Gender-based violence is a global phenomenon and significantly observed in war afflicted areas. It has become a growing concern worldwide, more so because women and children are the major victims in war-torn areas of armed conflict. According to Vu et al. [1], approximately one in five displaced women experience sexual violence in affected areas. This information can however be underestimated given the difficulty in obtaining accurate information in such areas. Furthermore, the same review reported an increase in sexual violence against displaced male as well. Hence, gender-based violence is a global phenomenon that is not restricted to one area or gender and needs prompt addressal and prevention. Moreover, violence does not only cause discernible harm directly, but also causes indirect effects such as malnutrition and poorly treated chronic and infectious diseases in women and children living within 50 km of armed conflict areas [2].

Because of the volume of the issue and the multiple armed conflicts seen over the last decade in the Middle East and Africa, we took it upon ourselves to shed light on the gravity of the situation, especially gender-based violence against women in these areas. Specifically, in this review, we focused on its effect on their reproductive health. A systematic review showed both an increase and decrease in adolescent marriages during conflict in different counties, influencing the reproductive well-being [3]. In addition, because of the increase in sexual violence and rape against women in these countries, the study aimed to assess the effect of violence on reproductive health during wars and conflicts in the Middle East and Africa.

We performed a search on PubMed and Google scholar using the MeSH terms “Violence” AND “Reproductive health” OR “Maternal health” AND “Conflict” OR “War” AND “Africa” OR “Middle East. We included all papers that met the objectives of our study, published from 2000 and beyond, and covered the issues of reproductive health and violence against women in war-affected areas in the Middle East and Africa.

The violence was directed at all ages and sexes. According to a 2014 World Health Organization (WHO) report on the subject, violence is “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.” However, it is not necessarily associated with physical, sexual, or psychological damage. Neglect is another type of violence as well [4-6].

The reason why some individuals behave more combatively than others and why violence is higher in certain communities is still unknown, although it can occur in any country or culture. According to the multifactorial ecological model of individuals and society, cultural and social backgrounds play significant roles. Towards the end of the 20th century, there was an increase in the number of internal political conflict areas, refugees, and displaced persons due to several factors: weak political institutions that lost public trust, easy access to possessing and distributing weapons, and ethnic and religious differences that increased inequality, creating more chaos.

Violence against women is a growing concern and a crisis that can affect all aspects of women’s health, including their physical, psychological, and reproductive health. Also known as gender-based violence, abusive behavior is sometimes exerted against a victim before birth and may continue over a lifetime. There are several forms of violence against women existing in different set-ups: within the family, community, prisons, and areas of armed conflict [7]. In areas of armed conflict, all forms of violence, including physical, sexual, and psychological can occur including intimate partner violence (IPV), which can be physical, sexual, or emotional [7].

Violence manifests in different ways in war-affected areas, and the target might be male or female. There are a number of incidents resorting to the use of humans as weapons and the child military for direct attacks and weapon trafficking. In such areas, women became an easy resource for trafficking, as they managed to gain some kind of flexibility during security checks. Women were used to distracting their opponents and were used as weapons, all of which were associated with a form of sexual violence. Most women in the war-affected area are dependent on men, as men work outside to earn a livelihood, and women take care of their children and handle households. Men are forced to become involved in war, and being killed makes women back home much more vulnerable to violence, particularly gender-based violence, ultimately impacting their reproductive health (Figure 1). The following forms of violence are prevalent in war-affected areas:

This study primarily focuses on violence against women, especially in areas of armed conflict, and its effects on reproductive health. Unfortunately, during wartime, violence, including sexual violence, was considered a type of weapon. According to Berman et al. [8], “women’s bodies become a battlefield where men communicate their rage to other men because women’s bodies have been the implicit political battlefields all along.” In Rwanda, approximately 500,000 women were raped during the 1994 genocide, and over 50% of women experienced some form of sexual violence during the conflict in 1999 [9]. However, IPV is the most common form of violence against women in refugee camp [10]. IPV rates in conflict-torn areas tend to be much higher than those of wartime rape and sexual violence committed outside the home. The WHO defines IPV as the use of power or force, threatened or actual, by a husband or an intimate male partner that results in injury, death, or psychological harm. In a WHO multi-country study, the proportion of women reporting either sexual or physical partner violence, or both, ranged from 15% (Japan) to 71% (Ethiopia), with most sites falling between 29% and 62% [4,6].

