Marwa (a pseudonym) lifts her trousers to show me the varicose veins and bruises that cover her calves. The 34 year-old Syrian woman says these became worse from daily trekking over rocky, uneven ground at a refugee camp outside Athens where she lived for five months.
When we met in June, Marwa had moved to a private house, was nine months pregnant, and struggling to walk. The baby she was expecting would be her sixth. The pregnancy, she explained, was unexpected — and undesired.
Globally, millions of refugee women must grapple with issues of reproductive control outside their home environments. Despite clear needs, access to contraception has remained a relatively low-ranking priority among governments and NGOs in refugee response.
United Nations estimates suggest that half a million displaced Syrian women, like Marwa, will become pregnant this year. Originally from Homs, she and her family fled Syria last year after her husband was injured by a barrel-bomb.
Upon arriving in Greece — which is struggling to accommodate 60,000 refugees amid ongoing economic crisis — the couple and their five young children tried to cross into Macedonia, just as the border was being sealed with the controversial EU-Turkey agreement.
Marwa told me that her two older children (then aged 8 and 10) slipped across the border in the chaos before it closed. She has not seen the pair since — though has been in regular contact with them since they reached a home for unaccompanied minors in Germany.
The rest of the family lived in a refugee camp in northern Greece until it closed and they were moved to a camp outside Athens late last year. Exhausted, Marwa says she fainted and vomited on this journey.
Several weeks later, she realised that she was pregnant. “Our situation was so bad…I thought ‘I cannot do this’,” Marwa told me. But her husband “was very anxious because we feared God, so we decided to have the baby”.
When we met, Marwa was also anxious for the birth as it was preventing her onward journey “to Germany, to be reunited with our children”. It was, she said, simply “too dangerous” to travel in her condition.
Reproductive Rights on the Move
Marwa’s story reflects practical, cultural and social factors that can limit refugee women’s control over their bodies.
Outside of localised academic and NGO studies, there is little data on these issues. But existing research echoes what aid and healthcare workers say they’re seeing on the ground: low and sometimes decreasing rates of contraceptive use amid movement and uncertainty.
In Greece, Lia Motska, manager of sexual and reproductive health at the NGO Medicins Sans Frontieres (MSF), told me that common forms of contraception available in the country are not suitable for refugee women.
Many of women seen by MSF, Motska explains, have used injectable contraceptives and implants which she describes as “for people on the move…some of the best options”. But, she says: “these methods are just not available in Greece. This is the main problem”.
Greek women primarily use condoms, pills and intrauterine devices (IUD). But Motska explains that religious norms and everyday chauvinism can make condoms an unrealistic option and pills can be impracticable for women whose routines and environments are in a continual state of flux.
MSF does promote and administer IUDs, but these require a medical procedure to be inserted. As a perhaps less familiar form of contraception, some women may also have reservations about using them.
Injectable contraceptives have become a mainstay for women across the developing world. They are, for example, the leading form of contraception for women in Afghanistan, Eritrea and Somalia. But their import and sale is illegal in Greece.
MSF is the largest provider of sexual and reproductive health services to refugees in the country, and has tried — unsuccessfully — to lobby the Ministry of Health to change this.
“We now have a big community of refugee and migrant women who need these,” said Motska, “but we have to tell them in consultations that we can provide limited methods…and often they say no, they do not want them”.
She shared the story of one young Afghan woman who requested a follow-up dose of an injectable contraceptive and, when told this was unavailable, refused alternatives. Three months later, she returned looking to terminate an unwanted pregnancy.
In Athens, some volunteer healthcare providers and midwives working in squats that house and support refugees have illegally imported injectables and independently administered them to women who request follow-up doses.
For some of the hundreds of refugee women who live in these squats, this might provide a short-term solution. For others, this practice merely reflects the challenges they face in exercising reproductive control.
Regardless of the method, Motska adds, refugee women often do not tell their partners that they are using contraception and there must be strict confidentiality in the provision of these services — as well as in abortion care.
Abortion is legal in Greece though it can still be an intimidating and logistically-fraught prospect. “Imagine being a woman living in a camp far outside Athens and the only person who you can move around with is your husband,” says Motska. “She is afraid because her husband doesn’t know, unsure about the decision, and often also has parents looking over her shoulder”.
Such constraints mean that some women undergo unsafe abortions in the camps, she adds. “We have had cases where women came to us bleeding and we know it is because they tried it the unsafe way…They don’t dare to say it, but we know it is happening”.
“A Constant Risk of Sexual Violence”
Rape and sexual violence — committed by people smugglers, authorities or other migrants — is not uncommon on journeys to Europe. Studies of specific migration routes, for example through Libya, suggest that some women take contraceptives before travelling specifically with this risk in mind.
The director of the Eritrean Initiative on Refugee Rights, Meron Estinfanos, told me that women setting out from Eritrea can expect to be raped at least twice before reaching Europe. “Women are now taking potent contraceptives before they leave to avoid the added risk of pregnancy,” she said, warning that this can also leave them “with long-term damage and reproductive problems”.
In Greece, a study of nine refugee camps found that insecure conditions left many women at constant risk of sexual and gender-based violence, including rape, forced prostitution, forced marriage and trafficking. Perpetrators, it said, have included volunteers and fellow refugees.
At MSF, Motska says “pregnancy from sexual violence is a big risk, especially crossing borders”.
There have been vocal demands at the international level — including from UN Women — for more to be done to increase access to safe contraception and sexual healthcare for refugee and migrant women. Yet such efforts remain under-resourced.
The UN’s refugee agency has itself noted that reproductive health is “crucial for the mental and social well-being of any individual”. But areas affected by conflict still receive 50% less funding for such services, compared to non-conflict zones.
In Athens, Marwa’s sixth child, a baby girl, was born last month. We have stayed in touch and she told me she is happy and recovering from the birth, trying to prepare herself to travel to Germany to be reunited with her other children.
Across Europe, meanwhile, half of the women seeking asylum are of prime reproductive age, between 18 and 34 years old. With so little control over their environments, how can they retain control over their bodies? For many, this is yet another matter of life, death and painfully restricted choices.