1 Background

During the first nine months of 2015, more than 487,000 people reached the European Mediterranean coast, which is twice the number compared to the entire previous year [1]. Most displaced people came from Syria, Iraq, and Afghanistan, where war and persecution forced them to leave [2]. While from a worldwide perspective no European country belongs to those hosting the biggest refugee population, the so-called European crisis still received most of the media attention. Overall, over a million people arrived in Europe by sea, mainly at the shores of Greece but also in the other Mediterranean countries Spain, Malta, and Italy [2, 3]. Conforming to the European asylum system and the Dublin regulations, the countries of first arrival are responsible for managing the asylum procedures and granting safe and dignified living until their referral to third countries [4, 5]. Greece became the main gateway to Europe and was one of the countries struggling to cope with the large number of arrivals [6]. Humanitarian assistance organizations repeatedly highlight the unworthy living conditions, poor health standards, overcrowded camps, and unsafe environments in those areas [7,8,9]. As such, unacceptable conditions as well as “gaps in health, water, sanitation and hygiene facilities” were reported [10]. The European Union-Turkey Statement and Action Plan came into effect on March 20, 2016 [11], resulting in new challenges for health provision and in an even more precarious situation for the refugees who were now stuck in the camps until their asylum procedure was processed [12]. Greece's healthcare system combines public and private elements. The public sector features a national health service alongside a social health insurance model, managed by the National Organization for the Provision of Health Services (EOPYY) since 2011. In the private sector, profit-making hospitals, diagnostic centers, and independent practices operate, many of which contract with EOPYY to offer primary and ambulatory care within the National Health System (ESY) [13]. In 2016, the Greek Parliament enacted a new law (law 4368/2016) that includes a provision (Article 33) granting refugees, asylum-seekers, beneficiaries of international protection, and individuals residing in Greece due to humanitarian reasons or exceptional health conditions the right to freely access services within the Greek Public Health System. Additionally, the law aims to secure free healthcare access for vulnerable groups like minors, pregnant women, and people with disabilities [14]. Disruptions in health care services due to forced displacement also result in negative sexual and reproductive health (SRH) outcomes [15]. SRH is an inalienable component of the right to health and is considered a human right that also applies to those living in constrained humanitarian settings [16]. It encompasses a safe and satisfying sexual life as well as the capability and freedom to decide if, when, and how often to reproduce. This implies, among others, access to safe contraception, health care services, and information [17]. In addition to basic health and needs services, which are crucial at the onset of an emergency, SRH service provision has additionally been recognized as a priority intervention at an early stage [18]. Although SRH care services concern the entire population, women and girls constitute a particularly vulnerable group. They are at increased risk of sexual violence and unsafe abortion, as the collapse of the health system may decrease access to contraception [16]. The Minimum Initial Service Package (MISP) was designed by the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) in 1995 to mitigate bad SRH outcomes. Among those are “preventable maternal and newborn morbidity and mortality; preventable consequences of unintended pregnancy such as unsafe abortion; and preventable consequences of sexual violence such as unintended pregnancies, increased acquisition of sexually transmitted infections (STIs), increased transmission of HIV, mental health problems including depression, and the sequelae of trauma” [17].

The 2018 MISP version encompasses a set of minimum interventions following six main objectives and serves as a guideline for SRH service provision in humanitarian settings. The 2018 version of the field manual additionally emphasizes the need to ensure the availability of safe abortion care “to the full extent of the law, in health centres and hospital facilities” [17] which was used as a seventh objective in the scoping review:

  1. 1.

    “Ensure the health sector/cluster identifies an organization to lead implementation of the MISP”

  2. 2.

    “Prevent Sexual Violence and respond to the needs of survivors”

  3. 3.

    “Prevent the transmission of and reduce morbidity and mortality due to HIV and other STIs”

  4. 4.

    “Prevent excess maternal and newborn morbidity and mortality”

  5. 5.

    “Prevent unintended pregnancies”

  6. 6.

    “Plan to integrate comprehensive SRH services into primary HC” (Healthcare)

  7. 7.

    Safe abortion care “to the full extent of the law, in health centres and hospital facilities”.

