Voices from the Field: A Qualitative Study of Humanitarian Practitioners’ Experiences in Delivering Sexual and Reproductive Health Services to the Rohingya in Cox’s Bazar

doi:10.21203/rs.3.rs-4986899/v1

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Voices from the Field: A Qualitative Study of Humanitarian Practitioners’ Experiences in Delivering Sexual and Reproductive Health Services to the Rohingya in Cox’s Bazar

https://doi.org/10.21203/rs.3.rs-4986899/v1

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Sexual and reproductive health (SRH) services for the Rohingya in Bangladesh’s Cox’s Bazar focus on critical interventions like maternal and newborn care, access to family planning and modern contraceptives, and community-based programming. This study explores the experiences of humanitarian practitioners in delivering SRH care during protracted humanitarian crises. This study uses qualitative research methods, including 23 semi-structured interviews with international and local humanitarian practitioners who were or are involved with the delivery of SRH care to the Rohingya in Bangladesh’s Cox’s Bazar. Although SRH services are available free of cost, religious and cultural beliefs, myths, and misinformation lead to low uptake among the Rohingya, particularly women and girls. Operational, infrastructural, and resource constraints also exacerbate the existing barriers in service delivery. Nevertheless, humanitarian and aid organizations have developed strategic interventions to continue the delivery of emergency and critical SRH services. Adopting cultural sensitivity and involving faith-based leaders in SRH-related communication has led to promising developments in Cox’s Bazar. The introduction of community-based transportation and volunteers has enhanced access to SRH services for women and girls. Capacity-building initiatives for local community health volunteers have also resulted in a greater sense of empowerment within the Rohingya community. The findings and discussion in this study reinforce the need for humanitarian practitioners to adopt community-involved and innovative strategies to increase SRH service utilization and build trust among conflict-affected populations.

Sexual and reproductive health

Rohingya

Bangladesh

humanitarian practitioner

humanitarian aid

refugee

health

health services

The United Nations Population Fund (UNFPA) leads the work of the sectoral sexual and reproductive health (SRH) working group in the Rohingya humanitarian response in Bangladesh’s Cox’s Bazar. At present, Bangladesh hosts almost one million Rohingya, half of whom are women and girls. The working group is responsible for critical and emergency interventions like family planning services, maternal and newborn care, facility-based delivery, and community training (1). Apart from efficient service delivery, the working group also identifies and resolves challenges related to quality, access, and coverage issues (1). Between 2017 and 2018, during the early phase of the crisis, UNFPA collaborated with Bangladeshi authorities, local NGOs, and international aid organizations to provide emergency reproductive services to pregnant Rohingya women and girls. The services included reproductive kits consisting of clean razor blades, antiseptics, and tapes to help prevent infection and training 100 midwives to assist with at least 60,000 deliveries in the camps (2, 3). Despite midwives being crucial in supporting Rohingya women and girls inside the camps, many facilities remain short of trained staff. As a result, UNFPA often recruits international medical professionals, including midwives, to act as mentors and support the local women who are newly trained in the profession (4). Between 2018 and 2023, there has been a steady rise in facility-based deliveries. According to the 2023 SRH working report, 70.9 percent of the total deliveries in the medical facilities were by Rohingya mothers (5). However, many Rohingya women and girls feel reluctant to visit the health post centers and instead prefer birthing in makeshift shelters due to their fear of hospitals (5). According to healthcare workers, many Rohingya men do not allow their wives and daughters to come to health posts to limit interaction with unknown men. Some also harbour negative beliefs that hospital staff pose a threat to their children (4). Home births in flimsy bamboo structures inside the camps raise concerns for the safety of both the mother and the newborn child, who remain vulnerable to infections and diseases (6).

