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Additional file 1. In-depth interview guide for PAC clients and Focus group guide.

Additional file 2. SRQR checklist

Background: Inadequate infrastructure, security threats from ongoing armed conflict, and conservative socio-cultural and gender norms that favour large families and patriarchal power structures contribute to poor sexual and reproductive health (SRH) outcomes in North and South Kivu provinces, Democratic Republic of the Congo (DRC). In order to expand contraceptive and post-abortion care (PAC) access in North and South Kivu, CARE, the International Rescue Committee and Save the Children provided technical support to the Ministry of Health and health facilities in these regions. Partners acknowledged that community leaders, given their power to influence local customs, could play a critical role as agents of change in addressing inequitable gender norms, stigma surrounding SRH service utilization, and topics traditionally considered taboo within Congolese society. As such, partners actively engaged with community leaders through a variety of activities such as community mapping exercises, values clarification and transformation (VCAT) activities, situational analyses, and education. Methods: This manuscript presents findings from 12 key informant interviews (KIIs) with male political and non-political community leaders conducted in six rural health zones of North and South Kivu, DRC. Transcripts were analysed thematically to explore community leaders’ perceptions of their role in addressing the issue of unintended pregnancy in their communities. Results: While community leaders in this study expressed overall positive impressions of contraception and strong support for ensuring access to PAC services following spontaneous and induced abortions, the vast majority held negative beliefs concerning women who had induced abortion. Contrasting with their professed opposition to induced abortion, leaders’ commitment to mediating interpersonal conflict arising between community members and women who had abortions was overwhelming. Conclusion: Results from this study suggest that when thoughtfully engaged by health interventions, community leaders can be empowered to become advocates for SRH. While study participants were strong supporters of contraception and PAC, they expressed negative perceptions of induced abortion. Given the hypothesized link between the presence of induced abortion stigma and care-avoidance behavior, further engagement and values clarification exercises with leaders must be integrated into community mobilization and engagement activities in order to increase PAC utilization.