Healthcare service provision in humanitarian settings is fluid and heterogeneous in the type, quality, and availability of services and differs with time as well as location. This scoping review focuses on the provision of SRH care services for refugees in Greece. Despite the high public attention and research coverage, little is known about this specific healthcare area. A preliminary search was carried out to determine whether any review studies exist on this specific topic. No such studies were found, which confirms that this scoping review could contribute to the literature. The aim of our study was to explore the sexual and reproductive health care services for refugees in Greece in the framework of the Minimum Initial Service Package and identify common gaps to guide sexual and reproductive health service provision in future humanitarian crises.

2 Methods

2.1 Study design

To map available evidence and provide an overview of the topic, a scoping review was performed according to the Joanna Briggs Institute (JBI) methodology for scoping reviews [19]. The design was chosen based on the aim of the study, as scoping reviews are useful for answering broad questions, can draw upon data from different sources, and are not restricted to a specific study design [20].

2.2 Search strategy and selection criteria

A comprehensive literature search was performed in the following electronic databases: CINAHL, PubMed, PsycINFO, Embase, and Scopus. Google Scholar was used only for search terms with no results in the other databases. Gray literature, including documents and reports from websites of well-known humanitarian organizations (nongovernmental or intergovernmental) working either on policy-making or implementing levels or both, such as the Inter-Agency Working Group on Reproductive Health in Crises (IAWG), International Organization for Migration (IOM), Médecins Sans Frontières (MSF), United Nations Population Fund (UNFPA), United Nations High Commissioner for Refugees (UNHCR), United Nations (UN) Women, Women’s Refugee Commission (WRC), and World Health Organization (WHO) were searched. The search words Greece or Greek and refugees or asylum seekers combined with the following terms were used in the databases as well as in the websites for gray literature: minimum initial service package, Inter-agency Field Manual, access services, sexual violence, gender-based violence, sexually transmitted diseases, maternal, newborn, pregnancy, contraception, contraceptive methods, sexual, reproductive, health, abortion, family planning, antenatal care, obstetric, child marriage, trafficking, AIDS or HIV, sexual reproductive health, and rape. To ensure reproducibility, the literature search is presented schematically in a search log (Supplementary Information 1). The latest search was executed on April 1, 2023. Evidence selection was achieved in a two-step process: (1) title and abstract screening; and (2) full-text examination.

The selection followed predefined inclusion criteria based on the Inter-Agency Field Manual on Reproductive Health in humanitarian settings [17] and the Population, Concept and Context (PCC) mnemonic was applied [20]. The selection process relied on the following inclusion criteria: (a) records focus on refugees and/or asylum seekers based in Greece and encompass at least one of the following themes based on the MISP: SRH service delivery, access to SRH care, any form of sexual violence, HIV and other STIs, contraception, abortion care, and maternal and neonatal health; (b) studies are peer reviewed; (c) studies are conducted between January 2015 and January 2023 following ethical guidelines; (d) records are written in English; (e) the full-text of the study is available. Editorial notes, letters, literature reviews, and articles that did not meet the ethical requirements were excluded.

2.3 Data charting, collating, summarizing, and reporting results

An Excel sheet was develop to extract relevant information from the included literature, such as source details (author, title, and year of publication), study characteristics, and key findings. The extraction sheet was inspired by the JBI Manual for Evidence Synthesis [20] and adjusted to fit the purpose of the present scoping review. The process was performed by the reviewers (FvD, ÁW) separately, and the results were compared and discussed before being entered into the extraction sheet. Disagreements were solved through discussion, and if no consent could be reached, a third reviewer was consulted and involved in the discussion. A quality assessment of the included articles was performed using the “critical appraisal tools” provided by the JBI [21] (supplementary information 2). The assessment was performed independently by the reviewers, and the results were discussed until consent was reached. An overview of the collated relevant results is presented in Supplementary Information 3.

Data were analyzed using a framework synthesis approach, and a reporting template was created for compiling and summarizing the results [22]. The MISP objectives provided the framework for the template and structured the themes for the deductive content analysis. The findings were examined through a descriptive content analysis using basic coding of data [20], which was done manually and then inserted under each corresponding objective. The content analysis was inspired by Elo & Kyngäs [23].

