Sexual Violence–Related Pregnancy Among Internally Displaced Women in an Internally Displaced Persons Camp in Northeast Nigeria

Abstract

Sexual violence is quite common in conflict situations and puts women at risk of unintended pregnancies. In the northeast region of Nigeria with the ongoing insurgency, a substantial number of women are kidnapped and subjected to forced marriages and repeated sexual assaults. This study set out to report on the disclosure and outcomes of sexual violence–related pregnancies (SVRPs) among women liberated from insurgents and relocated to one of largest Internally Displaced Persons (IDP) camps located in Borno State, northeast Nigeria. The clinic records of women with SVRP were reviewed. Forty-seven women with SVRP were identified by the health care providers using a snowball technique to reach as many of the women with SVRP as possible. The mean age of the participants was 15.3 years (SD = 3.4 years), and all the participants had spent 2 years or more in captivity. Most of the women first disclosed the pregnancy to their peers before disclosure to health care providers or family members. All the women initially requested to have the pregnancy terminated; however, abortion services are not offered in the clinic in line with the country’s restrictive abortion laws. Following counseling and psychosocial support offered in the clinic, 19 (40%) of the women continued with the pregnancy and were delivered in the camp clinic while the remaining 26 women left the camp shortly after disclosure and pregnancy outcomes are not known. SVRP is not uncommon in humanitarian settings with its associated stigma and unwillingness among the survivors to keep the pregnancy. There is a need for further studies to provide more insight into the extent of this problem and help-seeking for SVRPs especially for women in such difficult circumstances to provide needed empirical information to drive advocacy efforts for more comprehensive services.

Keywords

Introduction

Sexual and gender based violence (SGBV) is a common occurrence in populations affected by conflicts and other humanitarian crises such as that occasioned by the insurgency in northeast Nigeria. However, the prevalence of SGBV is typically difficult to measure in such conflict-affected populations (Ba & Bhopal, 2017). In a recent systematic review of sexual violence among female refugees and internally displaced persons in complex humanitarian settings, the prevalence of sexual violence was estimated at 21.4% (Vu et al., 2014). In Nigeria, SGBV is a core—though often hidden—dimension of the ongoing insurgency in northeast Nigeria. The Boko Haram insurgents’ tactics have included the abduction of women and girls primarily for sex, forced marriages, and labor, and the kidnapping of boys for indoctrination and recruitment as fighters (United Nations Population Fund [UNFPA], 2016). A UNFPA report documented that more than half (51.5%) of the sexual violence cases identified in northeast Nigeria were perpetrated by Boko Haram insurgents, another 23.7% by unknown assailants, and 17.8% attributed to members of the police and armed forces (UNFPA, 2016). Survivors and people at risk often face significant challenges in accessing services, including legal aid and psychosocial support.

Exposure to sexual violence places women at a high risk of unintended pregnancies (Ba & Bhopal, 2017; Peterman, Palermo, & Bredenkamp, 2011). Pregnancy is reportedly the most common health outcome of sexual violence for women caught up in conflict zones with reported rates ranging between 3.4% and 46.3% (Ba & Bhopal, 2017; Bartels et al., 2010; Dossa, Zunzunegui, Hatem, & Fraser, 2014). This figure is likely an underestimate as stigma affects disclosure of sexual violence–related pregnancies (SVRPs). Studies have shown that stigma may prevent survivors from disclosing that the pregnancy was conceived as a result of the sexual violence, and influence who is informed of the pregnancy (Onyango et al., 2016). This may lead to delayed or failure to seek pregnancy-related care, and may influence women’s decisions to continue or to terminate the pregnancy (Rouhani et al., 2015). Studies conducted in the United States report that approximately half of obstetric practices screen for pregnancy resulting from sexual violence and less than one third of SVRPs were disclosed as a result of the screening (Perry, Murphy, Rankin, Cowett, & Harwood, 2016). This has prompted calls for more widespread screening for SVRPs and creating an enabling environment for disclosure to alleviate some of the associated stress among survivors (Perry, Murphy, Haider, & Harwood, 2015; Perry et al., 2016).