According to the literature, reproductive health is not only measured by the absence of diseases. It is a state of physical, mental, and social well-being related to the reproductive system and its functions. Therefore, reproductive health signifies that people have satisfactory and safe sex lives, the ability to reproduce, and the freedom to choose if, when, and how to procreate [11]. In areas of war and conflict, attention has been focused mainly on providing basic needs and shelter, with little attention paid to reproductive health as a priority. However, this has started to change [11]. According to the United Nations Population Fund in Syria, approximately 1.7 million women require access to reproductive health services. Poor access to sexual assault treatments and emergency obstetric and gynecological care can contribute to adverse health outcomes [12,13].

Researchers state that combat has more profound adverse effects on a population’s health status than natural disasters. There is an inverse relationship between mortality in areas of armed conflict and reproductive health, which takes a toll on the healthcare system aspiring to improve reproductive health. During the war, women and children are at risk of sexual violence, early marriage, harassment, isolation, displacement, and exploitation. Sexual violence can occur at any stage of armed conflict when rape is used by armies as a weapons of war or committed by intimate partners [9,13,14]. Violence against women has several effects on their reproductive health. From a gynecological perspective, women who suffered IPV are 3 times more likely to have chronic pelvic pain, vaginal infections, dysmenorrhea, and dyspareunia. Women subjected to sexual violence are at risk of sexually transmitted infections (including human immunodeficiency virus [HIV]), psychological harm, and suicidal tendencies [15-17]. IPV makes it difficult for women to refuse sexual intercourse or use contraceptive methods. Forced sexual intercourse can cause vaginal trauma and increase the risk of HIV transmission. Moreover, childhood sexual abuse may increase the rate of high-risk sexual behaviors later in life, including reduced condom use, multiple partners, and subsequent violence. Fear of violence may prevent women from seeking HIV testing, counseling, or services to prevent the transmission of HIV to infants. According to a study in Kenya, the risk of pregnancy termination and infant mortality is increased in women subjected to IPV. In Liberia, a study showed that 69% of those who experienced sexual violence had post-traumatic stress disorder, 57% had depression, and 22% had thought of suicide. In the Middle East, the highest maternal mortality rates were reported in Yemen based on data from 1997 to 2013, in addition to low contraceptive use rates, low utilization of expert providers for deliveries, and high home birth rates. In Syria, women reported increased exposure to multiple forms of gender-based violence, including sexual assault, domestic violence, child marriage, and sexual exploitation. In 2015, 182 Syrian refugee women were interviewed in southern Lebanon. The study found that 26% of them had experienced emotional violence, 9.2% physical violence, and 8.7% had experienced sexual violence; many women also reported exposure to more than one type of violence. The Syrian refugees were interviewed in an another study conducted in Lebanon. In that study, approximately 50% of the patients reported menstrual irregularities, severe pelvic pain, and reproductive tract infections. Among pregnant women in the same study, 36%–39% experienced delivery or abortion related complications. Women are not immune to violence during pregnancy, which is also associated with complications. According to a study conducted in Mexico, pregnant women in areas of armed conflict are at risk of additional maternal complications in areas of armed conflict [18-24]. However, a broader study involving refugees from 52 camps in seven countries in Africa and Asia (Azerbaijan, Ethiopia, Myanmar, Nepal, Tanzania, Thailand, and Uganda) examined indicators such as maternal mortality ratio, neonatal mortality rate, and neonates with low birth weight. Surprisingly, compared with the host country and country-of-origin populations, the inhabitants of the camps experienced better health outcomes, which could be explained by improved reproductive health and healthcare services in refugee camps [25].

