objectives... 9 Methds Study design Study measures Data Cllectin Prcedures Key infrmant interviews Health facility assessments Fcus grup discussins Data analysis prcedures Key infrmant interviews Health facility assessments Fcus grup discussins Ethical cnsideratins Infrmed cnsent Cnfidentiality Results Descriptin f sample Key infrmant interviews iii

4 4.1.2 Health facility assessments Fcus grup discussins MISP awareness and knwledge Crdinatin f the MISP Meetings t discuss RH implementatin Use f RH prtcls Funding f RH activities RH Kits and supplies available and used Cmmunity participatin in service delivery Access t RH services Prevent and manage the cnsequences f sexual vilence Put in place measures t prtect affected ppulatins, particularly wmen and girls, frm sexual vilence Age at marriage Make clinical care available fr survivrs f rape Ensure the cmmunity is aware f the available services Reduce HIV transmissin Ensure safe bld transfusin practice Facilitate and enfrce respect fr standard precautins Make free cndms available Prevent excess maternal and newbrn mrbidity and mrtality Ensure the availability f emergency bstetric care (EmOC) and newbrn care services At health facilities, ensure there are skilled attendants and supplies fr nrmal births and management f bstetric and newbrn cmplicatins Establish a referral system t facilitate transprt and cmmunicatin frm the cmmunity t the health center and between health center and hspital Prvide clean delivery kits t visibly pregnant wmen and birth attendants t prmte clean hme deliveries when access t a health facility is nt pssible Plan t integrate cmprehensive RH services int primary health care Cllect existing backgrund data Identify suitable sites fr future service delivery f cmprehensive RH services Prvide cmmunity educatin abut the benefits f btaining RH services and hw t access such services Additinal pririties f MISP Ensure cntraceptives are available t meet demand iv

5 4.8.2 Make syndrmic treatment f sexually transmitted infectin (STIs) available t patients presenting with symptms Antiretrvirals (ARVs) are available t cntinue treatment fr peple already n ARVs, including fr the preventin f mther-t-child transmissin Integratin f reprductive health int disaster risk reductin and emergency preparedness Facilitating factrs and barriers t the implementatin f the MISP Facilitating Factrs Barriers Suggestins fr imprving the MISP in Jrdan General cncerns amng Syrian refugee wmen Meeting basic needs Livelihds Educatin Additinal cncerns Discussin Crdinatin f the MISP Prevent and manage the cnsequences f sexual vilence Reduce the transmissin f HIV Prevent excess maternal and newbrn mrtality Plan fr cmprehensive reprductive health services Limitatins Cnclusins Recmmendatins Immediate Medium term Lng-term References Appendix A. MISP Objectives, Activities & Indicatrs Appendix B. Key Infrmant Inteview Cnsent Frm and Questinnaire Appendix C. Health Facility Assessment Cnsent Frm and Questinnaire Appendix D. Fcus Grup Discussin Cnsent Frm and Questinnaire Appendix E. Acknwledgements v

6 List f Tables Table 1. Health Facilities Assessed at Zaatri Refugee Camp; MISP Evaluatin; Zaatri Refugee Camp and Irbid City, Jrdan, March 17-22, Table 2. Health Facilities Assessed in Irbid City MISP Evaluatin; Zaatri Refugee Camp and Irbid City, Jrdan, March 17-22, Table 3. Number f Beds at Facilities in Zaatri Camp and Irbid City; MISP Evaluatin; Zaatri Refugee Camp and Irbid City, Jrdan, March 17-22, Table 4. Human Resurces at Zaatri Camp and Mafraq Hspital; MISP Evaluatin; Zaatri Refugee Camp and Irbid City, Jrdan, March 17-22, Table 5. Availability f Relevant Departments; MISP Evaluatin; Zaatri Refugee Camp and Irbid City, Jrdan, March 17-22, Table 6. Family Planning Cmmdities; MISP Evaluatin; Zaatri Refugee Camp and Irbid City, Jrdan, March 17-22, vi

