Beyond the 72 h window: operationalizing safe abortion as essential care for sexual violence survivors in humanitarian settings

Abstract

In the Democratic Republic of Congo (DRC), sexual violence is systematically employed as a weapon of war, precipitating a profound reproductive health crisis. Current clinical protocols prioritize intervention within a 72-hour window; however, pervasive insecurity, displacement, and geographic barriers frequently prevent survivors from accessing care within this timeframe. This broken link in the referral chain effectively denies survivors safe abortion services, resulting in forced pregnancies and secondary institutional trauma. This review evaluates the DRC's humanitarian response by analyzing the integration of the Minimum Initial Service Package (MISP) against evolving domestic legislation, specifically the 2018 gazetting of the Maputo Protocol and the 2020 National Comprehensive Abortion Care Guidelines. Despite a supreme legal mandate under Article 14 of the Maputo Protocol authorizing safe abortion for survivors, implementation is obstructed by provider stigma, the misuse of conscientious objection, and a hierarchy of services that prioritizes physical trauma repair over reproductive autonomy. Clinical pathways for cases presenting beyond the 72-hour emergency window remain poorly operationalized. To bridge the gap between legal rights and clinical reality, the DRC must transition toward a Comprehensive Clinical Management model. This requires institutionalizing task-sharing with midwives and integrating the Addressing Reproductive Coercion in Health Settings (ARCHES) framework to manage reproductive violence beyond the emergency phase. Safe abortion must be repositioned as an essential, non-optional component of post-rape care. True recovery depends on aligning clinical practice with international human rights standards, ensuring reproductive self-determination is upheld amidst protracted crisis and systemic instability.