Available research suggests that nearly half of women with SVRPs seek or undergo termination of the pregnancy (Rouhani et al., 2015; Singh, Wulf, Hussain, Bankole, & Sedgh, 2009). A hospital-based study in Liberia found that 59% of women who presented with an SVRP requested termination upon seeking care (Tayler-Smith et al., 2012). In a study conducted in Goma, North Kivu province, Democratic Republic of the Congo (DRC), even though 87% of women with conflict-related SVRP carried the pregnancy to term, 55% stated they were willing to terminate the pregnancy, 39% said they would have terminated their pregnancies if appropriate care was available, and 10% attempted to terminate the pregnancy (Dossa et al., 2014). Termination of pregnancy (TOP) in most conflict-affected countries like DRC and Nigeria is highly restricted. TOP is permissible only to save the life of a woman, and access to skilled providers for termination services is limited which may further impact disclosure and help-seeking for SVRPs, especially among survivors considering pregnancy termination (Bankole et al., 2008; Singh et al., 2009; United Nations, 2014). Rouhani et al. (2016) found that among women with SVRP who terminated the pregnancy, most used medications or herbs that are not recognized as evidence-based methods of pregnancy termination and sought these methods outside of the formal health care sector.

Despite the long drawn out insurgency in northeast Nigeria along with the frequent reports of abduction of women, there is hardly any information available on SVRPs among this population. Information regarding the occurrence of SVRPs, disclosure patterns, and pregnancy outcomes will be important to inform the planning and provision of comprehensive health care services and drive needed policy changes to adequately cater to the needs of women caught up in this and similar crises situations. This study therefore set out to report on the occurrence, disclosure, and outcomes of SVRPs, and the utilization of available reproductive health services among women who were previously held hostage by the Boko Haram insurgents and relocated to one of the largest Internally Displaced Persons (IDP) Camp in Borno State, northeast Nigeria.

Materials and Methods

Study population and setting

The study was conducted in the health facility in one of the biggest IDP camps (Dalori) in Borno State in northeast region of Nigeria. The camp has a population of 35,000 and estimated 8,050 women of child bearing age and was established in March 2014. There is a government primary health care center that provides essential primary health care services including maternal, newborn, and child health and sexual reproductive health services. Health services are provided by medical doctors, nurses and midwives, laboratory technicians, and community health officers in addition to other support staff.

Study procedure

The study is a retrospective chart review of women with self-reported SVRP who were seen at the clinic. These women were identified using snowball or chain-referral method. Freed hostages immediately after arriving at the camp are usually offered routine medical screening and appropriate services at the clinic. During the course of receiving care at the clinic, a few of the pregnant women disclosed that the pregnancy resulted from being raped by the insurgents. These women were interviewed further by the health care workers regarding the circumstances leading up to the pregnancy, identity of the perpetrators, and who they had informed about the pregnancy. They were offered more intensive antenatal services with additional psychosocial support and were urged to help identify other women who had similar experience and direct them to the clinic. Over the course of the 12-month period reviewed (October 2015 and September 2016), a total of 47 cases of SVRP were enrolled into this specialized service. Treatment protocol for women with SVRP included weekly focused antenatal visits at the camp clinic and home visits in their accommodation in the camp at least twice a week by trained nurse/midwives assigned to provide individualized continuous medical and psychosocial counseling and support including linking them up with religious and community support during the pregnancy and perinatal period.

Data Collection and Analysis

The clinic records of the 47 women who reported getting pregnant as a result of being raped by insurgents were reviewed. Data were extracted using a form designed by one of the authors to capture relevant information. Data recorded included the following:

Sociodemographic data including age, marital status, level of education, and religion.

The details of the pregnancy and clinic visits which included the gestational age (categorized into trimesters) at the first visit to the clinic, details of the incident leading to the pregnancy, the identity of the perpetrators, disclosure of the SVRP, history of previous pregnancies, history of any complications in the present pregnancy, birth preparedness, number of antenatal visits, and services provided during each visit. Birth preparedness and complications readiness (BPCR) questions are routinely administered to women registering for antenatal care in the clinic. Items captured under BPCR include plans for delivery, identification of a safe place of delivery, emergency contact, transportation arrangements, and plans for financing in case of complications.