7 List f Acrnyms ANC ARV BPRM CDC CERF DFID DRC ECHO FGD GBV GFS HFA HIS HIV IAFM IAWG IDP IEC IUD JHAS JWU KII MMR MCH MISP MOH MFH NGO NRC OCP RH RMS PEP PHC PLHIV PMTCT PNC SDC STI SV Antenatal care Antiretrviral US Bureau f Ppulatin Refugee and Migratin US Centers fr Disease Cntrl and Preventin Central Emergency Respnse Fund UK Department fr Internatinal Develpment Danish Refugee Cuncil Humanitarian Aid and Civil Prtectin department f the Eurpean Cmmissin Fcus grup discussin Gender-based vilence Gynéclgie Sans Frntières Health facility assessment Health infrmatin system Human Immundeficiency Virus Interagency Field Manual Interagency Wrking Grup n Reprductive Health in Humanitarian Crises Internally displaced persns Infrmatin educatin campaign Intrauterine device Jrdan Health Aid Sciety Jrdanian Wmen s Unin Key infrmant interviews Maternal mrtality rati Maternal and child health Minimum initial service package Ministry f Health Mrccan field hspital Nngvernmental rganizatin Nrwegian refugee cuncil Oral cntraceptive pill Reprductive health Ryal Medical Service Pst-expsure prphylaxis Primary health care Persns living with HIV Preventin f mther-t-child transmissin Pstnatal care Swiss Agency fr Develpment and Cperatin Sexually transmitted infectin Sexual vilence i

8 UN UNFPA UNICEF UNHCR WHO WRC United Natins United Natins Ppulatin Fund United Natins Children s Fund United Natins High Cmmissiner fr Refugees Wrld Health Organizatin Wmen s Refugee Cmmissin ii

9 Executive Summary Intrductin The civil war between the gvernment f Syria and rebel frces, initiated in mid-march 2011, resulted in an estimated ne millin refugees fleeing Syria t neighbring cuntries, including Lebann, Jrdan, Turkey, Iraq and Egypt, by March Of this ttal, sme 355,493 were registered r awaiting registratin in Jrdan in mid-march, accrding t United Natins High Cmmissiner fr Refugees (UNHCR). The status f Syrian wmen s reprductive health (RH) has suffered due t the destructin in the health infrastructure and uncertain access and availability f services. Therefre, dcumentatin is urgently needed n the type and amunt f RH services that are currently available in Jrdan in rder t keep up with the grwing demand fr these services as the refugee ppulatin cntinues t swell. Evaluatin purpse The Minimum Initial Service Package (MISP), a standard f care in humanitarian emergencies, is a crdinated set f pririty activities designed t prevent excess newbrn and maternal mrbidity and mrtality; reduce HIV transmissin; prevent and manage the cnsequences f sexual vilence; and plan fr cmprehensive RH services. As part f the Glbal Evaluatin f Reprductive Health in Crises fr the Inter-Agency Wrking Grup (IAWG) n Reprductive Health in Crises, representatives frm Bstn University Schl f Public Health, the US Centers fr Disease Cntrl and Preventin (CDC), United Natins Ppulatin Fund (UNFPA) and the Wmen s Refugee Cmmissin (WRC) cnducted an evaluatin f the MISP frm March 17-22, The purpse f this study was t examine t what extent the MISP services were in place fr Syrian refugees living in Jrdan in rder t imprve the respnse and meet the RH needs f the refugees. Methds The MISP study team used bth quantitative and qualitative technique methds, including fcus grup discussins (FGD), key infrmant interviews (KII) and health facility assessments (HFA). Tw Syrian refugee ppulatins were included, ne living in Zaatri refugee camp (n=164,365) and ne in Irbid Gvernrate (n=40,339). FGDs amng the Syrian refugee ppulatin (wmen and adlescent girls, aged years) were cnducted t assess knwledge and attitudes f RH and access t RH services. KIIs (with health directrs, managers, physicians and nurses) assessed RH plicy issues and guidelines initiated and supprted by the Ministry f Health (MOH) and by relief agencies including the UN High Cmmissiner fr Refugees (UNHCR) and UNFPA. Health facility assessments were cnducted in cllabratin with medical dctrs, nurses and ther facility representatives wh serve the needs f the refugee ppulatin in primary health care clinics, hspitals and referral centers. Key Findings Key infrmants were aware f the five MISP bjectives. Hwever, there was very limited understanding f the additinal pririties f the MISP such as ensuring cntraceptives are available t meet the demand; treatment fr sexually transmitted infectins (STIs) is available t peple 1