The three terms ‘refugees’, ‘asylum seekers’, and ‘migrants’ are often used interchangeably, and it is not possible to distinguish the study participants’ legal status afterwards. Therefore, the three terms will be used in the results section as they were presented in the original literature; however, the term refugees is used in the Discussion section to describe all humans with foreign status who live in refugee camps.

3 Results

3.1 Search and selection of publications

The search and screening process is reported in Fig. 1. Of 1292 hits in six databases, 1261 were excluded. In total, 93 full journal articles were read, of which 70 did not match the aim and were consequently excluded. In total, 21 Gy literature sources were identified and read, 13 of which were excluded for the same reason. The distribution in study designs of the included literature is presented in Fig. 2.

Fig. 1
figure 1

PRISMA 2020 flow diagram of included literature

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Fig. 2
figure 2

Distribution of study designs by year of publication

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The final literature sample consisted of 23 journal articles and eight gray literature sources. Participants in the included literature were refugees, asylum seekers or migrants, and other key informants. The majority of the study population came from Afghanistan, Iraq, and Syria. A more extensive overview of the characteristics of the included literature is presented in Supplementary Information 2. The location of the different camps by source of literature is presented in Fig. 3.

Fig. 3
figure 3

Map showing the distribution of camps by location, name of camp and reference

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3.1.1 Objective 1: “ensure the health sector/cluster identifies an organization to lead implementation of the MISP” (n = 2)

None of the included research articles focuses on MISP objective 1. However, two of the included gray literature records touched on this objective, especially leadership and referral mechanisms [24, 25]. Criticism was directed towards the lack of leadership and a poor definition of the responsibilities of all local actors, particularly evident in sexual and gender-based violence (SGBV) prevention and response, although not limited to this area [24]. The authors report poor SGBV prevention programming and no evidence of a comprehensive and survivor-centered approach. Moreover, a dearth of cooperation and coordination among the humanitarian actors working on child protection was identified, as well as an inefficient scheme for family reunification and relocation. Referral mechanisms and standard operating procedures were lacking, as were systems supported by the government to respond to SGBV. The SGBV expertise among humanitarian staff was limited.

3.1.2 Objective 2: “prevent sexual violence and respond to the needs of survivors” (n = 16)

A total of 16 sources concerns sexual violence prevention, clinical care, and referral mechanisms, as well as the existence of safe spaces [24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39]. Three sources report on severe protection risks [24, 25, 35], whereof two also highlight security gaps [25, 35]. In terms of protection risks, inadequate facilities and a lack of staff capacity, as well as missing security measures such as police presence, artificial lighting, and secured housing, were mentioned [25]. Among the highlighted security gaps, inadequate infrastructure, deficient information distribution, and a lack of staff capacity and visibility–including a lack of translators and adequate interpretation–were mentioned [24]. In addition, an overall shortage of prevention and response services was reported despite the severe need [24, 35].

The lack of separate water, sanitation, and hygiene facilities and separate accommodations was pointed out by three sources [24, 25, 35]. Furthermore, a mere 20% (99/478) of participants in one study felt safe at night in their accommodations [30], and females felt unsafe using the washing facilities at night [35]. All respondents in another article reported difficulties of access to and a lack of hygiene and privacy, and the study found widespread humiliation related to menstruation and other gender-related elements [37]. Most sites the Women’s Refugee Commission (WRC) visited were inadequate to prevent or respond to gender-based violence [35]. As such, no site has separate accommodations, and the shared water, sanitation, and hygiene facilities do not have locks. No evidence of gender-sensitive site planning was found on the islands of Chios and Samos, while the Eleonas site in Athens was equipped with separate water, sanitation, and hygiene UNCHRfacilities and accommodations for women and children [24]. Children had no shelters available to them [25] and separate accommodations for vulnerable individuals and families were available in rare cases [35]. In one study, 26% of pediatricians reported healthcare needs related to non-accidental injuries or child abuse without specifically pointing out sexual violence. However, 49% of the respondents reported that migrant children require protection from trafficking and exploitation [29].