Summary of interventions/support provided in the clinic and during home visit conducted by the nurse/midwives.

The pregnancy outcome either carried to term or lost to follow-up/defaulted from the clinic.

Descriptive data are presented, with qualitative variables presented as proportions and quantitative variables summarized as means with their standard deviations.

Results

The record of 47 women with SVRP who were seen at the camp health clinic was reviewed, and with estimated population of women of reproductive age group of 8,050 in the IDP camp during the period under review, the estimated rate of SVRP is about 6/1,000 women.

Demographics of Participants

The demographics of participants are presented in Table 1. The mean age of the identified participants was 15.3 years (SD = 3.4). Most of the participants (79%) had no formal education, all were Muslim of the Kanuri tribe. All the participants reported that they were abducted from their communities and held hostage for more than 2 years before being liberated by the military.

Table 1.

Sociodemographic Profile of the Respondents.

Variables	Number (N = 47)n (%)
Age (years)
10-19	27 (57)
20-29	12 (26)
30-49	8 (17)
>50	0
M	15.3 ± 3.4
Marital status
Single	21 (45)
Married	13 (28)
Widow	11 (23)
Divorce	2 (4)
Level of education
No formal	37 (79)
Primary	10 (21)
Secondary	0
Postsecondary	0

Out of the 24 women who were married prior to the invasion of their community, 13 had lost contact and were not sure what happened to their husbands afterward, and the others (n = 11) reported that their husbands were killed by the insurgents.

Disclosure of Pregnancy and Clinic Visits

Most of these women (66%) reported that they first disclosed the pregnancy to their peers (i.e., other women they knew were similarly abused by the insurgents) while those (10%) who disclosed to their family members said they disclosed the pregnancy only after it became obvious they were pregnant.

Pregnancy status and outcome are presented in Table 2. On arrival at the IDP camp, most of the women (53%) were already in the second trimester of pregnancy.

Table 2.

Pregnancy Disclosure and Outcome.

Variables	N = 47n (%)
Disclosure of pregnancy
Peer similarly abused	31 (66)
Family members	5 (10)
Friends	11 (24)
Duration of pregnancy during first contact at the camp clinic
<3 months	14 (30)
3-6 months	25 (53)
>6 months	8 (17)
Ante Natal Care coverage
Completed Ante Natal Care in the clinic	19 (40)
Two or more Ante Natal Care visit but not complete	23 (49)
One Ante Natal Care visit (first visit)	5 (11)
Delivery status
Delivered in the clinic/camp	19 (40)

Only 19 (40%) completed the weekly ANC visits, 23 (49%) had documentation for two or more ANC visits while five (11%) did not visit the clinic again after the initial visit when they disclosed the SVRP to the health care providers. The health workers documented that all the participants requested for termination of the pregnancy at the initial contact stating that they were not willing to have the babies due to the circumstances associated with their becoming pregnant. In line with the treatment protocol, all were counseled and provided with psychosocial support both at the clinics and at their accommodation in the camp by trained midwives.

Pregnancy outcomes

Only 19 (40%) of the women continued with antenatal care and psychosocial interventions and were delivered in the camp clinic with ongoing psychosocial support. The remaining 26 (60%) left the camp shortly after disclosing they were pregnant. These women were reported by neighbors to have relocated outside of the camp to surrounding communities and became lost to follow-up.

Discussion

The findings of this study highlight an obvious but highly neglected problem faced by women caught in the midst of this humanitarian crises. While a number of agency reports and studies provided the prevalence of sexual violence among women in conflict situations, there is very limited information regarding the rate of SVRPs. This is possibly because reports by the United Nations include SVRPs under the common rubric of sexual violence in conflict as evidenced by this definition from a recent United Nations Security Council (2018) report:

conflict-related sexual violence refers to rape, sexual slavery, forced prostitution, forced pregnancy, forced abortion, enforced sterilization, forced marriage and any other form of sexual violence of comparable gravity perpetrated against women, men, girls or boys that is directly or indirectly linked (temporally, geographically or causally) to a conflict.