10 presenting with symptms; antiretrvirals (ARV) are available t current users; and menstrual hygiene supplies are available.. A number f key elements t supprt implementatin f the MISP were in place, including a dedicated lead agency t supprt MISP implementatin within the health sectr, a fcal pint fr RH crdinatin, regular RH crdinatin meetings in Amman and Zaatri camp, and RH kits and supplies, and funding fr MISP implementatin were nted. Hwever, key infrmants reprted that RH crdinatin was insufficient fr the urban areas; nt all key stakehlders participated in crdinatin; prtcls fr care fr survivrs f sexual vilence were incmplete r STIs did nt exist; and that key infrmants wuld like UNFPA t share the infrmatin that it cllects frm stakehlders amng stakehlders. Syrian refugee wmen discussed security fears that they had in relatin t using the latrines at night due t a lack f lighting. While services existed t manage sexual vilence (SV), they were limited, and cmmunity and prvider knwledge f the services was lw. Safe bld transfusin practices and standard precautins were in place; hwever, cndm distributin was limited. Clinical services t prevent excess maternal and newbrn mrbidity and mrtality were in place and utilized. Planning was underway fr expanding t have mre cmprehensive RH services. Baseline data cllectin and rutine mnitring f RH indicatrs were limited. In terms f additinal pririties t the MISP, mdern methds f family planning was available (althugh cndm distributin limited), syndrmic treatment fr peple presenting with symptms f STIs was nt available, the situatin f cntinuing ARVs fr refugees already n ARVs was unknwn and menstrual hygiene supplies were insufficient. Althugh there was a high level f specialty clinical care available, primary care clinics and utreach t the cmmunity was limited. Refugee wmen and adlescent girls that participated in the FGDs perceived clinical services negatively and they cmplained abut nt being included in the humanitarian relief respnse. MISP cntingency plans were established but nt activated. Jrdan has undertaken sme activities n disaster risk reductin althugh it was unclear if there have been initiatives t address health and RH. Barriers t MISP implementatin included a lack f adequate staffing in urban areas and f clear RH prtcls, particularly n care fr survivrs f SV, and management f STIs); less fcus by the RH wrking grup in Amman n urban ppulatins cmpared with the camp ppulatin; and lack f capacity t implement the MISP cntingency plan. Key Recmmendatins There are a number f interventins that can be implemented immediately and include the fllwing: Strengthen crdinatin in Amman t address the RH needs f urban refugee ppulatins; facilitate the participatin f key stakehlders such as the MOH, WHO, lcal NGOs, unfunded partners and inter-agency prtectin and gender-based vilence (GBV) wrking grups in bth Amman and Zaatri meetings; address RH prtcls, particularly, finalize the clinical care fr SV survivrs prtcl; identify STIs management and prtcls fr referral f and caring fr persn living with HIV (PLHIV); imprve data cllectin and use f data fr actin; and supprt infrmatin, educatin and 2