In 2023, UNFPA and other health sector collaborators in Cox’s Bazar, together with the Bangladesh government’s Ministry of Health, rolled out a strategic plan to increase Rohingya women and girls’ access to family planning (FP) services, including modern contraceptive methods through facility-based and community interventions (7). FP services include short-term contraceptives like oral pills, condoms, and injections, as well as long-term reversible contraceptives for those who request them (8). The facility-based planning interventions ensure that the refugees can access safe, accessible, and voluntary contraception, and the community-based approach includes door-to-door visits and courtyard meetings with Rohingya families and community leaders to raise awareness and sensitize them about different contraception methods and SRH services inside the camps (9). Although the services are available free of cost, several humanitarian practitioners and aid organizations report a low uptake among the Rohingya. Some of the reasons leading to low service utility include supply and staff shortages, poor transportation and infrastructural support, and myths and misconceptions among the Rohingya (10, 11). Some Rohingya women and girls who experience sexual and gender-based violence (SGBV) often find it difficult for survivors to seek out relevant services, fearing social shaming and stigmatization.

This article builds on my doctoral research findings from semi-structured interviews with 23 key informants, including international and local humanitarian practitioners and NGO workers who either served or are currently serving the Rohingya in the refugee camps in Cox’s Bazar. I received ethics clearance from Western University’s Non-Medical Research Ethics Board (Project ID: 2022-11-10, 121056). I conducted the interviews between December 2022 and May 2023. My sample included staff members in international NGOs, including the International Organization for Migration (IOM), CARE, Médecins Sans Frontières (MSF), and some Bangladesh-based national and local NGOs. I specifically contacted organizations with a gender equality mandate in their humanitarian programming. Through a few Bangladeshi colleagues, I was already acquainted with some local humanitarian practitioners working with the Rohingya in Cox’s Bazar. I applied snowball sampling to identify, contact and invite key informants to participate in the research. I conducted the interviews in English and virtually on Zoom. Each interview lasted about sixty minutes. I followed an interview guide and audio-recorded and transcribed the interviews. I also conducted a desk review of the existing scholarly and practitioner literature, including policy briefs, media and news articles, practitioner reports, and scholarly literature, to contextualize and understand practitioners’ insights about delivering SRH services in humanitarian contexts. I used theme identification and explanation building as analytical techniques in my research to ensure the validity and reliability of information gathered through interviews. I use pseudonyms when reporting my findings to maintain anonymity and protect my research informants. I included direct quotes in this article following explicit consent from the research informants.

The findings from the interview provide a detailed understanding of the barriers that my key informants identified while working with Rohingya beneficiaries. Situating the interviews into the existing literature, I categorize the findings into the following themes (a) religious beliefs, (b) myths and misconceptions about contraceptives and SRH services, (c) shame, stigma, and fear of identity disclosure, (d) service delivery challenges and the question of voluntary choices.

(a) Religious beliefs

Religious beliefs among the Rohingya were one of the significant barriers to providing SRH service to the Rohingya. According to Donald, an international healthcare practitioner,

The biggest challenge for us was to convince them (Rohingya) that contraceptives were not in contradiction with the teachings of Islam. In fact, there are quotes in Islam that can be viewed as supportive of child spacing, and we tried incorporating that into our communication materials and awareness programs.

According to Jannat et al., the reluctance to use SRH services, particularly contraceptives, among the Rohingya stems from a fear of divine punishment (12). Not only do most Rohingya women and girls believe that “children are blessings from god,” but that “disobeying their husbands” or denying them physical pleasure is a religious sin (12 p. 860). The Rohingya as a community also prefer bigger families. Discussing the role of religion, A.N.M. Zakir Hossain explains that such preference is rooted in certain value systems (13). First, the Rohingya believe they can benefit from their children’s good deeds since they are ‘God’s gift.’ And second, the political will or desire to have “more of their people” (13, pp. 18–19). In Myanmar, the military persecuted and expelled the Rohingya, an ethnic Muslim minority, from the country on the grounds of their religion. In this context, their “high fertility behaviour” can be considered a strategic and conscious choice to preserve their “Rohingya identity” and their cultural and religious attributes in the face of persecution (13).