Studies from the DRC suggest that up to 17% of survivors of sexual violence report a SVRP (Bartels et al., 2010; Johnson et al., 2010). While we are unable to provide the rates of SVRP among women who had experienced sexual violence in our study as we do not have information about the number of women in the camp who had experience sexual violence, we estimated that six out of every 1,000 female survivors of this conflict had a SVRP. This probably is a gross underestimation of the magnitude of this problem in this population. Considering the associated stigma and the social sequelae including isolation and abandonment, many women are unwilling to disclose the sexual violence or pregnancy resulting from it.

In this study, all the 47 participants identified spent prolonged periods in captivity increasing the chances for frequent exposure to unprotected sex coupled with a lack of access to contraception. Previous studies among survivors of the armed conflict in the DRC found that the risk of unwanted pregnancy is increased with high exposure to frequent, forced, and unprotected sex and lack of access to contraception (Lehmann, 2002). Onyango et al. (2016) reported that majority of SVRPs (up to 73%) were conceived while participants were held in sexual captivity for prolonged periods of time.

About two thirds of the women who had experienced SVRP in this study first disclosed their pregnancies to other women who had been similarly abused by the insurgents. This is similar to the findings from a qualitative study of disclosure of SVRP in the DRC, where disclosure was usually to friends, family members, other sexual violence survivors, community members, spouses, and health care providers perceived as being discreet, trusted, and supportive (Onyango et al., 2016).

As in other studies of women with SVRPs, a desire to terminate the pregnancy was expressed by these women. However, in line with Nigerian law, abortion services even when requested by the woman or her family under such special circumstances cannot be offered. With the counseling and psychosocial support services offered in the camp clinic and during home visit, 40% of the women continued to stay in the camp and access medical services and delivered their babies in the clinic while the other women left the camp and became lost to follow-up. Earlier studies suggest that nearly half of women with SVRPs seek or undergo termination of the pregnancy (Rouhani et al., 2016). It is also not unusual for women with rape-related pregnancy who initially request for termination to opt to continue with the pregnancies. For example, in a study conducted in Goma, North Kivu Province, DRC, 87% of women who reported an SVRP carried the pregnancy to term, even though 55% of them initially expressed a desire to terminate the pregnancy (Dossa et al., 2014). A report based on a national sample of women in the United States where abortion laws are less restrictive compared with that in most developing countries, 32.2% of women with rape-related pregnancies opted to keep the infant whereas 50% underwent abortion and 5.9% placed the infant up for adoption; an additional 11.8% had spontaneous abortion (Holmes, Resnick, Kilpatrick, & Best, 1996).

The outcome of pregnancy could not be documented for more than half of the women identified with SVRP in this study. These women chose to relocate outside the camp following disclosure of the SVRP. There is a possibility that these women decided to move out of the camp to seek help terminating the pregnancies. Even though abortion is illegal in Nigeria, community-based surveys have shown that up to 50% of unwanted pregnancies end in abortion and most are performed clandestinely and often by unskilled providers placing the women’s life at risk (Bankole et al., 2015; Bankole et al., 2008; Sedgh et al., 2006). Another possibility is that these women left the camp to escape the stigmatization and difficulties associated with re-integration into their families and the community. These women are sometimes tagged “Boko Haram wives” and their children “Boko Haram sin.”

This study is based on clinic records and subject to the limitations associated with studies utilizing routine data. We could not explore in further detail the context and frequency of the sexual violence that resulted in the pregnancy. Other key limitations are the small samples size and the high number of participants that became lost to follow-up for which the outcome of the pregnancy could not be ascertained; these may limit the generalizability of our findings. The sample reported on here was identified by chain referral to the clinic; there is likelihood that many women would not be unwilling to disclose the SVRP and seek care because of other associated psychosocial factors including stigmatization and exclusion which unfortunately we could not explore in this study.