11 cmmunicatin (IEC) campaigns n the benefits t seeking care and the availability, lcatin and hurs f services in bth urban areas and Zaatri refugee camp. Imprve free cndm distributin with sensitivity t cultural nrms. Scale up the availability f clinical care fr survivrs f SV at service delivery sites and cnsider integrating the prtcl int the Family Prtectin Department where frensic dctrs are available and culd be trained. Strengthen cmmunity utreach, participatin and services alng with infrmatin and educatin, including fr adlescents and peple with disabilities, by utilizing existing IEC campaign resurce materials n the MISP and family planning, and ensuring all service delivery is physically accessible and inclusive f peple with disabilities. Imprve the health care envirnment with adequate staffing, particularly female dctrs and by addressing the interactins between health care prviders and Syrians s that Syrian wmen feel cmfrtable while seeking care. Advcate fr Syrian health care prviders t be invlved in prviding health care services t the refugees. Cnclusin In spite f the steady influx f refugees int Jrdan that has strained the resurce capacity f this humanitarian emergency respnse, the agencies that prvide RH services have been able t implement the MISP fr the mst part, althugh there is need fr sme key imprvements. In this setting, the study team fund sme challenges, such as balancing the increasing demands fr services while maintaining quality and managing infrmatin flw amng multiple stakehlders. It is vital t stay infrmed and listen t the needs f Syrian refugees in Jrdan t imprve RH utcmes in the mnths t cme. 3

12 1. Intrductin The Inter-Agency Wrking Grup (IAWG) n Reprductive Health in Crises wrks t address the reprductive health (RH) needs f thse displaced by cnflict and natural disasters. IAWG members include United Natins (UN) and gvernmental agencies, nngvernmental rganizatins (NGOs), universities and dnrs. The IAWG was frmed in 1995 and currently has 1,500 individual members frm 450 agencies wrldwide. Frm 2012 thrugh 2014, the IAWG is reviewing the state f RH services fr ppulatins affected by crises wrldwide. The last review tk place between 2002 and 2004; IAWG is interested in understanding what has changed, as well as hw services can cntinue t be imprved fr cmmunities in an emergency. 1 As part f the current Glbal Evaluatin f RH, members f the IAWG, representing Bstn University Schl f Public Health (BUSPH), the US Centers fr Disease Cntrl and Preventin (CDC), United Natins Ppulatin Fund (UNFPA) and the Wmen s Refugee Cmmissin (WRC), cnducted an assessment f the Minimum Initial Service Package (MISP) f RH in ne urban area (Irbid City) and ne refugee camp (Zaatri) in Jrdan frm March 17-22, The MISP is a crdinated set f pririty activities designed t prevent excess newbrn and maternal mrbidity and mrtality; reduce HIV transmissin; prevent and manage the cnsequences f sexual vilence; and plan fr cmprehensive RH services. The purpse f this evaluatin was t examine t what extent the MISP RH services were in place fr Syrian refugees living in Jrdan in rder t address gaps in services and imprve respnse and scaling-up f services. 1.1 Overview f reprductive health in Jrdan In general, there is gd access t health services in Jrdan. 2 There are 12 health centers per 100,000 persns, with an average travel time f 30 minutes t the nearest health center. 3 The health sectr als cnsists f 24.5 physicians and 29.4 nurses per 10,000 persns, which prvides reasnable cverage fr the Jrdanian ppulatin. 4 The Ministry f Health, (MOH) als prvides free primary health care [PHC] services, such as maternal and child health, immunizatin and schl health services. 5 The Jrdanian Gvernment has established plicies arund the prvisin f reprductive health educatin and services. Reprductive health and family planning services are integrated int the PHC system; 6 hwever, reprductive health and family planning educatin and services are prvided t men and wmen nly after they are married. 7 The MOH, in cllabratin with the Health Systems Strengthening (HSS) and UNFPA, created the Reprductive Health/Family Planning Clinical Guidelines t establish standards arund reprductive health, family planning and maternal and newbrn care Maternal and newbrn health Jrdan s Maternal Mrtality Rati (MMR) has been declining steadily since 1990 and is currently at 59 per 100,000 live births. 9 Jrdan has clinical guidelines arund the implementatin and delivery f maternal and 1 UNFPA, Interagency Glbal Evaluatin f Reprductive Health Services fr Refugees and Internally Displaced Persns, Nvember last accessed September 18, Wrld Health Organizatin (WHO). Jrdan Reprductive Health Prfile: last accessed September 18, Ibid. 4 Ibid. 5 Ibid. 6 Ibid. 7 Issa S. Almasareweh, Adlescent Reprductive Health in Jrdan: Status, Plicies, Prgrams, and Issues, Plicy Prject (January 2003): 1. 8 The Hashemite Kingdm f Jrdan Ministry f Health. Reprductive Health/Family Planning Clinical Guidelines. 9 Wrld Bank. 4