The religious beliefs combined with existing gender norms also contribute to unequal power dynamics in marriages. Most of the time, Rohingya women need permission from their husbands to use contraceptives or seek SRH care. Hence, either disobeying or secretly using contraceptives may often result in men subjecting their wives to intimate-partner violence (IPV) (14, p. 5). While religious beliefs act as a significant barrier to the use of contraceptives among Rohingya women, it is essential to consider the role of bodily autonomy in their decision-making. Not choosing to use contraceptives to ensure their physical safety can also mean that Rohingya women choose to exercise agency over their bodies on their terms.

Additionally, it is essential to consider the socio-economic and living conditions in the camps. As most Rohingya women and girls depend on their husbands for their survival, ensuring the stability of their marriage gets a higher priority than using contraceptives (14). Prioritizing their marital stability and physical safety indicates that Rohingya women and girls negotiate their personal autonomy and reproductive choices within strict religious doctrines and the constraints of the camp setting.

(b) Myths and misconceptions about contraceptives and SRH services

There are prevalent myths and misconceptions among the Rohingya about contraceptive use and SRH services, which are rooted in religious beliefs and cultural practices. Islam et al., in their study, observed that one of the main barriers to condom use among married Rohingya men is rooted in the belief that contraceptives are a woman’s responsibility (15). Some of the key informants also shared that “Many Rohingya men stated that they feared irreversible physical damage, including impotence, as a result of using long and short-term contraceptives.” Khan et al. and Islam et al., in their respective studies, also found that similarly, Rohingya women and girls also sometimes believe that contraceptives cause serious harm to their health, including reducing their fertility and impacting their childbearing ability (16, 17). Many women mistakenly associate rashes and infections on the abdomen or becoming “skinny” as a negative side-effect of using short-term contraceptives, none of which are medically accurate (18). Some others believe that once a woman stops taking oral contraceptive pills, she cannot start taking them again. Regarding Long-Acting Reversible Contraceptives (LARC), some Rohingya women think that the effect is irreversible, and the intrauterine device (IUD) implant cannot be removed before three to five years (ibid). Due to repatriation-related uncertainty, many Rohingya hesitate to take contraceptives, worrying that they won’t have access to SRH services when and if they return to Myanmar (18). Further, due to their status in Bangladesh, many Rohingya also believe that the Bangladesh government insists on the usage of contraceptives in the community to lead to irreversible sterilization (16, p. 204).

Mary, an international midwife and nurse practitioner, also noted, “Many pregnant Rohingya women and adolescent girls prefer home births because they have deep mistrust and fear of going to hospitals and especially outsiders. Some women think that if they deliver in the hospitals, their babies will be killed.” It is important to note that these beliefs among the Rohingya are rooted in the violent experiences in Myanmar, which are also closely associated with the lack of education. The prolonged persecution and discrimination against the Rohingya in Myanmar not only resulted in a lack of educational opportunities but also a lack of knowledge about healthcare and SRH broadly. As Junaid, a local CHW, also reiterated, “For a community that has experienced horrific SGBV and the trauma from that and the living conditions in the camps – in an extended state of precarity, it is natural that they will be suspicious of the medical services.”

There is documented evidence of the Rohingya experiencing violence and discrimination in health facilities in Myanmar (19, 20), which has had severe consequences for maternal and infant mortality and created a persistent distrust of health facilities and services. Some media reports highlight that Rohingya women often fear that medical practitioners in health facilities would either extort money from them or kill their newborn male child (21). Rumours such as babies being sold off in the hospitals and male doctors performing deliveries in the facilities instead of female birth attendants dissuade many Rohingya women and girls from delivering in health facilities (22). Some women also fear humiliation and abuse from their husbands, in-laws, and other family members in retaliation for delivering in mixed-gendered health facilities (23, p. 43).

(c) Shame, stigma, and fear of identity disclosure

Shame and stigma associated with rape and sexual violence and the fear of confidentiality breaches prevent Rohingya women and girls from accessing SRH care. Afreen, a Dhaka-based humanitarian practitioner, shared,

Rape, sexualized violence, and intimate partner violence (IPV) are very common in the camps. It is a taboo and a matter of shame for Rohingya women. Most women, even if their husband or any other man sexually abuses them, would think twice before reporting them or going to a clinic.

