War and Gender Inequalities in Health: The Impact of Armed Conflict on Fertility and Maternal Mortality

This article directly assesses one of the most likely explanations, namely that war negatively affects reproductive health, and finds armed conflicts are associated with higher overall fertility in low-income countries only and maternal mortality rates are elevated, albeit moderately, in conflict countries.

Abstract

Background\nArmed conflict has been described as creating a public health problem and an important contributor to the social and political determinants of health and a driver of poverty and health inequity. Of the armed conflicts that have taken place since World War II, about 90% have been in developing countries, with Sub Saharan African (SSA) countries experiencing more conflicts than any other region of the world. The impact of these conflicts on health systems often extends beyond the period of active warfare, working its way through specific diseases and conditions, thus indirectly affecting the health of women and children severely. Health systems in conflict and post-conflict countries are therefore faced with huge challenges. One major challenge has been the neglect of MRH resulting in increased maternal mortality; lack of information about and limited access to family planning services; and increased incidence of sexual violence, rape, complications of abortion, sexually transmitted infections, and unwanted pregnancies among others.\nAim of the study\nThe aim of this study is to assess the impact of armed conflict on maternal and reproductive health (MRH) in sub-Saharan Africa. Specifically, the study seeks to assess the impact of armed conflict on maternal mortality and fertility levels, and stakeholders’ perceptions of the effects of armed conflict on MRH services and outcomes. Additionally, the study seeks to explore the determinants of women’s utilisation of MRH services as well as the barriers to the effective delivery of emergency obstetric and neonatal care (EmONC) services in post-conflict Burundi and Northern Uganda.\nMethods\nThis study is multidisciplinary in nature and uses a multi-method strategy, utilising both qualitative and quantitative research techniques. Quantitatively, a cross-national time-series regression analysis using armed conflict, total fertility, and maternal mortality datasets from the Uppsala Conflict Data Program (UCDP), the United Nations Population Division, and World health Organization respectively was undertaken to determine the relationship between armed conflict intensity (independent variable) and maternal mortality ratio and total fertility rate (dependent variables). The qualitative data includes 63 semi-structured in-depth interviews and eight focus group discussions among 115 key stakeholders involved in the provision and utilization of MRH services to qualitatively explore the perceived effects of armed conflicts on MRH and the current state of MRH in Burundi and Northern Uganda vis-à-vis the past armed conflicts.\nResults\nUsing two global cross-national time-series studies covering 1970–2005 (fertility rates) and 1990 – 2005 (maternal mortality rates) along with the UCDP/PRIO armed conflict dataset, the following findings were observed: Armed conflict does not affect overall total fertility rates, whether it takes place in the country in question or in a neighbouring country. However, in low income countries, armed conflict intensity is positively associated with the total fertility rate (TFR), where increase in battlerelated deaths is associated with increase in TFR. Armed conflict is moderately associated with increased maternal mortality rates; an armed conflict of median intensity (2,500 battle-related deaths) is associated with a 10% increase in the maternal mortality rate. Finally, armed conflict in a neighbouring country is associated with a lower maternal mortality rate.\nThe findings from the qualitative study revealed the following: With respect to the perceived effects of armed conflict on MRH, the main themes that emerged from the study were: armed conflict as a cause of limited access to and poor quality of MRH services; armed conflict as a cause of poor MRH outcomes; and armed conflict as a route to improved access to health care. The main mechanisms through which armed conflict led to limited access to and poor quality of MRH services varied across the sites and included: attacks on health facilities and looting of medical supplies across the sites; targeted killing of health personnel and favouritism in the provision of healthcare in Burundi; and abduction of health providers in Northern Uganda. Overall, there was disruption of infrastructural development and the training of health personnel, and poor retention of health personnel. The perceived effects of the conflict on MRH outcomes included: increased maternal and newborn morbidity and mortality; high prevalence of HIV/AIDS and SGBV; increased levels of prostitution, teenage pregnancy and clandestine abortion; and high fertility levels. Relocation to government recognized IDP camps improved access to health services for many women.\nFurthermore, regarding the determinants of women’s utilization of MRH services, a complex and interrelated set of factors cutting across the individual, socio-cultural, and political and health system spheres were observed. The main determinants include women’s fear of developing pregnancy-related complications, status of women empowerment and support at the household and community levels, removal of user-fees, proximity to the health facility, and attitude of health providers. Additionally, exposure to armed conflict affects women’s utilisation of these services mainly through impeding women’s health seeking behaviour and community perception of health services.\nFinally, with respect to the barriers in the delivery of EmONC services, the barriers in the delivery of quality EmONC services were categorised into two major themes; human resources-related challenges, and systemic and institutional failures. While some of the barriers were similar, others were unique to specific sites. The common barriers included shortage of qualified staff; lack of essential installations, supplies and medications; increasing workload, burn-out and high turnover; and poor data collection and monitoring systems. Barriers unique to Northern Uganda were demoralised personnel and lack of recognition; poor referral system; inefficient drug supply system; staff absenteeism in rural areas; and poor coordination among key personnel. In Burundi, weak curriculum; poor harmonisation and coordination of training; and inefficient allocation of resources were the unique challenges. To improve the situation across the sites, efforts are ongoing to improve the training and recruitment of more staff; harmonise and strengthen the curriculum and training; increase the number of EmONC facilities; and improve staff supervision, monitoring and support.\nConclusions\nThe study illustrates that armed conflicts have a substantial negative impact on MRH, including health services and health outcomes that linger well into the post-conflict phase. Additionally, in post-conflict settings women’s utilization of MRH services is affected by a complex set of factors cutting across the socio-cultural and political and health system domains. Finally, the delivery of EmONC services postconflict health systems is hampered by a series of human resources-related challenges, and systemic and institutional failures. Therefore, MRH in conflict and post-conflict countries requires more global attention. The needs and challenges vary from one setting to another and will require context-specific interventions to effectively address them.