MSF provided care for sexual violence survivors, including mental health care, in Athens beginning in September 2016 and in Lesvos beginning in August 2017 [34]. MSF activities were outlined in the provision of health care for survivors of sexual violence in Lesvos between September 2017 and January 2018 [27]. They reported limited treatment options because most survivors presented for care months after the event. Among male and female survivors provided with physical, genital, and anal examinations, only 2.8% (6/215) could be treated with optimal care. Although mental health services are the central service for survivors presenting late for care, only severe cases could be transferred [27]. Moreover, in several camps, no formal or informal referral mechanisms were reported, and standard operating procedures were missing (Eleonas, Victoria Square, and Galatsi Stadium in Athens, Chios, and Samos) [24]. In line with that, dysfunctional and slow referral processes for child survivors were reported [25]. Post-rape kits are unavailable, and the clinical management of rape is deficient [24]. In line with that, a lack of post-rape care medications and staff not skilled in the treatment of survivors were reported [35]. Similarly, unskilled staff were identified for the provision of care for and identification of child survivors [25].

Multiple authors point to the difficulties and barriers that refugees face when seeking care for sexual violence. A lack of information concerning which services exist and which personnel to approach was highlighted [24]. The remote locations of most sites with limited available services and culturally insensitive services were noted [35]. Insufficient infrastructure as well as language and gender barriers, such as difficulties for male healthcare providers in addressing gender-based violence, were reported [31]. In line with that, an insufficient number of female translators and gender-based violence staff speaking Farsi and Arabic were identified [35]. Last, they outline bureaucratic barriers such as accessing legal documents necessary for most medical services, the short validity of police notes that allow refugees to legally lodge a claim, and gender-based violence regulations that require a police report for accessing post-rape medication [35].

MSF provided care for survivors of domestic violence and human trafficking on Samos Island and Elliniko site (Attica region) [33, 36]. Between September 2017 and January 2018, 215 survivors attended the MSF clinic in Lesvos, of whom 60 (28%) were male [27]. The patients reported rape, sexual slavery, forced prostitution, and sexual touching during transit and in their country of origin. Cases of rape, transactional sexFootnote 1 [40], early and forced marriage, and domestic violence were identified prior to arrival in Greece [24]. High incidences of forced prostitution and transactional sex were reported [35]. One article found that 32/80 (41%) women had experienced sexual abuse, and 17% of the full study sample suffered gender-based or intrafamily violence [37]. Degrading treatments, such as strip searches and forced genital examinations, were reported by MSF patients [38].

In the MSF Lesvos clinic, 10/215 (5%) of the sexual violence incidences occurred in Lesvos [27]. During their stay on Samos, 39 survivors of SGBV were reported. Among the victims, 28 were male and 11 were female, however, the highest risk was seen among females living alone in the camp [30]. One article quotes women stating that they were harassed every day [35], and another article finds that 17% of the respondents (n = 160) claimed humiliation of a sexual nature [37]. In three articles, the widespread sexual exploitation and abuse of migrant children was highlighted [25, 29, 35]. One article observed arranged marriages paired with virginity tests for underage girls [37]. Contrary to the above, in a study among Syrian refugees in Greece, no participants reported any sexual violence happening during transit in Türkiye or the Greek camps of Ritsone, Katsikas, Hotel Ioannina, Samos, and Athens hotel, with only one participant reporting sexual violence that occurred in the country of origin [28]. Similarly, no cases of sexual abuse trauma were reported among asylum-seeking war refugees residing in United Nations High Commissioner for Refugees (UNHCR) apartments in Larisa [32]. No SGBV episodes were reported by women from Afghanistan, Syria, or Iraq [30]. However, the authors report a high (13.4%) nonresponse rate in their questionnaire for sexual violence. One article highlighted the tendency of survivors to only seek assistance if urgently needed [24].

Safe spaces were highlighted for their importance in protection against GBV [39], however, a lack of such spaces was reported [24]. Some humanitarian organizations established safe spaces [35], while elsewhere, one safe space with limited opening hours and two camps without any safe space were identified [39]. Protection gaps were especially severe in camps with many single men and minors [31], trans and nonbinary people [26], and women living alone [30, 31]. It was reported that several people had to be evacuated because of homophobic aggression [37].