In May 2018, the UN published a statement indicating that almost 40,000 Rohingya women in Cox’s Bazar were pregnant, out of which several were a result of the military-perpetrated rape and sexual violence in Myanmar (24). Due to the fear of social ostracization and stigma, many women refused to admit to healthcare workers about their experience of surviving sexual violence or seek appropriate service (25, 26). Between July and December 2019, one in four Rohingya women and girls in Cox’s Bazar attending health centers for screening was a GBV survivor. Between January and October 2020, 94 percent of reported GBV cases were IPV (26). Taylor, an international humanitarian practitioner, in her testimony, highlighted the low reporting rates among Rohingya male survivors of sexual violence in Cox’s Bazar. Since the SRH services are primarily designed to meet the needs of women and girls, there is not only a lack of targeted services but also severe stigma related to male-on-male sexual violence. According to Taylor,

It is not uncommon for men and boys to experience (S)GBV within or outside the camps; however, it is not reported to the extent we hear about SGBV cases against women and girls. We don’t see men and boys targeted through SRH programming or communications. Very few male survivors also come forward because of internalized shame and the fear of being judged by healthcare professionals. There is research and evidence from global studies that show most male survivors of sexual violence do not seek adequate support or services for fear of being perceived as less masculine.

Past studies show that Rohingya men and adolescent boys were survivors of conflict-related sexual violence (CRSV) in Myanmar (27, Chynoweth, 2018). CRSV against Rohingya men and boys in Myanmar often included forced witnessing of rape of women and girls, genital mutilation, and rape (27). In 2018, the Women’s Refugee Commission published a report indicating that “of 89 percent of the Rohingya men who participated in the study, 33.07 percent personally knew another Rohingya male CRSV survivor from Myanmar” (27, p. 18). Further, the report also stated that the adolescent Rohingya males and youth, particularly those with disabilities and those working as child labourers in Cox’s Bazar, were among the groups vulnerable to SGBV (27 pp. 34–35). While there are services available for women and girls, there are few clinical rape-management services available to Rohingya men and boys in Cox’s Bazar (27).

In Cox’s Bazar, women-only spaces offer post-rape-related care, including mental health counselling and referral pathways, which makes it difficult for men to access those resources (28). Practitioners working in Cox’s Bazar have identified confidentiality breaches in accessing SRH care as a significant concern among women and girls, which inadvertently compromises the readiness to support Rohingya male survivors of SGBV (26). According to Cox’s Bazar-based SRH service providers, the complex interplay of shame, social and cultural stigma, and religious perceptions often prevent survivors from reporting cases within 72 hours, after which evidence of rape is more likely to be lost (10). The Rohingya refugee camps in Cox’s Bazar are overcrowded, offering limited privacy to service seekers. Hence, publicly accessing SRH care and services may not be favourable for Rohingya women and girls, men and boys alike, as it may result in repercussions, including social ostracism, humiliation, and stigma (29). Due to the extreme shame and the sense of feeling disempowered, many men and boys, when seeking care or support, may mask their experience with more “masculine language of torture than rape” (30). This linguistic masking makes it difficult for male sexual violence survivors to effectively seek out support, risking their trauma to be left untreated.

(d) Service delivery challenges and the question of voluntary choices

Service delivery challenges also present barriers to SRH service delivery and utilization in Cox’s Bazar. Inaccessible transportation and poor road infrastructure sometimes cause delays and damage to necessary medical equipment and materials. It also exacerbates physical discomfort among patients who travel to the clinics for emergency obstetric care (23, 31, p. 9). Barua et al. (32) observe that, in most cases, ambulances serve two health clinics/centers. During a high load of emergency cases, healthcare workers struggle to provide timely support. The ambulances also cannot drop off patients back to their homes from the health centers if another patient needs urgent transfer (32, p. 11). Since the camps are in hilly terrain with no concrete roadways, it is also difficult for the ambulances to reach patients on time. (32, p. 12).