13 newbrn care in the fllwing areas: antenatal care (ANC), high-risk pregnancy, pstnatal care and pstabrtin care. 10 Virtually all pregnant wmen in Jrdan (99%) receive ANC and have their births attended by skilled medical persnnel. 11 Abrtin in Jrdan is illegal unless justified by a medical reasn. 12 The Reprductive Health/Family Planning Clinical Guidelines, used by maternal and child health and primary health care prviders, utlines prtcls fr first aid fr cmplicatins f abrtin, including pst-abrtin cunseling. 13 An abrtin induced fr nnmedical reasns is categrized as a criminal abrtin in the guidelines Family planning The Jrdanian MOH has established guidelines arund the prvisin f family planning services by health care prviders in the fllwing areas: cunseling fr reprductive health and family planning, family planning methds, and the management f infertility. 15 The Reprductive Health/Family Planning Clinical Guidelines utlines permanent, temprary and emergency family planning methds and prvides a descriptin f the methd, hw t use it, wh shuld use it, side effects and effectiveness. 16 The use f emergency cntraceptive pills (ECP) is als described in the family planning methds with instructins abut the prescribed dsage per drug and hw and when t start temprary family planning methds after its use. 17 The manual prvides infrmatin n the cmbined ral cntraceptive pills fr ECP; 18 hwever, there is n registered prduct fr ECP in Jrdan. 19 There are high levels f cntraceptive knwledge amng wmen in Jrdan (99% f married wmen knw all mdern methds and 94% knw where t receive cntraceptin), yet the mdern cntraceptive prevalence rate remains lw 20 at 59.3%. 21 Of the wmen wh are using sme frm f cntraceptin, 38% are using the intrauterine device (IUD), 14% the ral cntraceptive pill (OCP) and 16% are using anther mdern methd. 22 In cmparisn data frm 2002 in Syria shws a cntraceptive prevalence rate f 54%. The main frm f methd is the IUD fllwed by ral cntraceptive pills, 43% and 26% respectively. In additin, mst cuples make a jint decisin t use a mdern methd and use fr spacing childbirth, 63% and 73%, respectively. 22 The Jrdanian Gvernment develped the Reprductive Health Actin Plan t meet the cntraceptin and family planning needs f Jrdanians The Hashemite Kingdm f Jrdan Ministry f Health. Reprductive Health/Family Planning Clinical Guidelines. 11 Wrld Bank. 12 S. Almasareweh, Adlescent Reprductive Health in Jrdan: Status, Plicies, Prgrams, and Issues, Plicy Prject (January 2003): The Hashemite Kingdm f Jrdan Ministry f Health. Reprductive Health/Family Planning Clinical Guidelines. 14 Ibid. 15 Ibid. 16 Ibid. 17 Ibid. 18 Ibid. 19 Internatinal Cnsrtium fr Emergency Cntraceptin. 20 Japan Internatinal Cperatin Agency, Cmprehensive Study n Family Planning and Wmen in Develpment Prjects in Jrdan: Analysis frm a Capacity Develpment Perspective (Nvember 2006). Studies/english/publicatins/reprts/study/capacity/200611/pdf/ pdf, last accessed September 18, Wrld Bank, 22 Farzaneh Rudi-Fahimi, Ahmed Abdul Mnem, Lri Ashfrd, and Maha El-Adawy, Wmen s Need fr Family Planning in Arab Cuntries (UNFPA Arab States Reginal Office. July 2012). last accessed September 18, USAID, Stries frm the Field: Jrdan Mves Tward FP Self-sufficiency, (December 2006). last accessed September 18,