3.1.3 Objective 3: “prevent the transmission of and reduce morbidity and mortality due to HIV and other STIs” (n = 4)

A total of four studies and one gray literature mentioned provided health care services related to MISP objective 3 [27, 34, 41,42,43]. Treatment for transmittable sexual diseases has been offered in MSF clinics in Athens since 2016 [34] and in Lesvos since July 2015, with extended services for mental health care and social support for survivors of torture and sexual violence from the summer of 2017, including STI prophylaxis and treatment, postexposure prophylaxis (PEP) for HIV, and vaccination against hepatitis B [27]. Evidence of health issues, including hepatitis, was reported in one study [41], in contrast to another study, where no cases of hepatitis A, B, or C infections were observed [42]. One study showed that refugee or migrant women had approximately seven times higher odds of never having had a Pap test (screening for cervical cancer) than Greek women and that refugee or migrant women had less knowledge in the prevention of cervical cancer than Greeks, even when nationality, level of education, and age were taken into account, which suggests a barrier to their participation in prevention activities [43].

3.1.4 Objective 4: “prevent excess maternal and newborn morbidity and mortality” (n = 18)

A total of eighteen sources provided information related to MISP objective 4 [24, 30, 34, 35, 37,38,39, 41, 42, 44,45,46,47,48,49,50,51,52]. In terms of establishing a referral system, the findings show that most antenatal and postnatal care is provided by the humanitarian sector, and pregnant women are referred to public hospitals when needed [34, 44, 47]. In contrast, MFS reported the situation in Samos, where one woman gave birth without any medical assistance and another woman was in labor when the team arrived [38]. To fulfill objective 4, the availability and accessibility of essential services need to be in place [17]. In six of the included sources, difficulties in accessing health services among pregnant women were mentioned [24, 35, 39, 41, 50, 51]. Evidence was found that even when services were provided, asylum-seekers were not accessing them [41]. One of the reasons mentioned was that pregnant women did not want to delay their migratory journey [24, 47]. Apart from that, pregnant women were not sure where to go to give birth [35]. Lack of interpretation services was mentioned as one of the biggest challenges [39, 44, 45]. Similarly, difficulties in communication both in the camps and the national hospitals were reported [39]. An overburdened health system and a lack of healthcare professionals were reported reasons for the high rate of cesarean births [39, 44]. A participant quotation reflecting this finding was: “The only time you would have a natural birth was if you came in and they didn’t have time to get you to an operating room” [32]. However, Liori et al. reported a lower rate of cesarean birth among refugees compared to Greek citizens [52]. Moreover, women received poor postnatal support [35, 39, 51]. Maternal vitamin D deficiency (VDD) was significantly higher for refugees than for Greeks, which led to most of the refugee newborns being affected by VDD [52]. The quality of food was poor; pregnant and postpartum women did not get any specialized food [35, 37], and it was generally difficult to access vitamins and minerals [51]. Similarly, lactating women had a risk of developing malnutrition disorders in the camps they visited [24]. This finding is in line with evidence of a low prevalence of acute malnutrition but a high prevalence of stuntingFootnote 2 [53] in children below five years of age living in refugee camps in Greece, which may be caused by malnutrition in mothers or incorrect administration of formula milk [48]. In the Moria reception center, it was reported that one baby had died from dehydration [37]. One study interpreted the low level of urinary and gastrointestinal infections as an indicator of overall good hygiene in the camps [42], whereas two other sources stated that the living conditions are not suitable for children and that there are large challenges to keeping newborns clean [37, 41, 49]. The low percentage of overall mortality and referrals was found to be an indicator that primary care is adequate for refugees [42]. However, an increased demand for pediatricians was found that cannot be met, which is why pediatric patients have been turned away when seeking care (approximately 15 patients per day) [49]. In line with that, no access to neonatal care was reported [51]. Vaccination was mentioned briefly: MSF provided vaccination for children from three weeks of age [41], and gaps in vaccination programs and a lack of access to vaccines were reported [45, 51].

3.1.5 Objective 5: “prevent unintended pregnancies” (n = 6)

Family planning services were discussed in six sources [27, 35, 39, 50, 51, 54]. In terms of providing information and contraceptive counseling, two sources report that refugee women need and ask for family planning options [35, 39]. While evidence was reported in one study that contraception education was provided to women visiting safe spaces [39], no such service was available at the sites WRC visited [35]. In addition, 36.8% of staff in various Greek camps reported no access to family planning or contraceptive services [51]. In the study by Desipris et al. (2022), 5.6% of the 132 participants sought family planning consultation [50]. In terms of availability of long-acting, reversible, and short-acting contraceptive methods, no extensive information could be found on which contraceptive methods were provided. One study addressed emergency contraceptives; among 155 female survivors of sexual violence attending the MSF clinic, due to their late arrival at the facility, a mere five were eligible and three were provided with emergency contraception [27].

