A Quiet Crisis: Reproductive Health Among Displaced Syrians

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Miriam Stats

Miriam Stats

Miriam Stats is a fourth year student at Northeastern University in Boston. She will be graduating with a bachelor’s degree in Health Sciences and plans to attend medical school with the hopes of becoming a pediatrician. She currently works at Brigham and Women’s Hospital in the Newborn Medicine department and has completed global health work in Panama. Her particular areas of interest in global health are in the fields of maternal and reproductive health.

Every day, almost 500 women die during pregnancy or childbirth in humanitarian settings. Additionally, nearly sixty percent of preventable maternal deaths take place in regions affected by conflict, displacement, or natural disaster. Physical injury, psychological trauma, unsanitary conditions, and deterioration of health infrastructure create a deadly combination for women that are pregnant and cause women to experience worse pregnancy outcomes as a result. Even though over twenty-five percent of the 100 million individuals around the globe in need of humanitarian assistance at this moment are women of childbearing age and face great vulnerabilities, they are often treated as an afterthought during a humanitarian response, and are provided with inadequate services to meet their needs.1 Because the health of women and children are disproportionally and adversely affected during humanitarian crises, it is a natural imperative that reproductive health services be prioritized. As a global community, we have many times seen the profound impact of a humanitarian crisis on pregnant women and infants. We have seen it in war-torn Afghanistan, where by 2003 levels of prenatal care dropped alarmingly low, and maternal mortality had risen to 1,600 per 100,000 live births2, while in developed countries, maternal mortality is only 12 per 100,000 live births.3 Post-conflict Sierra Leone has a similar story, with one in eight women dying during pregnancy or childbirth, compared to one in 8,000 in the developed world.4

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Since March of 2011, the complex humanitarian crisis provoked by civil war in Syria has resulted in social disruption, political instability, violence, massive population displacement, resource shortages, and the collapse of public health infrastructure. By May of 2014, over 9 million Syrians had fled their homes and among these, nearly half a million of the displaced women were pregnant. In 2014, the UN High Commissioner for Refugees estimated that there were over 1 million displaced Syrians in Lebanon alone5, with pregnant or lactating women in 41% of households. A field-based survey conducted between July and October 2013 of 420 self-identified pregnant Syrian refugees found that nearly 75% of the women wished to prevent future pregnancy, and 52.1% did not desire the current pregnancy at all. However, the study found that only 42.3% of women had access to contraception prior to pregnancy.6 Another study, in which 452 Syrian refugees were interviewed, found that over half reported menstrual irregularity, pelvic pain, and reproductive tract infections. Of the pregnant women interviewed, over 30% experienced complications during pregnancy or during delivery and over 25% of newborns were born prematurely. The women interviewed attributed the barriers to accessing reproductive health services to be cost, distance, shame, unavailability of a female physician, and fear of mistreatment.7 Additionally, many pregnant women were found to be reluctant to access health services even when they were available, out of fear that it would delay their journey or they would become separated from their families.8

As the Medecins Sans Frontieres is currently providing reproductive health care to the Syrian and Palestinian refugees that have fled to Lebanon, we can see a glimpse of the severity of the situation. Many of the pregnant women have come by themselves, leaving behind families that were killed during the war. Most have not had access to antenatal care. This is especially concerning in a humanitarian setting because women that have suffered severe physical and psychological stress are at a significantly higher risk for complications during pregnancy, even if they are otherwise healthy.9 Since the conflict began, there has been an increase in fetal mortality, low birth weight, premature labor, antenatal complications, and puerperal infections.10 Additionally, despite assistance from organizations such as the United Nations High Commissioner for Refugees (UNHCR), Medecins Sans Frontieres, the Lebanese Ministry of Health, and humanitarian NGOs, many women are still unable to afford the cost of a delivery, whether it is a normal delivery or a Caesarean section. This has forced many of the refugees to deliver alone in circumstances that are precarious. Due to the unsanitary conditions that many women are forced to live in, there is a high incidence of infections of the reproductive tract, a primary risk factor for premature birth. Also, many refugee women lack access to basic food sources, which often results in a malnourished and premature newborn. Finally, even if the birth is successful and the newborn is healthy, both the mother and the baby remain at high risk.8 Women must still be provided with postnatal care as severe bleeding and infections after childbirth, along with complications during the delivery, and unsafe abortions account for the majority of maternal deaths.11