More than 50 million people were forcibly displaced from their homes at the end of 2014, the highest number since World War II; 38 million of these were displaced within their own country rather than crossing an international border. Many have been displaced multiple times by chronic and recurring conflict. Complex humanitarian emergencies caused by armed conflict are characterized by social disruption, population displacement and the breakdown of national health systems. The negative impact of war and displacement on women has long been recognized, including by compromising their right to sexual and reproductive health (SRH) services. The ten countries with the highest maternal mortality ratios in the world are affected by, or emerging from, war; these countries are also characterized by low contraceptive prevalence. The provision of SRH services is a minimum standard of health care in humanitarian settings; however access to these services is still often compromised in war. A 2012-2014 global evaluation on the status of SRH in humanitarian settings showed that although access to SRH services has improved in humanitarian settings, gaps persist and the availability of contraceptive services and information is still weak relative to other SRH components. This dissertation addresses this gap by providing evidence that good quality contraceptive services can be implemented in humanitarian settings and that women and couples will choose to start and continue contraceptive use. The first paper of this dissertation, a systematic review, explored the evidence regarding SRH services provided in humanitarian settings and determined if programs were being evaluated. In addition, the review explored which SRH services received more attention based on program evaluations and descriptive data. Peer-reviewed papers published between 2004 and 2013 were identified via the Ovid MEDLINE database, followed by a PubMed search. Papers on quantitative evaluations of SRH programs, including experimental and non-experimental designs that reported outcome data, implemented in conflict and natural disaster settings, were included. Of 5,669 papers identified in the initial search, 36 papers describing 30 programs met inclusion criteria. Some SRH technical areas were better represented than others: seven papers reported on maternal and newborn health (including two that also covered contraceptive services), six on contraceptive services, three on sexual violence, 20 on HIV and other sexually transmitted infections and two on general SRH topics. In comparison to the program evaluation papers identified, three times as many papers were found that reported SRH descriptive or prevalence data in humanitarian settings. While data demonstrating the magnitude of the problem are crucial and were previously lacking, the need for SRH services and for evaluations to measure their effectiveness is clear. Contraceptive services were mostly limited to short-acting methods and received less attention overall than other SRH technical components. In response to this lack of evidence for the implementation of contraceptive services in humanitarian settings, two contraceptive services programs implemented by CARE and Save the Children among conflict-affected populations in eastern Democratic Republic of the Congo (DRC) were evaluated. DRC has experienced chronic conflict for two decades, ranging from acute to post conflict phases. People have been displaced internally for many years while others have experienced repeated cycles of displacement and return. First, cross-sectional surveys in 2008 (n=607) and 2010 (n=575) of women of reproductive age using a multi-stage cluster sampling design and facility assessments were conducted in Maniema province. Data on the numbers of clients who started a contraceptive method were also collected monthly from supported facilities. Current use of any modern contraceptive method doubled from 3.1% to 5.9% (adjusted OR 2.03 [95%CI 1.3-3.2]). Current use of long-acting and permanent methods (LAPM) increased from 0 to 1.7%, an increase that was no longer significant after adjustment. Program changes were made to improve service quality in 2010; provider skills and counseling improved and commodities became consistently available. Service statistics indicate that the percentage of clients who accepted a LAPM at supported facilities increased from 8% in 2008 to 83% in 2014. This study demonstrates that when good quality contraceptive services, including LAPM, are provided among conflict-affected populations, women will choose to use them. Second, a retrospective cohort study measured 12-month contraceptive continuation in North Kivu province. A total of 548 women (304 short-acting and 244 long-acting method acceptors) were interviewed about their contraceptive use in the previous year. At 12 months, 81.6% women reported using their baseline method continuously, with more long-acting than short-acting method acceptors (86.1% versus 78.0%, p=.02) continuing method use. Use of a short-acting method (HR 1.74 [95%CI 1.13-2.67]) and desiring a child within two years (HR 2.32 [95%CI 1.33-4.02]) were associated with discontinuation at 12 months. Given the association between service quality and contraceptive continuation, the program’s focus on service quality including improvements to provider skills and activities to address provider attitudes likely contributed to these results. The impressive continuation rates found here indicate that delivering high quality contraceptives services in these settings is possible, even in a difficult and unstable setting like eastern DRC. This dissertation represents a major contribution to the field of SRH in humanitarian settings, and has implications for research and programs. First, these results strengthen the evidence base for the implementation of contraceptive services in humanitarian settings, and demonstrate to implementers and donors of humanitarian aid that effective programs resulting in adoption and continuation of contraceptive methods can be successfully implemented in these challenging settings. Second, these programs were implemented in full collaboration with the Ministry of Health (MOH), supporting MOH facilities and health workers, thus strengthening the health system. Third, the programs achieved these impressive results in rural DRC where they attracted early adopters, most of them first time contraceptive acceptors. In addition, these programs were implemented by multi-sectoral, as opposed to SRH-specific, non-governmental organizations that made good quality contraceptive services a priority, further reinforcing the inclusion of contraceptive services as a routine component of humanitarian health response. Finally, both programs evaluated in this dissertation focused strongly on improving the quality of contraceptive services with specific attention to training, supervision, provider attitudes, data use and commodities management. This program focus on quality contributed to the positive findings. Making good quality contraceptive services available is challenging and requires sustained commitment, funding and program adjustments, but, in the programs studied here, was ultimately successful. Given true choice, when a range of methods was routinely available, women, many of whom had no prior experience with contraceptive use, were able to choose the method that best served their needs and continued to use their preferred method. These results add to the limited evidence on contraception in humanitarian settings, and demonstrate that even in remote and unstable settings, when good quality contraceptive services, with a choice of short-acting, long-acting and permanent methods, are in place, women will not only choose to start, but also continue, to use contraception to exercise their right to reproductive choice.