title: Progress and gaps in reproductive health services in three humanitarian settings: mixed-methods case studies.
abstract: BACKGROUND
  Reproductive health (RH) care is an essential component of humanitarian response. Women and girls living in humanitarian settings often face high maternal mortality and are vulnerable to unwanted pregnancy, unsafe abortion, and sexual violence. This study explored the availability and quality of, and access barriers to RH services in three humanitarian settings in Burkina Faso, Democratic Republic of the Congo (DRC), and South Sudan.
  
  
  METHODS
  Data collection was conducted between July and October 2013. In total, 63 purposively selected health facilities were assessed: 28 in Burkina Faso, 25 in DRC, and nine in South Sudan, and 42 providers completed a questionnaire to assess RH knowledge and attitudes. Thirty-four focus group discussions were conducted with 29 members of the host communities and 273 displaced married and unmarried women and men to understand access barriers.
  
  
  RESULTS
  All facilities reported providing some RH services in the prior three months. Five health facilities in Burkina Faso, six in DRC, and none in South Sudan met the criteria as a family planning service delivery point. Two health facilities in Burkina Faso, one in DRC, and two in South Sudan met the criteria as an emergency obstetric and newborn care service delivery point. Across settings, three facilities in DRC adequately provided selected elements of clinical management of rape. Safe abortion was unavailable. Many providers lacked essential knowledge and skills. Focus groups revealed limited knowledge of available RH services and socio-cultural barriers to accessing them, although participants reported a remarkable increase in use of facility-based delivery services.
  
  
  CONCLUSIONS
  Although RH services are being provided, the availability of good quality RH services was inconsistent across settings. Commodity management and security must be prioritized to ensure consistent availability of essential supplies. It is critical to improve the attitudes, managerial and technical capacity of providers to ensure that RH services are delivered respectfully and efficiently. In addition to ensuring systematic implementation of good quality RH services, humanitarian health actors should meaningfully engage crisis-affected communities in RH programming to increase understanding and use of this life-saving care.
authors: Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, New York, NY 10032 USA.
authors: Sara E
authors: SE
authors: Casey
authors: University of New South Wales, High St, Kensington NSW 2052, Australia.
authors: Sarah K
authors: SK
authors: Chynoweth
authors: United Nations High Commissioner for Refugees, Rue de Montbrillant 94, 1201 Geneva, Switzerland.
authors: Nadine
authors: N
authors: Cornier
authors: Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, New York, NY 10032 USA.
authors: Meghan C
authors: MC
authors: Gallagher
authors: Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, New York, NY 10032 USA.
authors: Erin E
authors: EE
authors: Wheeler
keywords: Burkina Faso; Democratic Republic of the Congo; Reproductive health; South Sudan; humanitarian; refugees