3.1.6 Objective 6: “plan to integrate comprehensive SRH services into primary HC” (n = 18)

Eighteen of the included sources deal with the implementation of the provision of healthcare services, i.e., which services were available and which gaps and barriers existed [24, 26,27,28,29, 31, 33,34,35,36,37, 41, 47, 49,50,51, 54, 55]. In terms of information sharing with the affected community, one study reported that information on how to obtain health care was high, at 60.3% in Samos and 84.9% in Athens hotels [28]. In contrast, one study focused on cervical cancer found that no Syrian refugees were aware of the free-of-charge cervical cancer screening program available to them [55]. Seventeen of the included sources brought up limitations to accessing health services for a variety of groups and services [24, 27, 29, 31, 33,34,35,36,37, 41, 46, 47, 49,50,51, 54, 55]. As such, access to antenatal and perinatal care and access to a physician, pediatrician, midwife, and psychologist were assessed as minimum or non-satisfactory by key informants from the migration camps in Greece [51]. In another article, 27% of the participating European primary care pediatricians (2.9% from Greece) reported that migrant children have barriers to accessing health services [29]. Similarly, reproductive health, child health, and protection were health needs that were not met [47]. This is in line with the finding that target care and referral mechanisms need to be in place to protect children and adolescents who need specific protection and women at risk of GBV [31]. Limited access to response services for survivors of SGBV was reported [24]. Similarly, an unmet need for mental health services for survivors of sexual violence who requested support for coping with their mental health was found [27]. In terms of human resources management, it was found that healthcare providers had limited training regarding the clinical management of rape [35]. Moreover, one of the main barriers to accessing healthcare was understaffing, as well as structural and economic barriers and administrative delays [36, 50, 51]. Six articles touched on the availability of supplies, which is another central aspect of integrating comprehensive SRH services [31, 35, 36, 50, 51, 54]. Last, healthcare services were limited because nongovernmental organizations and local pharmacies did not systematically stock medicines [31].

3.1.7 Objective 7: safe abortion care (n = 2)

One of the included research articles and one of the gray literatures drew on safe abortion care provided to refugee women. At local MSF clinics providing SRH services, it was found that among 10 pregnant survivors of sexual violence, three requested abortions, with no information on whether this service was accessed after referral or not [27]. Refugees, asylum seekers, and migrants face bureaucratic barriers when accessing abortion care in the Greek public health system. These are, among others, multiple appointments with health professionals, long waiting times, and language barriers, as well as the legal limit of abortion up to 12 weeks gestational age [56].

4 Discussion

This scoping review outlined the state-of-the art of research on sexual and reproductive health services in Greek refugee camps between 2015 and 2023 against the framework of the Minimum Initial Service Package (MISP) highlighted gaps in service provision as reported in the included studies. The low coverage of the MISP objectives in the original research is one important finding and constitutes a major obstacle to fulfilling the aim. The analysis reveals the uneven distribution of research attention, which leads to a lack of data on coordination, STI treatment, family planning services, and safe abortion care, while much research focuses on sexual violence prevention and response. As such, the results show huge protection gaps and a dearth of support services for survivors, of which mental health care may be the most central. Moreover, multiple sources highlighted the difficulties in gathering data on sexual violence incidence due to the topic's sensitivity and cultural barriers. In line with that, various limitations to accessing services are identified, hindering refugees from receiving the high-quality care they need.

One of the main findings concern the lack of data on essential SRH services. When it comes to the transmission of HIV, limited availability of data and research were found in studies on Syrian refugees in Türkiye [15, 57]. Similarly, the European Centre for Disease Prevention and Control (ECDC) finds very limited data availability on the continuum of care for HIV, with only four out of 55 European Union member states, plus Liechtenstein and Kosovo, providing data on all stages of the continuum [58]. Our findings support a need for HIV/STI transmission surveillance in humanitarian settings in which vulnerable groups are especially exposed due to risky sexual practices such as survival sex. This is also supported by the finding of a steep rise in annual HIV infections, corresponding to 17% in the Middle East and North Africa [59]. A systematic review on HIV-TB co-infection among migrants in European countries found a disproportionally higher infection rate among migrants compared to nationals [60], and a cross-sectional epidemiological survey among undocumented migrants in the Bordeaux region and Paris found an HIV prevalence of 3.5% [61].