14 1.1.3 HIV/ AIDS Jrdanian law states that refugees wh are HIV psitive can be deprted, which may reduce HIV testing and availability f treatment amng refugee ppulatins. 24 Hwever, Jrdan has a strng plitical cmmitment t reduce HIV/AIDS transmissin amng their citizens. 25 A natinal strategy t cmbat HIV/AIDS was intrduced n Wrld AIDS Day in 2006 by her Ryal Highness Princess Mna Al-Hussein. 26 The MOH runs a htline that prvides free cunseling and testing fr peple living with AIDS 27 and HIV testing has been available in Jrdan since In additin t cunseling and testing, the Jrdanian Gvernment prvides free ARVs fr bth males and females. 29 Jrdan s natinal health insurance plicy was als amended t prvide cverage fr ARVs and treatment fr any pprtunistic infectin. 30 Althugh treatments are prvided withut discriminatin, wmen still face barriers t receiving care due t their desire t travel utside f their cmmunities fr treatment s as t nt be recgnized Gender-based vilence There is n unified plicy in Jrdan t handle gender-based vilence (GBV) r t care fr survivrs f sexual vilence, 32 but there are sme plicies and prgrams t help survivrs f dmestic vilence. In 2000 the Natinal Cmmittee fr Family Safety and the Unit f Family Prtectin was created t mnitr and prtect vulnerable family members wh experience dmestic vilence Syrian refugee ppulatin in Jrdan At the time f this MISP evaluatin in mid-march 2013, civil unrest in Syria that started in March 2011 had resulted in tw millin internally displaced persns (IDP) and fur millin peple in need f humanitarian assistance. Further, mre than ne millin Syrians had fled the vilence and its aftermath t neighbring cuntries, including Jrdan, Lebann, Iraq, Turkey and cuntries in Nrth Africa. 34 There were als an estimated ttal f 355,493 Syrian refugees in Jrdan with 298,025 registered by the United Natins High Cmmissiner fr Refugees (UNHCR) and 57,468 awaiting registratin at the time f the evaluatin. An verwhelming majrity f unregistered refugees were residing in urban areas. The majrity (55.2 %) f registered refugees were residing in Zaatri camp, with an additinal 47,087 (15.2%) and 39,339 (13.2%) residing in Irbid and Amman gvernrates, respectively. Refugee influxes cntinued at an average f mre than 1,500 arrivals per day during March 10-17, Within that time frame, females aged years represented the majrity f new arrivals (at nearly 30% f the ttal registered), with females f all ages cmprising 53% f thse registered during that time UNHCR Standard Operating Prcedures fr Preventin f and Respnse t SGBV, Amman, Jrdan UNHCR. May 6, Nisreen Qatamish and Jenine Jaradat, UNGASS Cuntry Reprt Hashemite Kingdm f Jrdan, (January 2008): 19. last accessed September 18, Ibid. 27 Issa S. Almasareweh, Adlescent Reprductive Health in Jrdan: Status, Plicies, Prgrams, and Issues, Plicy Prject (January 2003): Nisreen Qatamish and Jenine Jaradat, UNGASS Cuntry Reprt Hashemite Kingdm f Jrdan, (January 2008): Ibid Ibid. 31 Ibid. 32 Wmen s Refugee Cmmissin, Reprductive Health in Jrdan: Fllw-up Reprt, (2009): 6. last accessed September 18, Issa S. Almasareweh, Adlescent Reprductive Health in Jrdan: Status, Plicies, Prgrams, and Issues, Plicy Prject (January 2003): OCHA Syria Humanitarian Bulletin Issue 21, 5 March 18 March, last accessed n September 13, UN Weekly Inter-agency Situatinal Reprt JORDAN, Syrian Refugee Respnse Update: March 10-17,

