Assessing the implementation of the minimum initial service package for sexual and reproductive health (MISP) among refugees in the Eastern Mediterranean region: a systematic review

The Minimum Initial Service Package (MISP) for Sexual and Reproductive Health (SRH) is essential for delivering life-saving interventions during humanitarian emergencies. This systematic review aimed to assess the implementation of the MISP among female refugees aged 15–49 years in the Eastern Mediterranean Region (EMR) by synthesizing evidence on MISP-related service utilization indicators and maternal and reproductive health outcomes. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted comprehensive searches of multiple electronic databases and reports from United Nations agencies published between 2013 and December 31, 2024. The risk of bias of the included studies was assessed using the Newcastle–Ottawa Scale. Eleven peer-reviewed studies and one report met the inclusion criteria. The included studies demonstrated substantial variation in MISP-related indicators across refugee populations. Unplanned pregnancy rates ranged from 26% to 70%, contraceptive prevalence from 35% to 54%, and antenatal care coverage from 30% to 100%. The proportion of births attended by skilled health personnel ranged from 72% to nearly 100%, while cesarean section rates varied from 5% to 35%. Reported rates of sexual violence ranged from 3% to 68%, and neonatal mortality varied considerably across the included studies. Overall, the available evidence indicates important gaps and considerable variability in the implementation of MISP-related SRH services and associated maternal and reproductive health outcomes across the EMR. While indicators such as skilled birth attendance and cesarean section rates were generally within acceptable ranges in several settings, substantial gaps remain in family planning, prevention of unplanned pregnancy, and the availability of evidence for several core MISP components. These findings underscore the need to strengthen MISP implementation, improve monitoring of key indicators, and expand high-quality research on sexual and reproductive health services for refugee populations in the EMR.