Mary also noted that the Bangladesh government prevents humanitarian organizations from building permanent structures inside the camps, and healthcare providers sometimes work in community facilities and shelters made of bamboo. She added, “Since these bamboo shelters are not very durable, it is very difficult to ensure confidentiality in our treatment and maintain patient privacy. It was very hard for us to get a separate room that would be soundproof.” Concerns about confidentiality breaches, especially sensitive issues like pregnancy termination and post-rape care, often deter patients from seeking appropriate care. And as the evidence suggests, persistent infrastructural challenges also compromise the overall quality of care.

Mary further pointed out internal organizational challenges that affected service delivery, mainly how some staff treated the patients. She noted:

When you work in an emergency setting for a long time, you become used to seeing the same things over and over. Some staff could be abrupt, and others could be abrasive when talking to patients; it is their way of dissociating. But there is also a bit of cultural difference. Sometimes when I would hear it in the passing, I would try to intervene. My goal was to start cultural sensitivity training, but unfortunately, I had to leave early.

Discussing the barriers to providing SRH care to refugees in humanitarian settings, Tazinya et al. (33) highlighted that cultural and language differences between medical service providers and patients impacted and “interfered” with the delivery of SRH care (33, p. 3). Similarly, Sidamo et al. (34) also found that an “unsupportive environment” and “unfriendly behaviours and mistreatment” from healthcare providers presented some of the significant barriers to the uptake of SRH care among women and adolescent girls (34, p. 110). The above findings emphasize the need for cultural sensitivity among practitioners, particularly during humanitarian crises. Practitioners need to be mindful of the fact that the patients seeking care are already quite vulnerable and experience various levels of existing sociocultural hierarchies and violence. Negative behaviours reinforce the existing barriers that discourage patients from seeking care.

Mary also discussed the use of family planning methods among refugee women and the role of government policies in facilitating the delivery of those services. She shared,

It was very well known (at that time) that my organization had a difficult relationship with the Camp-in-Charge, and I suspect that it was with other organizations, too. The goals of the government versus the intent of our organization did not necessarily align, and it created different opportunities where there was a bit of moral conflict. We were asked to incentivize birth control (by the camp in charge) with food or something else because they didn’t want population increases in the camps. It had nothing to do with choice or the rights of females; it was strictly about numbers in the camp, and so was encouraging actors to incentivize giving out birth control. What we were seeing was that women were going out getting implants with one actor and then coming to us to have them removed. We did not incentivize birth control and sought informed consent from our patients.

The fact that the Bangladesh government had sought to introduce voluntary sterilization for the Rohingya to put a check on their fertility rate is documented in both international and local news sources (35, 36). According to Bangladeshi journalist Mustafizur Rahman, the government’s concern about the growing rate of population among the Rohingya is a result of the strain on its economic and environmental resources (37). Despite UN agencies acknowledging that the Rohingya crisis needs a global response, there has been a steady decline in funds in recent years, pushing Bangladesh to disproportionately bear the responsibility of almost one million Rohingya (38). Sources highlight that rapid deforestation leading to the construction of make-shift refugee camps has contributed to ecological degradation, negatively impacting the livelihoods of the host community members (39, 40). While there is no denying that incentivizing sterilization is unethical, one also has to be mindful of the mounting pressure on Bangladesh’s resources against the backdrop of rapidly declining international funding.

Despite negative assumptions that religious practices do not support FP, most religions encourage child spacing and healthy pregnancy timing (41, 42). During the interviews, several key informants indicated that situating FP messaging within religious beliefs, particularly connecting it with the teachings in the Quran, had positive impacts in dispelling misinformation and promoting contraceptive use among the Rohingya. My research informants shared that involving religious leaders to disseminate knowledge and create awareness about how FP can lead to healthier and more manageable families, given the resource scarcity in the camps, resulted in greater acceptance among Rohingya families.