Other essential SRH services are contraception provision and access to abortion services. A survey on contraception usage among asylum-seeking and refugee women of reproductive age living in government-funded community shelters in Berlin was able to obtain detailed information on (the unmet) contraceptive needs, used methods, and the abortion rate of their study participants. They found an unmet contraceptive need of 47% and a knowledge gap on effective methods and how to access them in Germany. Moreover, 7.8% of the sample reported having had at least one abortion [62]. Our findings are further supported by evidence that family planning is the least prioritized reproductive health activity and receives limited attention in humanitarian contexts. When mentioned in proposals, activities were rarely described in the included literature. Already in 2015, it was shown that abortion care services were rarely mentioned in humanitarian activity proposals [57]. Since then, the Inter-Agency Working Group on Reproductive Health in Crises has emphasized the importance of ensuring the availability of safe abortion care to the full extent of the law [16]. A more recent study in Cox’s Bazar identified organizational and structural challenges in providing comprehensive abortion care due to funding bodies' requirements and international policies like the Mexico City Policy [63]. It is known that contraception prevents unwanted pregnancies and reduces abortions and maternal mortality or morbidity [61]. In light of the disrupted healthcare during displacement and provision gaps in camps, a failure to meet contraceptive needs is especially serious in refugee populations.

Many of the included literature sources examined sexual violence, and they reported contradictory results concerning its prevalence. One reason for the contradictory findings may be the variety of included literature and differences in methods for evidence collection. Other possible confounding factors mentioned in our corpus are the presence of family members or interpreters during evidence collection and unspecific questioning for SGBV due to cultural sensitivities, difficulties in understanding the questions, differences between individuals traveling alone or in groups and family units, and variations in travel routes. Multiple studies emphasize the topic's sensitivity and note that SGBV survivors tend to keep their experiences of violations to themselves. Moreover, the answers between the affected population and key informants may vary. One study on SGBV among refugees, asylum seekers and undocumented migrants in the Netherlands and Belgium reports that 39% of study participants have experienced SGBV, and another 35% know at least one close peer who has experienced SGBV [64]. Similar to our findings, several studies examining the phenomenon in Lebanon were identified [15]. However, in contrast to our findings of inadequate mental health services for sexual violence survivors and a lack of formal referral mechanisms, protection and prevention programs were identified in Lebanon, along with clinical and psychological healthcare services for survivors [15]. In the few articles on GBV among refugees from Syria residing in Türkiye, a prevalence of sexual violence and harassment ranging from 8 to 30% was found [57], whereas the sexual violence incidence in Lebanon were 8.7% [15]. However, these numbers might be underestimations as our results show many barriers to accessing care and a tendency among survivors to only seek care when urgently needed. Also in Lebanon, the low number of survivors seeking medical care was emphasized [15, 65]. Moreover, in line with our findings, fear of sexual violence leading to women restricting their freedom of movement as a consequence are reported. Inadequate protection and infrastructure, such as unisex latrines, insufficient lighting, and insecure housing, further promote this fear and feeling of insecurity [15, 65].

Multiple sources brought up the high rates of cesarean births, which were attributed to the lack of healthcare providers and the overburdened Greek health system. Over half of all births in Greece are cesarean sections, which is 35–40% more than recommended by the World Health Organization [66, 67] and it could be argued that not being admitted to a health facility when opting for a vaginal birth is a violation of women's rights. Women can face disrespect and abuse throughout pregnancy, and childbirth is a particularly vulnerable situation for any woman [68]. In settings with limited capacity, the importance of making decisions regarding cesarean sections based on medical indications has been emphasized, as they can cause permanent complications, disabilities, and, in the worst cases, even death [69].

