Home / Syria‘s Women / Health

AUGUST 16, 2017

Summary

  • Since the start of conflict in 2011, 57% of Syria’s public hospitals have been damaged, and 37% are no longer functioning; the Syrian government and its allies have perpetrated 90% of these attacks.
  • Women’s health care is sidelined by urgent trauma care, yet prolonged emergencies create issues with family planning, mental health, and children’s health that have lasting impacts on communities.
  • International law prohibits targeting of hospitals and health facilities, and new Sustainable Development Goals set targets for improving women’s health care, but international action and assistance to Syria have not lived up to these.

Current Situation

For the vast part due to the systematic destruction of health facilities and murder of health care providers by the Syrian government, less than 25% of women in Syria have access to reproductive services. As a result, women’s healthcare—particularly safe pregnancy and delivery—has suffered greatly: the rate of cesarean sections has almost tripled, accounting for 70% of births in private hospitals, as World Health Organization (WHO) representative Elizabeth Hoff reported, despite high risks for both mother and child that are heightened by the reduced access to continuing care. Preventative care, such as mammograms and pap smears, is all but nonexistent, and women with chronic conditions lack access to medicine and care. Additionally, sexual violence has reached crisis levels, but access to mental health care is minimal, with only one functioning mental hospital in the country and intense stigma surrounding sexual assault and its discussion.

The WHO requested $163 million for its 2017 Humanitarian Response Plan in Syria, allocating more than $60 million to strengthening secondary and obstetric care, but delivering this aid is difficult. In 2014, the UN Security Council unanimously adopted resolution 2139 demanding safe delivery of humanitarian assistance and respect of medical neutrality, but since then the Syrian regime has continued its use of targeted (mortars, missiles, arson) and indiscriminate (barrel and cluster bombs) artillery, expressly condemned in the resolution.

Background

Prior to the outbreak of violence in 2011, Syria’s health care had been steadily improving for four decades. Life expectancy increased from 56 years in 1970 to 73.1 years in 2009, while maternal mortality dropped from 482 out of every 100,000 live births to 52 in the same period. This put the country on track to meet Millennium Development Goals (MDG) of reducing maternal mortality rates by three quarters by 2015, despite difficulty with the second target of achieving universal access to reproductive healthcare. But, since 2011, the Assad regime has routinely targeted health facilities and personnel: in 2012, the Syrian government passed an anti-terrorism law criminalizing medical aid to the opposition, thus justifying the bombing of hospitals and the arrest and execution of doctors. Between 2011 and June 2017, there were 478 attacks on 325 health facilities, killing at least 826 medical personnel. Over 90% of these attacks perpetrated by the Syrian government or allies (with 7% carried out by rebel forces and 3% unknown).

Women living in areas occupied by opposition forces or in actively besieged zones have almost no access to health care at all, and those who do manage to make it to hospitals are at high risk of bombing and shelling. The lack of formal healthcare services has led to an upsurge in the number of clandestine gynecological clinics, but these are often run by “inexperienced and uncertified midwives,” putting newborn children at risk. Even within hospitals, the number of qualified health care providers is extremely limited, with assessments estimating that only 0.3% of health staff were qualified emergency doctors.

The Islamic State, in a propaganda video from 2015, boasted of an “advanced” healthcare system: clean, modern, and fully staffed. However, in reality, Islamic State areas face a personnel shortage as doctors flee or die. Strict gender separation and dress codes on women pose problems during birth or any other neonatal complications, issues compounded by policies like a ban on the importation of Iranian medical products.

Refugees have better access to healthcare than those within Syria, but challenges remain. Rape and sexual harassment are major issues in camps, and over half of all Syrian refugees are in need of psychological services, but only 5% currently receive it. In Lebanon, 41% of young women reported thoughts of suicide and over half of all refugee children are estimated to suffer from PTSD. Women often have to use the same bathroom and shower facilities as men and report being watched while they use the toilet. This leaves women vulnerable to assault, and leads some women to avoid using the bathroom, causing discomfort and frequent urinary tract infections. Births under 18 are rising as contraceptive use falls, though the vast majority of births are in health facilities; reportedly 96.9% of refugee women in Jordan gave birth in health facilities in the first quarter of 2014.

Policy Implications and Challenges

UN Security Council attempts to address the targeting of medical facilities and personnel have met with little success, and 2015 was deemed the deadliest year yet for healthcare in Syria. New development goals—known as the Sustainable Development Goals (SDG)—renewed global commitments to women’s health by 2030, but came without structural changes. US allocation for humanitarian assistance to Syria for 2017 dropped $62 million from 2016 and the defunding of reproductive health programs greatly reduces any possibility additional assistance may be provided for women’s health in Syria in the near future.

