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 works with local partners to provide services to women IDPs and Syrian refugees in the Kurdistan Region of Iraq.
“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, providing women with information on family planning.
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 article has been updated to accurately reflect the nature of services provided by Women for Women International.