Dalarna University's logo and link to the university's website

Background: Inadequate access to Sexual and Reproductive Health (SRH) Care contributes to maternal morbidity and mortality in low resource settings and especially in humanitarian settings such as Cox Bazar in Bangladesh. More than 1.3 million Rohingya refugees are affected an estimated 316,000 women of reproductive age sheltering in Cox-Bazar after they have escaped from Myanmar. They live in spontaneous overcrowded settlements, the humanitarian needs are considerable and women are at high risk of gender-based violence. Around 64.000 women are pregnant and 2500 experience complications and their access to SRH care is limited. There is a lack of data on the quality of care women receive during early and late pregnancy in humanitarian settings and there is a need to provide scientific evidence to evaluate the effectiveness of SRH interventions delivered in humanitarian crises.

Aim: The aim of this study will explore midwives experiences of providing Comprehensive Sexual and Reproductive Health Care in Humanitarian Settings (Cox-Bazar). More specifically to illuminate the barriers and facilitating factors for women‟s access to safe abortion and family planning in humanitarian crisis

Methods: An inductive qualitative design was chosen. Data were collected through In-depth interview based on a topic guide and analyses by inductive content analysis. A pre-defined topic guideline was constructed for the IDI allowing the midwives to share their experiences and probe in to issues of significance for the research questions. The interviews were performed on a place and time chosen by the interviewee. Informants are midwives (n= 15) engaged in providing sexual and reproductive health care in Cox Bazar, Bangladesh and were recruited based on the inclusion criteria‟s: three years Diploma in Midwifery completed registered with the Bangladesh Nursing and Midwifery Council and have a at least 2 month working experience in health facilities in Rohingya influx areas at Cox‟s Bazar. The recorded IDIs have been transcribed along with the notes taken during the interviews. The transcripts will be analyzed using inductive Content Analysis where emerging codes will be discussed and re-evaluated to reach consensus and codes divided into categories and furthermore the identification of a theme. 3

Results: The study findings illuminated the midwives experience to provide care in the humanitarian setting in Cox,s Bazar. Inadequate supplies, space, un-availability of medical doctors in humanitarian context, and inadequate pre-service education and training of informants were identified as structural barriers to provide quality care of comprehensive SRH care. Harmful cultural beliefs, social norms & values about modern contraceptives manipulate the women to choose and use family planning methods and receive care during early and late pregnancy were expressed by the respondent as a cultural barriers to provide quality care. Counseling on sexual and reproductive health issues by the health care providers were identified as a motivating factors of the women for seeking health care were the expressed as an opportunities for improvements in the existing health care system in humanitarian setting were highlighted in this study.

Conclusion: Comprehensive Sexual and reproductive health is a significant public health need in all communities, including those facing emergencies. It highlights the fact that midwives and paramedics were recognize their fundamental role in detecting cultural norms and ideological opposition to family planning, abortion and other sexual and reproductive health matters often impede access to services, stigma associated with sex, unintended pregnancy, abortion, and concerns about privacy, may inhibit many from using services.

Clinical application: Study finding will help the policy maker, to identify the professional gaps and equip them to meet the challenge of health care delivery system in humanitarian context. In addition, evaluate the readiness of health care providers to provide comprehensive sexual and reproductive health and rights. Policy expert will be benefited to finally, the finding will explore the areas need to be conduct research in future.