Despite these limitations, this study has implications for policy and service provision for this population of women affected by the Boko Haram crises in northeast Nigeria and other similar settings. There is further need to ascertain the magnitude of this problem and draw attention to the needs of women with SVRP as different from other SGBV by improving reporting standards in health care settings providing care for affected populations. While some women provided with appropriate medical and psychosocial support could be helped to manage the associated stigma and psychological trauma and opt to parent children conceived as a result of SVRP, others may require other services. Such services could include adoption placement, psychosocial support, and community support to aid re-integration and provision of safe abortion. Nigeria like many other countries in Africa is a signatory to the 2003 Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (the “Maputo Protocol”). Article 14 (2) (c) of the protocol states the need to “protect the reproductive rights of women by authorizing medical abortion in cases of sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the fetus.” This is yet to translate into changes in policy and legislation.

There is a need for further studies to provide more insight into the prevalence, disclosure, and help-seeking for SVRPs especially in conflict exposed population with a high likelihood of exposure to sexual violence. Such studies will provide needed empirical information to help drive advocacy efforts for the provision of more comprehensive services as well as policy and legislative changes to better meet the needs of women survivors of conflicts with the additional burden SVRPs.

Footnotes

Acknowledgements

The authors wish to thank all reproductive health workers in Dalori IDP camp clinic, especially Mrs. Gamboya Abdullazeez, the reproductive health nurse who headed the reproductive health services in the camp clinic and coordinated the services provided for the survivors.

Authors’ Note

The findings of this study and recommendations arising from this study are the sole responsibility of the authors and do not represent the position of the organizations they work for. Olusola Oladeji conceived the documentation, analyzed the data, and drafted and finalized the manuscript. All the authors read, reviewed, and approved the final draft of the manuscript. All authors reviewed the final draft and consented to the publication.

Ethical Approval

The Borno state Research and Ethics committee reviewed the study protocol and cleared the use of clinic records for the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Olusola Oladeji is public health physician with PhD in community health and master’s degree in public health and relevant experience and training in health care issues including primary health care, reproductive health humanitarian/emergency response and operation research. He worked as the health specialist in UNICEF Maiduguri Office where he coordinated the health response to the humanitarian crises in the Borno and Yobe state and currently works with UNICEF South Sudan as Health Emergencies Specialist.

Bibilola Oladeji is a senior lecturer in the Department of Psychiatry, College of Medicine, University of Ibadan, and a consultant to the University College Hospital, Ibadan. Her research focus is psychiatry epidemiology and implementation science with special interest in maternal mental health.

Dick Chamla is a medical doctor with masters in public health and training in health economics and financing, currently working in Health section in UNICEF New York. He has substantial experiences in health policy development and system strengthening, HIV and TB, monitoring and evaluation, and research in both development and humanitarian settings. He has served in many WHO guidelines committees, TB Alliance Pediatric Advisory Group, and provided strategic and technical support to more than 18 countries in Africa and Asia. He has published widely in peer reviewed journals and co–authored various reports.

Garba Safiyanu is an obstetrician and gynecologist with over 15-year experience in maternal and reproductive health services in public, private, and NGOs settings in Nigeria. He currently works as health specialist at UNICEF Country Office in Nigeria where he coordinated maternal and newborn health and humanitarian response.

Sule Mele is the executive director/CEO, Borno State Primary Health Care Development Agency, an agency overseeing and coordinating all primary health care including humanitarian response in Borno State. He is a medical doctor with master’s degree in public health. He is responsible for the overall coordination of partners involved in primary health care services both in humanitarian and development context in Borno State.

Helni Mshelia is the director of primary health care in the SPHCDA. She is a medical doctor with postgraduate training in public health and currently works as the director of primary health care with the Borno State primary health care development agency where she supervises primary health activities which include immunization, nutrition, and reproductive health both in the health facilities and IDP camps in the state.

John Agbor, MD, MPH, is a senior program manager at UNICEF, currently serving as team lead for polio eradication in Pakistan. Formerly, he was Chief of Health in Nigeria, Somalia, and Liberia and previously with MSF serving as field coordinator, medical coordinator, and head of mission. He is a seasoned public health specialist and manager in development and humanitarian context including complex emergencies.

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