15 Almst 30% f this ppulatin, r 74,493 36, are wmen f reprductive age (WRA). Due t the disruptin in health services in Syria, many refugee wmen use refugee clinics fr verdue medical attentin. In camps set up in areas brdering Syria, the MOH, UNHCR, UNFPA, NGOs and ther agencies assist in prviding lifesaving RH care services and psychscial supprt. Relief agencies ensure that the specific needs f wmen and girls are factred int the humanitarian respnse in the regin. It is estimated that ne in five wmen f childbearing age is likely t be pregnant. 1 Cnflict typically puts these wmen and their newbrns at risk f pr health utcmes due t deterirating health services. In Syria and in neighbring cuntries, UNFPA deplyed emergency supplies and equipment t make childbirth safer and t supprt medical interventins Reprductive health cntext A literature review undertaken by the WRC prir t this evaluatin shwed that Syrian refugees wh are registered with UNHCR are able t access public health services fr free in Jrdan. 37 Hwever, due t limited infrmatin regarding the current situatin fr Syrian refugees living in Jrdan, especially with respect t their ability t access RH services, sme studies n the Iraqi refugee ppulatin living in Jrdan were examined. Fr example, Iraqi refugees were nt legally recgnized by the Jrdanian Gvernment. 38 Jrdan als did nt have a natinal strategy t prvide cmprehensive assistance frm state, religius and cmmunity-based rganizatins. 39 Humanitarian agencies that were nt already active in Jrdan faced resistance frm the Jrdanian gvernment t prvide scial and health services t the Iraqi refugees ut f fear that this wuld nly encurage Iraqis t stay in Jrdan instead f returning t their hme cuntry. 40 As a result, rganizatins that already existed, like a Cathlic-based internatinal rganizatin, were ne f the few internatinal aid rganizatins available t prvide services. 41 And while these Cathlic faith-based rganizatins prvided basic health services, they did nt prvide any supprt arund family planning r emergency cntraceptin and n maternal health services t pregnant wmen and girls wh culd nt prduce a marriage certificate. 42 A gvernment-run health clinic was als available, but due t high demand, the wait fr a visit was up t tw mnths. 43 There was a demand fr family planning amng Iraqi refugees that went unmet; One-quarter f Iraqi wmen reprted a need fr cntraceptin, citing csts and access t reprductive health services as key barriers. 44 Iraqi refugees are treated as uninsured Jrdanians when accessing health services in the public sectr and while they are able t attend public clinics, the high cst fr health services fr the uninsured makes it difficult fr refugees t cver their c-payments and medicatins. 45 A study cnducted by UNHCR, the WRC and the CDC als fund that ut f seven clinics visited in Amman, three did nt prvide family planning services. 46 Examining the experiences f Iraqi refugees prvides a cntext fr understanding sme f the challenges that Syrian refugees may currently be 36 Syrian Refugee Crisis Data. 37 Un Pnte Per. Cmprehensive Assessment n Syrian Refugees Residing in the Cmmunity in Nrthern Jrdan. (August 2012). 38 Sarah K. Chynweth, The Need fr Pririty Reprductive Health Services fr Displaced Iraqi Wmen and Girls, Reprductive Health Matters, vl. 16, n. 31, 2008: 95. last accessed September 18, Ibid.: Ibid.: Ibid.: Ibid.: Ibid.: Sctt Harding and Kathryn Libal, Iraqi refugees and the humanitarian csts f the Iraq war: What rle fr scial wrk? Internatinal Jurnal f Scial Welfare, 21, (2012): 98. last accessed September 18, Susan F. Martin and Abbie Taylr, Urban Refugees in Amman: Mainstreaming f Healthcare, Institute fr the Study f Internatinal Migratin, last accessed September 18, UNHCR, the Wmen s Refugee Cmmissin, CDC, Baseline Study: Family Planning Amng Iraqi Refugees in Amman, Jrdan, (2011). last accessed September 18,

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