In 2020, UNFPA introduced the community-based patient transportation system to provide free and safe transportation to health facilities within and outside the camps, particularly during the COVID-19 pandemic. Barua et al. found that expectant mothers regularly used the shuttle service to access health facilities. Within one month of its introduction, “512 mothers sought shuttle service for antenatal care, 19 for delivery, 13 for post-natal care, and 14 for family planning” (43, p. 4). In 2023, 10,492 patients, of which 97 percent were emergency obstetric cases, used the community transportation service (43). UNFPA also reported that the use of the community shuttle had increased by 34 percent since its introduction (44). The evidence indicates that the implementation of the shuttle service was timely to ensure that Rohingya women and girls could access critical SRH services.

Since international healthcare providers working with international donors and organizations are deployed in the field for a limited period, their focus may only be on responding to crises within the available time (45). The transient nature of the deployments emphasizes the need for effective cultural and language training to maintain proper communication. Therefore, it is critical that humanitarian practitioners dedicate resources to training and appointing local healthcare workers who understand the cultural context and can continue the delivery of SRH care for an extended period. Additionally, the involvement of community volunteers in promoting SRH services also helps foster a sense of ownership and empowerment in the communities they serve (46). This, in turn, leads to greater acceptance and uptake of services, allowing vulnerable populations to trust initiatives led by their community members, ultimately leading to equity and overall better health outcomes for women and girls. Chowdhury et al. found that during the COVID-19 pandemic, due to severe service disruption, Rohingya volunteers became so crucial in conducting door-to-door visits that many organizations increased their numbers (39, p. 7). Since volunteering and cash-for-work programmes are the primary sources of income generation inside the camps, integrating the Rohingya in the SRH service delivery not only helped mitigate the related challenges but also provided them with a vital source of income generation and economic empowerment (47). Therefore, the evidence reiterates the need for community-driven sustainable practices in humanitarian emergencies.

The SRH working group mandates that practitioners and healthcare providers must maintain a respectful and free environment while delivering FP services, ensuring that patients can make informed choices about utilizing those services (8). A human-centric approach where healthcare providers prioritize the confidentiality and dignity of patients, particularly sexual violence survivors, can increase the uptake of services. This also includes capacity-building of healthcare providers. The SRH working group’s strategy related to FP also includes improving the knowledge and skills of healthcare providers, including midwives, to maintain and uphold the quality of care and to meet the needs of the patients, particularly women and girls (9, p. 15).

Martin and De la Puente note that during humanitarian emergencies, the pressure to continue “business as normal” is due to the expectation and “pressure to respond” (48, p. 632). This urgency to respond leads to poor prioritization of women’s issues and often leads to it being “overlooked” (52). In humanitarian settings, particularly concerning refugee populations, the government in host countries often considers “fertility” an issue that needs to be scrutinized and “managed” (49). Family planning methods, therefore, become a tool for host governments to manage overpopulation (45, p. 28). This leads to an underlying assumption among healthcare providers to prescribe long-term contraception or pregnancy termination. This assumption is based on the belief that crises-affected people should not or “might not desire to have (more) children” (46).

There is no denying the fact that incentivizing birth control takes away the informed and voluntary reproductive choices of Rohingya women and girls. On the flip side, it also becomes apparent that the assumption that “crisis-affected people” cannot make choices is simplistic and problematic. In the context of the precarious camp living conditions, the fact that Rohingya women would get implants at the facilities that incentivized them and remove them in other facilities that sought informed consent regarding implants shows that they can make practical decisions regarding their reproductive health owing to their social circumstances. Instead of reducing refugee women to their victimhood, humanitarian practitioners need to consider how these women are motivated to exercise their agency and negotiate their bodily autonomy despite their highly constrained circumstances and work with them to find solutions that honour their choices and preferences.

