Conflicts and their aftermath can have dire consequences for reproductive health (RH). First, the preponderance of political emergencies occurs in the world's poorest nations, where the population's pre-conflict health is often already suboptimal . Second, such crises bring sharply decreased access to services in a context of intensified threats. As health systems collapse and people flee in search of safety, access to health facilities that can offer safe delivery, provide emergency caesarean sections, or treat other complications of pregnancy and childbirth becomes limited or eliminated entirely. In many-even most-cases, women may be unable to obtain family planning methods during a time when few would choose to become pregnant if they had another option . Safe abortion is often impossible to obtain even in peacetime, and during crises, women who have complications of unsafe abortions have no access to treatment . Furthermore, women and girls may be raped or subject to other violence-as a strategy of war, due to the accompanying breakdown of order, or both-causing emotional and physical trauma and rendering them vulnerable to unwanted pregnancy and STIs, including HIV .
Despite these challenges, the provision of RH services to populations affected by armed conflict was long overlooked in traditional humanitarian response to complex emergencies . Starting in the mid-1990s, however, the international community began to acknowledge the systematic absence of reproductive health services for these populations [3, 4]. A 1994 report by the Women's Refugee Commission first documented this pervasive lack of attention to RH for refugees and internally displaced persons (IDPs), and its implications . Although various human rights documents protect the right of all people to comprehensive reproductive health care , the 1994 International Conference on Population and Development (ICPD) and the Fourth World Conference on Women formally and specifically recognized this right of refugees and IDPs [6, 7]. At ICPD, key agencies, including the United Nations Population Fund (UNFPA), the United Nations High Commissioner for Refugees (UNHCR), and the World Health Organization (WHO), committed to addressing this issue .
Subsequently, non-governmental organizations and national and local government authorities also began to acknowledge this need and examine ways to address it [1, 8]. The Inter-agency Working Group on Reproductive Health in Crisis Situations (IAWG), comprised of UN agencies, humanitarian organizations, academic institutions and donors, was formed in 1995 . In 1999, IAWG released the widely-used Reproductive Health in Refugee Situations: An Inter-agency Field Manual, a practical, concise guide to reproductive health programming for humanitarian workers, including health and other workers not expert in the topic.
After a decade and a half of sustained attention to the topic, much progress has been made in the field of RH in crisis settings in terms of policy, guidance and practice. For example, the Minimum Initial Services Package (MISP), a programmatic piece of the Field Manual that offers guidance on a suite of reproductive health services to be implemented during the earliest stages of an emergency, has been adopted into the Sphere Humanitarian Charter and Minimum Standards in Disaster Response. IAWG recently released a 2010 update to its 1999 field manual, now titled Inter-agency Field Manual on Reproductive Health in Humanitarian Settings. A number of other guides have been developed that directly relate to the various RH services for conflict-affected populations, or that can be adapted for use in such a context: Field-Friendly Guide to Integrate Emergency Obstetric Care in Humanitarian Programs; Family Planning: A Global Handbook for Providers; HIV Prevention and Control: A Short Course for Humanitarian Workers; and Clinical Care for Sexual Assault Survivors[10–13]. In addition, stakeholders at many levels have had the opportunity to share field results and experiences at three conferences specific to RH in conflict and at annual IAWG meetings [14–17].
Furthermore, inroads have been made toward integrating RH into humanitarian response: for example, funds for reproductive health were included during the initial humanitarian response to the earthquake in Haiti in January 2010 .
Yet despite these important successes most conflict-affected women still do not have adequate access to RH services, and family planning services are often particularly neglected. A 2004 global evaluation of 10 years of attention to the reproductive health of populations affected by crisis concluded that most people affected by conflict still lack adequate RH care; refugees, camp populations and those living in stable settings had better access to care than did internally displaced people, non-camp populations and those in insecure areas, however. Regarding family planning, the evaluation found that where available at all, methods offered were frequently limited to oral contraceptives and condoms. Long-term and permanent methods were rarely offered, and for all methods, supplies were not reliable .
Program reports at conferences and meetings illustrate that gaps in services persist even now [14–16], but filling these service gaps presents a range of challenges. First, improving reproductive health services in conflict-affected countries presents all of the same difficulties faced by peaceful developing nations, plus a host of additional issues specific to conflict and post-conflict settings . In general in conflict-affected areas, health systems have collapsed; communities are compromised; human resources are scarce and little attention is given to training for health workers who remain; health policy and management structures are in disarray; and logistical problems such as insecurity and damaged or nonexistent infrastructure circumscribe the movement of supplies, staff, and people in need of care [21, 22].
Second, the long-term nature of conflict and its aftermath fits neatly into neither the mission of humanitarian groups nor development groups, meaning that neither sector is fully prepared to meet the reproductive health needs of refugees and internally displaced people. Humanitarian agencies are often structured to address the immediate needs of populations undergoing acute, short-term crises. Yet, emergencies-particularly political conflicts-are often far longer and more complex than this structure recognizes, and people may remain displaced for years, even decades. Even under UNHCR's relatively narrow definition of 'long-term displacement,' (25,000 people in exile for 5 years or more), 5.5 million people were in protracted refugee situations in 2009 . Furthermore, protracted displacement situations are increasing in duration: in 1993, the average length of time a refugee lived in exile was 9 years; in 2003 it was 17 years . Those affected by conflict may therefore live out a large portion of their lives in a context of displacement. This has significant implications for the needs of these populations and the nature of programs intended to meet these needs. Development agencies, on the other hand, work from a durable, systems-oriented perspective suited to the delivery of routine services over time to populations that include those experiencing protracted displacement, but such agencies may be ill-prepared to manage the challenges specific to working in insecure regions.
The RAISE Initiative and its partners work with populations and in regions identified by the 2004 global evaluation as especially under-served. In Africa, RAISE and its partners work in South Darfur (ARC), North Darfur (IRC), West Darfur (Save the Children-US), Southern Sudan (ARC), northern Uganda (MSU) and the Democratic Republic of Congo (CARE). The majority of residents served by these programs do not live in camps; at virtually all sites, insecurity has periodically affected delivery of services. This article describes the results of baseline studies of and the services at RAISE program sites in three countries. The studies' purposes were to guide program activities and to serve as a baseline against which program accomplishments could be measured. A further purpose of the studies, and a purpose of this article, is to document and disseminate data on family planning knowledge, attitudes and practices among population groups-conflict-affected, displaced women in this case-for whom such information is rarely available.