HIF Case Study: Addressing Reproductive Coercion In Healthcare Settings (ARCHES)

One million forcibly displaced Rohingya people – half of them women and girls – live in densely populated refugee camps near Cox’s Bazar, Bangladesh, where they face limits to their freedom of movement and access to work and essential services. Women’s mobility is further reduced by societal constraints, as is their decision making power, including their reproductive autonomy. Intimate partner violence is considered a social norm, and among the many Rohingya refugee women not using contraception, the majority cite their husband’s disapproval as the primary reason for abstaining from birth control. Reproductive coercion is a form of gender based violence where abusive behaviours are used to control a woman or girl’s family planning use or pregnancy decisions. It strips away autonomy and heightens health risks for the women and girls who experience it.

Addressing Reproductive Coercion in Health Settings (ARCHES) is a harm reduction intervention designed to help women use family planning methods without interference. It is thought to be the first intervention of its kind focusing on reproductive coercion. It consists of three core elements, delivered by healthcare workers: a rights-based counselling and screening session on reproductive coercion; counselling and screening for intimate partner violence without pressure to disclose; and the offer of a discreet information booklet.

ARCHES has been used in several countries, and through two Elrha innovation grants Ipas has pioneered its first use in a humanitarian response. Ipas used user-centered design to adapt ARCHES to Cox’s Bazar, not just translating materials into Rohingya, but, crucially, contextualising them with input from community members and an advisory group. Piloting ARCHES saw women receiving the intervention report a 92% increase in self-efficacy to use modern contraceptive methods despite partners’ opposition, and a 17% increase in self-efficacy to use intimate partner violence support services.

The approach is now increasing in scale in Bangladesh: it has reached more than 25,000 Rohingya women and girls and United Nations Population Fund (UNFPA) has provided funding to roll ARCHES out across more health centres in Cox’s Bazar. While the original ARCHES is a clinic-based intervention, Elrha’s second grant has supported further adaptation for the delivery of ARCHES in humanitarian settings where women and girls face heightened barriers to accessing health clinics. Ipas has now developed a community-based ARCHES intervention, to be implemented outside of clinics, through community health-workers.

Drawing on project data and key informant interviews with project staff and other stakeholders, this case study explores the critical need for an intervention such as ARCHES in Bangladesh. It includes reflections on their experience of the adaptation and implementation work, including success factors and some notable challenges. Although there is compelling impact data from the clinic-based intervention, such data was not yet available for the community-based intervention so is not included here. This data will be available in 2025.

The case study shares key learnings from Elrha’s support for ARCHES, such as:

• User-centred design proved highly valuable to the adaption process. Adapting ARCHES was a challenging process in which key terms could not simply be translated but instead required substantial contextualisation, and taking a design approach to this helped meet user needs.
• Integrating ARCHES into existing workflows adds to its scalability and sustainability. The intervention works best when it is not a standalone service, but results and practices during implementation need to be continually monitored to mitigate risks and understand further adaptation needs.

The case study concludes that ARCHES is a valuable, scalable and unique intervention that responds to the immediate needs of women and girls to have reproductive autonomy and make informed choices with or without their family’s support.