Limitations for accessing health care and different informal barriers that hinder refugees in Greece from accessing the health care services they need emerged from much of the included literature, while one study reported high information on how to obtain health care, yet without reporting on the actual access. This discrepancy could be explained by the differences between the studied camps or by a difference in having information on how to obtain and access care. Apart from that, the lack of interpretation services was a major challenge and a reality both in the camp and the national hospitals. This is supported by another study that similarly points to the lack of interpretation services and cultural mediation services as a barrier [70]. Another barrier to providing adequate health care services for refugees in Greece was limited training for the health care providers, which is similarly reported in multiple other settings [15, 70, 71]. Some of the included literature highlights the difficulties in accessing healthcare services provided for women, which is in line with findings in Türkiye where insufficient access to healthcare services for women was reported [41, 57]. A formal barrier found in this study was the challenge of obtaining legal documents that are required to access GBV response services and a regulation that required survivors to report to the police to obtain post-rape medical care [35]. Compared to other countries within the European Union, access to health services varies among states and the legal status of the migrant, but restrictions on emergency services for undocumented migrants are common in most countries [72, 73]. Moreover, for asylum-seekers, the permanent Social Security Number (A.M.K.A.) was stopped in November 2019, and the issuing of the Provisional Social Security and Health Care Number (PAAYPA) was delayed until January 2020, limiting access to health services for the period in between [74].

4.1 Ethical considerations possibly affecting the results

Research ethics concern both the research object itself and the personal conduct of a researcher [75]. In this scoping review, the reviewer’s conduct was the object of all ethical considerations. Ethical principles were considered during the screening and selection of articles, meaning specifically that either the underlying study needed to be approved by an ethical review committee or informed by an international agreement on research ethics, such as the Declaration of Helsinki [76]. Critical points can be the inclusion of refugees as a vulnerable group as study participants, which may impact the voluntariness of participation [77]. In a refugee context, this may encompass the false perception that participation positively influences access to services or benefits [78]. Language and literacy constitute further potential barriers to informed consent [5]. Moreover, some of the included studies encompassed very sensitive topics such as sexual violence and child abuse, which may have the potential for re-traumatization. It cannot be ascertained how the researchers dealt with sensitivities in conducting research.

4.2 Strengths and limitations

The major strength of this study is the scoping review methodology, with synthesis of data retrieved from multiple databases along with inclusion of gray literature which rendered a body of literature including different study designs and a broad coverage of different migrant populations and refugee camps. Another strength of this scoping review is the added quality assessment of the included articles. Although this is not a standard procedure when conducting scoping reviews, the assessment ensured inclusion of articles of higher quality and trustworthiness, however, no articles were assessed as low in quality. Furthermore, the search process was guided by a professional librarian with experience in building search blocks to find relevant literature. A limitation in this aspect was the criteria to only include English articles available in full text since relevant data might be missed, thus affecting credibility. Google Scholar provides literature across many disciplines but was used only for search terms with no results on the other databases. This is a limitation, but, on the other hand, it limits the number of duplicates to be removed and increases reproducibility as Google algorithms are constantly changing. The choice of the nongovernmental and intergovernmental organizations, from which relevant gray literature was retrieved was subject to the reviewer's opinions to only include those sources that are generally recognized as credible and trustworthy and most recognized internationally, i.e. well-known. This could introduce selection bias as other gray literature sources were not searched. To minimize bias in evidence selection and data extraction and ensure the results' trustworthiness and credibility, the review process was conducted separately by the two reviewers and followed by joint comparisons and agreements.

5 Conclusion

Greece hosted a large proportion of refugees migrating to Europe from 2015 and onwards, and in their refugee camps people faced multiple barriers in accessing SRH services outlined in the MISP. The available research on the essential SRH services family planning and safe abortion care is scarce, while much literature focus on areas such as sexual violence and maternal and child health. In extreme humanitarian crisis, provision and access to healthcare services are subject to priorities, available funding, and staffing. However, every gap in essential health service provision, including SRH services, constitutes a fundamental breach of basic human rights. Extending SRH services to meet the needs of refugees living in humanitarian settings and facilitate access to quality care is crucial. Existing knowledge must be implemented to mitigate bad SRH outcomes and humanitarian coordinators must be trained on the MISP and work to fulfill all objectives, including safe abortion care. More research is needed to investigate the availability of family planning services and safe abortion care to identify barriers, facilitate access, and implement best practices. As the number of people on the move is expected to rise, more research on long-term solutions and comprehensive SRH is needed.