During the United Nations General Assembly 2015 in New York, UN Secretary-General Ban Ki-moon launched the Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016-2030, a road map toward ending all preventable deaths of women, adolescents, and children.12 This initiative is a big step forward in prioritizing the health of women and children, but as the crisis in Syria has shown us, there is still much to be done. First and foremost, it is vital that comprehensive sexual and reproductive health services be available at the onset of every humanitarian crisis. The global community must ensure this availability. This should include initiatives addressing prevention of maternal and infant mortality, prevention and treatment of sexually transmitted infections, prevention and response to complications during pregnancy and childbirth, and provision of family planning services. Comprehensive inclusion of modern contraception in humanitarian settings would empower women to take control of their reproductive health. It is estimated that adequate family planning services could prevent up to 30% of the 287,000 global maternal deaths that occur each year, by enabling women to delay pregnancy and space pregnancies to safe intervals.6 Additionally, there must be more attention to violence against women, as many births are a product of trafficking or rape. Finally, while the cost and long distances appear to be the primary barriers to care, it is also important to realize that lack of availability of a female gynecologist is also a significant barrier for women in the Middle Eastern population.7 This indicates a need to increase culturally sensitive care and increase the availability of female physicians to provide these services. The situation in Syria has exemplified the unique needs of displaced women, especially those that are pregnant. These women bear a great burden during a complex humanitarian crisis that the global community should strive toward alleviating.

 

References:

  1. Al Gasseer N, Dresden E, Keeney GB, Warren N. Status of women and infants in complex humanitarian emergencies. J Midwifery Womens Health. 2004; 49 (suppl 1): 7-13.
  2. Bartlett LA, Mawji S, Whitehead S, Crouse C, Dalil S, Ionete D, Salama P. Where Giving Birth is a Forecast of Death: Maternal Mortality in Four Districts of Afghanistan, 1999–2002. Lancet. 2005; 365: 864-870.
  3. Maternal Mortality. http://www.who.int/mediacentre/factsheets/fs348/en/ Updated November 2015. Accessed November 27, 2016.
  4. Child and maternal mortality worst in the world – UNICEF. http://www.irinnews.org/report/77087/sierra-leone-child-and-maternal-mortality-worst-world-%E2%80%93-unicef Published March 3, 2008. Accessed November 27, 2016.
  5. World Food Programme, UN High Commissioner for Refugees, and UN Children’s Fund. Vulnerability assessment of Syrian refugees in Lebanon: 2015 report. file:///Users/miriamstats/Downloads/2015VASyR.pdf Published 2015. Accessed November 28, 2016
  6. Benage M, Greenough PG, Vinck P, Omeira P, Pham P: An Assessment of Antenatal Care among Syrian Refugees in Lebanon. Conflict and Health. BioMed Central, 2015. Web.
  7. Reese Masterson A, Usta J, Gupta J, Ettinger AS. Assessment of reproductive health and violence among displaced Syrians in Lebanon. BMC Womens Health. 2014.
  8. INITIAL ASSESSMENT REPORT: Protection Risks for Women and Girls in the European Refugee and Migrant Crisis. UNHCR. http://www.unhcr.org/en-us/protection/operations/569f8f419/initial-assessment-report-protection-risks-women-girls-european-refugee.html Accessed November 27, 2016.
  9. Syrian Refugees in Lebanon: Pregnant Women Often Have No Idea Where to Go. MSF USA. http://www.doctorswithoutborders.org/country-region/syria Accessed November 27, 2016.
  10. US Agency for International Development, Division of Family Planning. Healthy timing and spacing of pregnancies: a family planning investment strategy for accelerating the pace of improvements in child survival. Brief, 2012. http://www.usaid.gov/sites/default/files/documents/1864/calltoaction Accessed November 29, 2016.
  11. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels JD, et al. Global Causes of Maternal Death: A WHO Systematic Analysis. Lancet Global Health. 2014; 2(6): e323-e333.
  12. The Global Strategy For Women’s, Children’s and Adolescents’ Health (2016-2030). WHO. http://www.who.int/pmnch/media/events/2015/gs_2016_30.pdf Accessed November 29, 2016.