Think of providing for a state in conflict, and you’ll probably imagine rations of food and water. Life-saving medicines. Stitches and surgical tape.
You probably wouldn’t think of birth control pills.
And you wouldn’t be alone. “The humanitarian health response has focused on food, water, shelter, and primary health care,” said Sara Casey, a professor of population and family health at the Columbia University Medical Center.
However, that kind of thinking leaves gaps in women’s health care that can sometimes prove fatal.
“Fifteen percent of pregnant women experience life-threatening complications,” Casey explained.
In addition, women in the midst of a humanitarian conflict are less likely to have reliable access to birth control than women who aren’t. They’re more likely to experience unwanted pregnancies and unsafe abortions.
“People don’t stop having sex once they’re displaced, but a lot of people don’t want to be pregnant or have children when they’re in this unstable situation,” Casey said. “It makes it more difficult for a woman to flee.”
Women in conflict are also vulnerable to sexual and gender-based violence, including rape and intimate partner violence. And in patriarchal societies where women are less empowered, a woman who experiences violence may be less likely to seek help.
Women struggling to feed themselves or their families are in danger of turning to transactional sex, increasing the risk of unwanted pregnancies and sexually transmitted disease. To provide for very young women or protect them from other forms of gender-based violence, a family may urge a young daughter to marry early.
If a woman is pregnant, the list of dangers goes on. A lack of access to healthy food places an unborn infant at risk. Younger mothers may be at higher risk of complications – a January 2019 report by the Syrian American Medical Society, known as SAMS, found that young mothers made up a disproportionately high number of C-sections at a facility in southern Syria.
In Syria, conflict has been ongoing since 2011. 6.5 million people are displaced within the country itself, and even more are refugees.
Among one population of Syrian refugees, Foster found, rates of early marriage – itself considered a form of gender-based violence – had doubled.
Dr. Ikram Haboosh, a Syrian obstetrician, heads a maternal and pediatric hospital in Idlib, which has frequently been the object of airstrikes. For her patients “displacement has resulted in a sharp increase in risk of morbidity and mortality among children, projecting significantly higher rates of underweight and premature births,” she wrote in an email to Direct Relief.
And in a conflict in which hospitals and health workers are regularly the targets of bombing, labor can become more dangerous. Dr. Haboosh described an incident from about eight months ago: The area around her hospital came under fire, and expectant mothers and children urgently needed to be evacuated.
The hospital emptied out. Dr. Haboosh, however, couldn’t leave immediately. She was in the middle of performing a C-section. An while she managed to deliver the infant safely, she credits the stress with causing her own miscarriage that day.
Even in less dramatic circumstances, it’s increasingly difficult to provide health care. “For all doctors in every specialty, there is a shortage in staff, in medications, and in medical equipment and supplies,” Dr. Haboosh said. “We’re constantly suffering from this shortage and are often prevented from receiving patients as a result.”
Because of the shortage of doctors, midwives have frequently been forced to fill the gap, taking on greater responsibility during deliveries.
Direct Relief is working to help fill the gaps in sexual and reproductive health care in Syria, working with two organizations that support Syrian hospitals.
Through NuDay Syria, an aid group that focuses on women and children, Direct Relief is supplying birth control pills to Jisr ash-Shughur, an area of the larger Idlib governorate that, because it’s comparatively safe, is currently home to a high number of displaced women and children.
The hospitals that NuDay supports will provide contraception to women in their facilities and also through mobile clinics that are designed to reach displaced women living in camps.
“When we did a needs assessment…asking different doctors what they’re seeing the patients asking for the most,” explained Huda Alawa, development director at NuDay Syria. One of the most common requests was for birth control.
“In points of conflict, it’s most important as a woman to know that you have this agency,” Alawa said. “If there’s any violence, you know you have a backup.”
Primarily, those seeking birth control have been married women in their 30s.
That’s in line with what Foster describes as cultural norms. For younger brides, “there’s a tremendous amount of pressure to prove fertility as soon after marriage as possible,” she said. Younger brides seeking birth control is “not a thing.”
In addition, Direct Relief has supplied 59 full midwife kits, and 12 replenishment kits, to the Syrian American Medical Society, a long-term partner. SAMS supports and provides health care throughout Syria and in a wide variety of refugee settings.
Midwives will use the kits during deliveries in Syrian hospitals. “As [midwives] have taken on greater responsibilities in normal delivery, their skills, experience, and qualification have likewise improved from before” the conflict, Dr. Haboosh said.