In weaponizing access to health care, the Syrian government’s primary purpose is to contribute to siege conditions by denying both civilian and combat populations essential health care. The widespread targeting and destruction of medical facilities is not only a flagrant abuse of international law, but also has profound negative consequences on the civilian population both now and in the future. Reduced access to healthcare, particularly for women, reverberates for years through disrupted family planning and children’s health. Additionally, attacks on health care contribute to the mass exodus from Syria and the resultant destabilization of an entire region. Healthcare must be protected and prioritized, and the international community’s material contributions to health care and implementation of accountability mechanisms for those who target health facilities must match their rhetoric against actions that threaten further damage.

This report is part of TIMEP-News Deeply’s Syria’s Women: Policies & Perspectives partnership. It first appeared on News Deeply’s website here.

For Many Syrian Women, Healthcare is a Matter of Geography

Author: Florence Massena and Youmna al-Dimashqi

For many Syrian women, destruction of the country’s medical system means access to health facilities can be determined by location. But as hospitals and clinics continue to come under attack, civil society organizations are trying to fill the gap in women’s healthcare.

Healthcare in SyriaFemale doctors in Syria perform a cesarean section on a pregnant women. (Molham Volunteer Team/ Facebook)

In Syria, access to critical and life-saving healthcare for women is now often determined by where they live in the war-torn country, according to research and multiple organizations on the ground.

Lack of access to healthcare is primarily due to the numerous devastating attacks on health facilities and health workers over the past six years of war. More than 320 health facilities were attacked between 2011 and June 2017, some more than once. The Kafr Zita Specialty and Maternity Hospital in Hama province, for example, has been attacked at least 10 times since the conflict started, according to Physicians for Human Rights, and the last attack in April 2017 put the facility out of service.

At least 34 attacks between 2014 and 2017 targeted facilities that specialize in women or children’s healthcare, according to data compiled by Syria Deeply.

The deliberate targeting of doctors and nurses and other healthcare providers has also taken a tragic toll. At least 826 medical workers have been killed since 2011, including 85 women, according to Physicians for Human Rights.

This has left certain medical fields “particularly understaffed, notably sexual and reproductive, and mental healthcare,” according to a report from the Whole of Syria Health Cluster.

“In general, women have access to limited care that is dependent on a security situation that is never stable,” said Halima Husein, project medical referent for the French medical organization Medecins Sans Frontieres (MSF) in Syria. “Sometimes this access can be limited or nonexistent, depending on the location of the patient [and] the nearest primary health center (PHC). Assistance … is often improvised due to the limited medical and staff resources.”

Attacks on health infrastructure and personnel continue in Syria with relative impunity, making hospitals some of the most dangerous places in the country.

An estimated 360,000 women in Syria and 112,800 Syrian refugees in neighboring countries were pregnant in 2016, according to the United Nations Populations Fund. Most did not have access to proper healthcare or facilities for safe childbirth.

Of the 43 childbirth centers in Syria, by the end of 2015, only 16 remained, according to Elizabeth Hoff, WHO representative in Syria, who added that most of them are located in rural areas that are hard to reach because of the unstable security situation. “Women and some health professionals fear to leave their homes to reach the facility at night time and prefer cesarean delivery at a planned time,” she told News Deeply.

In 2015, 70 percent of childbirths were done by cesarean section in private clinics and 37 percent in public hospitals – a significantly higher rate than the 26.4 percent in public hospitals in 2009. Maternal mortality rates have also risen from 52 deaths per 100,000 live births in 2009, according to the Ministry of Health, to 68 in 2015, Hoff said.

“There are no 24-hour clinics that treat pregnancy complications. During bombings many pregnant women would bleed or even have a miscarriage because of fear,” said a member of the Molham Volunteering Team (MVT) who asked not to be named for security reasons. MVT is a local NGO in northern Syria that helps to fund hospital fees and other childbirth costs.

In light of the grim healthcare situation for women in Syria, international and local organizations like MVT are trying to fill the gap.

For example, despite the number of attacks on women and pediatric health facilities in Idlib province, civil society and NGO groups have opened hospitals and specialized centers in the cities of Idlib and Ariha that are relatively safe for women to access, according to Husein.

She added that this was not the case in the town of Qirata in Hama province, where the nearest PHC is difficult to access. There were at least 10 attacks on maternity and pediatric facilities in Hama between 2014 and 2017, according to Physicians for Human Rights.

In Idlib, advocacy group the Syria Campaign is in the process of constructing an underground health facility for women and children, the Avicenna Hospital, to keep patients and doctors safe from aerial attacks. The Violet Organization (VO), a south Turkey-based NGO that operates in six Syrian provinces, runs another center in rural Idlib where women can go for pregnancy checkups, consultations on reproductive health and family planning. The hospital also offers treatment of diseases that predominantly affect women, such as ovarian or breast cancer.

“Women’s health is especially important because of the changes that they go through, such as pregnancy and childbirth, in addition to diseases such as AIDS and others, that can lead to death when not treated,” said a member of VO, who also asked not to be named for security reasons.

The hospital also provides some pediatric services, such as checkups and incubators. Though some women do return to the hospital after giving birth to check on the health of the baby, the number is much lower than those who visit for pregnancy checkups, according to the member of VO.