Although there have been promising developments related to SRH health outcomes, serious access barriers persist regarding the service uptake among the Rohingya. According to health experts working with MSF even though some women are willing to travel to health facilities and avail of services, they must seek their husbands’ permission (50). Many medical practitioners observe that since women’s access to medical services relies on men’s approval in Rohingya households, they usually do not get timely care and intervention due to the delay or denial of permission from their husbands (50). Further, the lack of awareness about the available services, combined with low decision-making powers in households and misinformation about healthcare practices together, lead to barriers significantly impacting Rohingya women and girls (51).

Globally, practitioners suggest that integrating a gender-transformative approach to SRH, mainly by making services accessible to women and men, can lead to positive health outcomes (52). Considering men as clients, partners, and active agents of change in SRH programming in emergency contexts can help challenge traditional views and attitudes toward masculinity, increase men’s active participation in supporting and sharing their partner’s reproductive needs, improve men’s access to SRH services, and help prevent GBV (53). According to UNFPA, assessing service gaps is crucial to delivering SRH services to men and boys. Although there has been considerable research on Rohingya women’s SRH needs, uptake, and barrier issues, little is known about how Rohingya men access SRH services in Cox’s Bazar. The SRH WG bulletin (1) mentions training local male healthcare providers; it does not focus on mapping SRH needs and service utilization among Rohingya men. There have been promising recent developments as more Rohingya women and girls are choosing facility-based deliveries and SRH services. In 2023, UNFPA recorded 10,600 facility-based safe births in the refugee camps, representing an 85 percent increase in the uptake of services among the Rohingya population since 2018 (54).

To ensure the delivery of quality SRH care, humanitarian practitioners must focus on providing women with care from trained and qualified professionals such as doctors and midwives, not necessarily relying solely on facility-based delivery. Sometimes, from a logistical and financial perspective, it also makes better sense to send midwives and other trained community health workers out to communities rather than to make women travel to health facilities. Historical experiences of abuse and harm in health facilities further reinstate the pervasive fears and mistrust of medical professionals preventing the Rohingya from accessing essential care. The persecution-related trauma, socio-economic precarity, and unsafe conditions in the camps necessitate that humanitarian and medical practitioners continue to adopt a culturally sensitive and human-centred approach to dispelling misconceptions and ensuring that the Rohingya can continue to access comprehensive SRH care.

As much as one should appreciate the continuous efforts of the SRH working group and its partners to deliver effective services to women and girls, it is also crucial to continue to work towards trust-building and raising awareness about service utilization among Rohingya men and boys. It is also essential that services and supports reach men and boys who have experienced (S)GBV. Not only are men and boys sometimes survivors of SGBV, but the gendered assumptions about men’s invulnerability to sexual violence make it even more difficult for them to report their experiences and for practitioners to respond to their needs appropriately. Even an awareness among international and local humanitarian practitioners and aid workers that men and boys are also vulnerable to sexual violence is an important starting point for developing appropriate responses to prevent and address it.

FP Family Planning

GBV Gender-Based Violence

IPV Intimate Partner Violence

LARC Long-Acting Reversible Contraceptives

MSF Medicines Sans Frontiers

SGBV Sexual and gender-based violence

SRH Sexual and Reproductive Health

UNFPA United Nations Population Fund

Ethics approval and consent to participate

Western University’s Non-Medical Research Ethics Board approved this study on 10 November 2022. Per the ethics protocol letters of information and consent were shared with the key informants before the interviews.

Consent for publication

No identifiable data was used.

Competing interests

The author declares no competing interest

Funding

The author did not receive any funding to conduct this study

Authors' contributions

Deeplina Banerjee developed the study protocol, questionnaire, and methods, conducted the interviews, and analyzed the data.

Acknowledgements

The author would like to acknowledge and appreciate the valuable insights shared by key research informants for this study.

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Voices from the Field: A Qualitative Study of Humanitarian Practitioners’ Experiences in Delivering Sexual and Reproductive Health Services to the Rohingya in Cox’s Bazar

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Version 1

Abstract

Introduction

Methods

Results

(a) Religious beliefs

(b) Myths and misconceptions about contraceptives and SRH services

(c) Shame, stigma, and fear of identity disclosure

(d) Service delivery challenges and the question of voluntary choices

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1