Abstract
BACKGROUND: Despite the vulnerability of maternal and reproductive health services in fragile and conflict-affected settings (FACS), family planning-an essential service for protecting women's health-tends to be overlooked. To better understand family planning in a frozen conflict, we examined reproductive choices among the indigenous population of Nagorno-Karabakh during a ceasefire period prior to their forced displacement. METHODS: Multistage cluster sampling was used to sample 1023 households in Nagorno-Karabakh during the summer of 2022. From each household, one woman aged 18-49 participated in an interviewer-administered survey. Family planning behaviors were assessed among all women. Logistic regression was used to assess factors associated with type of contraception used. RESULTS: Less than one-fifth of women (16.5%) reported currently avoiding pregnancy. Among these women, 69.5% used modern contraception (IUD, pill, condom). Only 4.3% planned to use contraception in the future, of which 76.7% would choose a modern method. Most (84.9%) reported their physician as the most trusted source of information on contraception. There were no differences by demographic characteristics among the women in the type of contraception used. CONCLUSIONS: Most women in Nagorno-Karabakh were not actively avoiding pregnancy, which can occur in FACS. Among those who were, most used a modern method, and the few with a future need mostly preferred a modern form. Combined with a lack of demographic differences in utilization, these findings suggest knowledge, availability and access to family planning among the women. The decision not to avoid pregnancy, combined with previous findings of robust maternal health services, underscores the capability of Nagorno-Karabakh's healthcare system to prioritize women's health and the value of community support and empowerment. This study demonstrates the importance of family planning services in FACS to safeguard women affected by crises. KEY MESSAGES: • Although not used by most women, family planning services were available in Nagorno-Karabakh, demonstrating the ability of the healthcare system to prioritize women’s health in a frozen conflict. • Health systems in FACS should ensure availability and access to family planning services in order to protect the health of the women in humanitarian settings.