“Women often come only when necessary,” the VO member added.

The majority of local organizations specialize in healthcare issues arising from pregnancy and childbirth – women are particularly at risk during that time and many cannot afford the costs.

“There are no specialized hospitals that provide free care, and each visit to a doctor costs $4, in addition to the cost of medication. Some free hospitals exist but don’t provide good healthcare and are sometimes hard to reach,” said the member of MVT.

“Most pregnant women give birth in private hospitals in an effort to care for their children and for themselves,” the volunteer said, adding that “many others choose to give birth without medical care because of the high fees. Some women rely on midwives.”

The gap in access to specialized healthcare also increases the fatality risk associated with illnesses that predominately affect women, such as breast cancer. Kids Paradise Organization (KPO), a Turkey-based Syrian NGO that supports children in hostile or unstable situations, has tackled this issue by opening a center dedicated to breast cancer, “the most common cancer in women both in the developed and less developed world,” according to WHO.

“There is a lack of awareness among women. They have a great need for healthcare throughout different stages of their lives, especially during pregnancy and childbirth. Women are also at risk for many health problems, such as tumors,” according to a member of KPO, who again requested not to be named for security reasons. “The center was a response to meet the needs of many women, especially those who with tumors and cancers who lacked the medical care to detect or treat those diseases.”

The situation does not improve for women who fled Syria for neighboring countries such as Jordan, Turkey, Iraq and Lebanon, where they often lack money to consult a gynecologist.

“For many refugee women, access to safe and clean sanitation facilities, menstruation pads, gynecological services and information about their health can be extremely rare,” said Mandana Hendessi, director of the Iraq and Syria response for Women for Women International, a nonprofit organization that provides services to women IDPs and Syrian refugees.

“This is also related to gender-based violence. Having safe sanitation facilities and spaces for women in refugee camps is particularly important, as many have been attacked while on their way to or from the toilets. While regulations state that these facilities must be well-lit and have lockable doors, these standards often go ignored,” Hendessi said.

The organization also addresses contraception needs through family planning sessions, giving options to women who don’t want or can’t afford to get pregnant.

But supporting women’s health is not only a question of facilities, staff and access, it also involves enabling them to take care of themselves and their children.

The Mazaya Center, a local Syrian NGO that deals exclusively with women’s issues in northern Syria, provides first-aid and paramedic training, workshops and seminars to women in northern Syria. The training sessions, offered to 25 women for two months, are conducted by female nurses and aim to raise women’s awareness of reproduction, health and family matters. The organization also publishes a weekly magazine dedicated to women’s issues, including health-related concerns.

Empowering Syrian women in matters of health, in addition to helping them access proper medical care, could be a step toward make them more autonomous in overcoming the lack of basic health services in the country.

“Women’s issues are certainly very important and we must pay great attention to them, especially during this war that increases their responsibilities by turning many of them to the only breadwinner in their families,” the KPO member said.

“There is also an urgent need to raise awareness, not only among women but also among their husbands and children, about diseases that affect women’s health.”

This report is part of TIMEP-News Deeply’s Syria’s Women: Policies & Perspectives partnership. It first appeared on News Deeply’s website here.

Mapping Attacks on Women and Children’s Healthcare in Syria

Author: Alessandria Masi, Tomás Pfeffer and Ella Pfeffer
Bio: Tomás Pfeffer is a News Deeply intern. Ella Pfeffer is a News Deeply intern.

Syria Deeply has gathered data and mapped major attacks on Syrian health facilities that provided maternity, pediatric and obstetrics and gynecology services.

BEIRUT – On November 16, 2016, Syrian warplanes dropped around 20 barrel bombs on the Children’s Hospital in Aleppo, disrupting services for roughly 90,000 children. Two days later, two missiles destroyed the hospital, the last pediatric facility in the eastern side of the city.

On April 28, 2017, airstrikes hit the largest maternity ward in Kafr Takharim, a town in the northeastern Idlib province. The facility delivered about 550 babies each month.

On the same day, a series of attacks hit the Kafr Zita Specialty and Maternity Hospital in Hama province in just under 24 hours. The final attack, on April 29 at 2 p.m., completely destroyed the hospital, which provided 4,050 consultations, 100 natural birth deliveries and 40 C-sections a month.

More than 320 health facilities in Syria were attacked between 2011 and June 2017, which has taken a devastating toll on women and children. Among the attacked facilities were dozens specialized in maternity, pediatric and obstetrics and gynecology facilities. As a result, access to healthcare for women in Syria is now often determined by where they live.

Syria Deeply compiled the latest available data on the major attacks on Syrian health facilities that either exclusively or primarily provided services to women and children. The findings show that attacks on women and children’s health facilities have been concentrated in the provinces of Aleppo, Hama and Idlib.

https://batchgeo.com/map/2745e641269de50560edb9ce3bbbc017

The data is not exhaustive, as credible reports are unavailable in certain areas of the country. We will continue to update our database as new information becomes available, and we invite contributions.