Climate change is one of the most prominent topics of discussion in recent times, with increasing recognition of its particular effects on women. For those engaged in post-disaster reconstruction, attention to reproductive health should be a primary concern. The Asia-Pacific region is indisputably one of the most vulnerable areas to climate-change induced disasters, as evidenced in recent time in Myanmar, China and Tsunami-affected countries. For pregnant women in this area, any environmental disaster severely limits safe delivery options, which in turn exacerbates pre-existing vulnerabilities to maternal death and disability. Access to contraceptives and other family planning is often interrupted or stopped altogether, which may lead to increased numbers of unsafe abortion as a result of unplanned pregnancies.

This is not a new idea. As early as June 1995, an Inter-Agency Symposium on Reproductive Health in Refugee Situations, held in Geneva, UN agencies, governments and NGOs recognized the reproductive health impacts of environmental devastation. A Minimal Initial Services Package (MISP) for Reproductive Health was developed to provide a set of priority reproductive health activities and services necessary to address maternal and newborn mortality and morbidity, the spread of HIV, prevention and response to sexual violence and planning for comprehensive reproductive health in crisis situations. The MISP calls on all stakeholders involved to prioritize reproductive health needs in the very early phases of disaster management.

Yet, more than 10 years later, neither the MISP or comprehensive reproductive health in emergency settings, are the norm. Marie Stopes International (MSI), together with the Columbia University's Heilbrunn Department of Population and Family Health in the Mailman School of Public Health, developed the RAISE Initiative (Reproductive Health Access, Information and Services in Emergencies) specifically to boost the profile of reproductive health in emergency responses, improve the implementation of the MISP on the ground and increase funding and policies for agencies providing health services.  Maaike van Min, Advocacy Manager from MSI/RAISE, believes that there are a number of factors at play that are hindering the implementation of MISP in the field. "Reproductive health is not seen as a life-saving intervention," she says.
"We also face practical challenges in getting MISP packages to the field level, like dealing with customs clearance and having to worry about storage and expiration of drugs."

The Women's Commission for Refugee Women and Children also started working to promote the MISP almost five years ago when its field assessments revealed the lack of implementation at the onset of a crisis. Sandra Krause, Reproductive Health Program Director at the Women's Commission, agrees that "things are not where they should be," with reproductive health often shadowed by infectious disease control. The bottom line for Krause is "being prepared, making sure people have done emergency preparedness training in their country, that they're skilled and ready." 

Cyclone Nargis, which hit Myanmar on May 2 and 3, 2008, and officially killed 84,537, with 53,836 people counted as missing, offers an example of why the need for readiness. Unfortunately, training the trainers on the MISP in Malaysia, with attendees from across the Asia-Pacific, ended the very day Nargis hit Myanmar, with no time for in-country roll-out of the training. If anything, this reflects the importance of advanced preparedness for disaster management.

The need to prioritize reproductive health after Nargis was obvious. The United Nations Population Fund (UNFPA) reported that in the Ayeyarwady Delta, where women traditionally give birth at home with the assistance of midwives, the destruction of homes, roads and means of transport severely heightened the risks of child birth, due to the inability to reach a health facility during an obstetric emergency and with at least 10 midwives having perished during the cyclone. Given that an estimated 20 percent of women of reproductive age in a refugee population will be pregnant at any one time, the effect of this devastation should not be underestimated. From June 2008 onwards, a joint initiative between UNFPA and the Myanmar Medical Association (MMA) began sending teams of doctors to hard hit areas, with many women seeking pre- or post-natal exams and contraceptives at mobile clinics. 

Similar stories concerning interrupted access to reproductive health services emerged in post-Tsunami Indonesia. The 2004 Tsunami, which followed the largest recorded earthquake in history, had profound impacts on Indonesian islands such as Aceh and Nias. According to Oxfam International, in the four villages in the Aceh Besar district surveyed for their report, women comprised three to four times the number of men who died as a result of the Tsunami. This shocking imbalance is partially explained by the tendency for women to stay behind and look for children and other relatives and the relatively lower ability of women to swim or climb a tree to survive when compared with men. In Aceh alone, UNFPA reported the death of 10 per cent of the 5,500 midwives, highlighting an immediate need in terms of safe delivery.

An evaluation by the Women's Commission for Refugee Women and Children of the reproductive health service provision in Aceh following the Tsunami states that condoms were not visibly made available in health centers, which is a key activity of the MISP, due to the assumption that they would not be tolerated by  Islamic culture. The report also states that some midwives reported that emergency contraception (EC) would not be provided to rape survivors due to the religious restrictions of Islam. Rather than being a religious issue, Krause puts this down to a lack of understanding that exists elsewhere around the globe, that EC is not an abortifacient. Other issues are the stigma around rape and general sexual taboos. "In Thailand they distributed EC quite readily and this created a belief that adolescents were abusing them. People began believing that it promoted promiscuousness," Krause explained.  

In addition to immediate needs, there are also long-term impacts of environmental disasters that fall on the shoulders of women. With the heightened numbers of internally displaced persons (IDPs) and refugees, women are more vulnerable to becoming victims of domestic and sexual violence. The household workload increases substantially after a disaster, which forces many girls to drop out of school to help with daily tasks. Oxfam International notes that surviving women may also be encouraged to have more children, with shorter intervals between them, to replace those lost by the community, impacting women's reproductive health, their right of choice in family planning and their ability to earn an independent income.  

Clearly, environmental disaster management raises many complicated issues that are beyond the scope of this discussion. The head of Doctors Without Borders has recently commented that the influx of donor money for Nargis victims has left many others in need without help. Van Min of MSI believes that "it is often the case what when a natural disaster strikes, media and donor attention is focused on the most affected areas, when there are other areas also in dire need." This situation highlights the importance of taking the approach of groups like MSI in ensuring that country-based programs are not fully donor dependent to ensure they are sustainable "if and when donor funding dries up." In addition, Krause highlights the longer-term benefits of ensuring comprehensive reproductive health care in post-conflict reconstruction: "A reproductive health response has the capacity to make longer-term improvements. It is a chance to ignite long-term investment and change in a country." 

Indeed, the two-way relationship between reproductive health and women's empowerment is undeniable. Women's equity is needed to achieve reproductive health, whilst improved reproductive health affirms women's equality in the long-term. A gendered approach to disaster management, including ensuring women's participation in the recovery-phase, will unquestionably catalyze lasting reproductive choice, gender equity and women's empowerment.