The lower the level of social development, the lower the level of reproductive health too. Additionally, countries with low levels of social development are at greater risk of armed conflict. When comparing the effects of armed conflict and natural disasters on reproductive health, the impact of armed conflict was more extensive than that of natural disasters. An increase in sexual assaults is associated with living in insecure areas. Survival sex has been reported among Syrian refugee women as being used to paying living expenses. The scarcity of healthcare providers during emergencies could also play an important role in providing basic healthcare that outweighs reproductive health services. In addition, accessing and obtaining healthcare services is a major obstacle in times of war because of insecurity [11,14].

One suggested theory for the association between reduced reproductive health status and IPV is reproductive coercion. This phrase refers to an intimidating tactic that male partners engage in to take away a woman’s control over her reproductive health decisions and force her to become pregnant. Reproductive coercion increases the risk of unintended pregnancy and abortion. A compelling American research model describes how some clinics helped women use contraception methods that were undetectable by their husbands, which could be a reasonable and practical solution under certain conditions. In the Middle East, a United Nations High Commissioner for Refugees (UNHCR, 2022) strategy was used to prevent and respond to sexual violence emergencies and to empower women [26,27]. The UNHCR works with national authorities and non-governmental organizations in the region to achieve their goals in areas of armed conflict. Barriers to the delivery of healthcare services exist at different levels. In doing so the UNHCR faces many obstacles due to a pushback from political parties, limiting their power. At the individual level, cultural stigma may prevent women from seeking help or services, while perpetuating a lack of awareness, misconceptions, or beliefs about family planning, financial difficulties, and mistrust of the system. Barriers exist at the healthcare provider level due to a lack of training in ways to broach sensitive topics, and at the systemic level due to a lack of coordination, collaboration, and leadership. During such emergencies, the accuracy of biostatistical data is deficient, leading to underestimation of the prevalence of violence against women. Therefore, attention should be paid to reproductive health improvements in areas of armed conflict. Women should have easy access to healthcare services and contraceptive methods. These services and methods should be provided by trained personnel in the area’s healthcare system during armed conflicts, and by camps established in displaced areas or countries. Different types of media should focus on women’s empowerment within the cultural limits of the affected countries. In terms of IPV, a broader approach should be implemented by communities involving different social parties (imams, pastors, healthcare professionals, educators, and teachers) to educate males against engaging in IPV. To improve reproductive health, more effort is needed to obtain accurate numbers and significant data on key indicators.

Due to war, millions of people in the world have displaced thousands of people who have lost their lives, yet war is present in different areas of the world. The reason for the war can be a political, geopolitics, economics, religion, culture, exercising power, and so on. Victims were humans and all creatures living on Earth, including the globe itself. It ultimately impacts the economy, infrastructure, and well-being of humans. Women and children are more vulnerable to violence than are men. Women become an easy resource for their utilization during the war, and this is related to gender-based violence against women (Figure 1). War causes women to suffer not only from those who are directly involved in war but also from those who are not involved, which directly impacts women’s reproductive health. Control over war is not in individuals’ hands, as it is mostly political in nature; however, some adverse effects of war that impact women’s health can be minimized. Policymakers should focus on women’s education and employment as it makes them independent and aware of what is wrong for themselves and society. In a war, all stakeholders, government and nongovernment organizations should work together to minimize the risk to women and people who are not involved in the war. The initiation of peaceful discussions and ceasefires can mitigate this risk. Healthcare professionals and volunteers should be provided access to the affected areas. All stakeholders should collaborate to provide medical and logistical support. Ultimately, war is not a solution, but strong guidelines should be established that everyone should follow. In summary, gender-based violence specifically against women is more prevalent in armed conflict areas during wartime, and spills into displaced countries. Studies have shown improvements in reproductive health when effective methods and services. More accurate information is needed regarding reproductive health indicators in armed conflicts. We need a better reporting system and more training for assessors on how to handle sensitive subjects. Additional coordination and leadership are needed at the systemic level to provide essential wartime access to effective reproductive healthcare and medical supplies. Given its neutral role and name, the UN may have acted as a mediator in these times and areas.