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By Annie Ramsay-Stagg, Refugees, Health and Humanitarian Action course student, SPS 2021-2022 academic year

Syrian women flee their homes seeking safety in unfamiliar countries. However, for many, their journey is often not one of solitude as they carry a precious companion, - their unborn child. At a time when ideologies of western mothers focus on nesting and preparation, refugees face a multitude of challenges occluding access to essential care. In this blog, I shall expose a key barrier Syrian women face in accessing maternity care in host countries - poverty.

Firstly, let's consider- why is maternity care needed?  

I reflect on this topic as a midwife; I painfully and joyfully understand that paramount to safe childbirth is the right for all women to receive care and for humanity to respond to people in need. Statistics reveal Syrian refugees face higher maternal mortality rates than mothers from host countries (El Kak et al, 2021). This alarming fact calls for us to question the health inequalities women face and the devastating impact of childbirth risks for women and their families. Morbidity in childbirth endured by Syrian refugees includes longer labours and higher rates of cesarean sections compared to non-immigrant women (Alnuaimi et al, 2017). The resulting physical and psychological harm has lifelong implications for women and should never be dismissed or normalised. For Syrian babies, born into a chaotic world, statistics indicate higher incidences of newborn resuscitation, preterm birth and low birthweight (Alnuaimi et al, 2017; Turkay et al 2020). These combined risks build a picture of the unacceptable realities of the health inequalities and disparities that refugees face. And it's time the world responds.

Why are Syrian refugees unable to access care to mitigate health risks? 

I urge you to consider the following - poverty is a major determinant effecting access to care.

It is deeply unjust that accessing care is an unattainable prospect for refugees living in poverty. In Jordan 78% and in Lebanon 73% of Syrian households live below the poverty line (Brown et al, 2019; VASYR, 2019). Thereby, refugees are vulnerable to the harms of reduced engagement with care and impoverishing effects of hospital fees. Poverty is the primary barrier preventing access to maternity services for Syrian refugees living in Jordan, where women only attend 0-4 antenatal checks (Mazhar, 2015). This highlights major disparities, as The World Health Organisation recommends a minimum of 8 antenatal checks (WHO, 2016).

economic barriers also cause delays in care-seeking during childbirth, with 51% of women attending hospitals two hours prior to delivery (Alnuaimi et al, 2017). This statistic allows us to acknowledge  the experiences of women unsafely labouring at home, in pain and without medical attention. concerns of childbirth fees are forcibly hindering care-seeking behavior and subsequently heightening health risks. There is a clear correlation between poverty and its influence in diminishing the right of care for all women.  

Fluctuating commitments of the provision of free maternity care exacerbate health disparities faced by those living in poverty. Many host countries are at the mercy of oscillating international funding and aid. Health funding has direct implications for women living in poverty, as without external financial aid and minimal personal savings, women are deprived of the power to seek care for a safe pregnancy experience. Syrian women have faced substantial costs for care with 33% of women in Jordan and 94% of women in Lebanon paying for care through out of pocket (OOP) payments (Tappis et al, 2017). This lays stark the reality of poverty creating an indestructible barrier to accessing care.   

With host countries facing ever-growing financial challenges to meet refugee health needs, cracks in care provision are deepening. Countries including Jordan have previously rescinded free care due to mounting financial pressures (Mazhar, 2015). This resulted in an increase in childbirth fees from approximately $85 to $338, alongside a 14% increase in women not receiving antenatal care (Karasapan, 2018). Here, families have questioned whether to attend hospital or prioritise saving for other basic needs- a terrifying thought. In 2019, Jordan suspended childbirth fees in public hospitals, however fees remain prohibitively high in secondary and tertiary hospitals (Vos, 2020). Focusing on the experience of Syrian women, this calls to question whether healthcare financing is in line with the WHO's emphasis on the right of all women to have a safe childbirth experience, including refugee women whose rights should be protected (WHO,2018).   

What action could aid the mitigation of poverty preventing access to maternal care? 

The answer is not simple or singular in nature, yet there is lifesaving potential in the actions of humanitarian responses to displaced childbearing women.   

As the global displacement of women grows, greater international solidarity of humanitarian action is needed to save the lives of childbearing women. Development-orientated actors, including financial actors, must work collaboratively and sustainably to strengthen health systems and provision of universal health care to reduce the impact of poverty on access to care (UN, 2015). We must remember the role health financing policies play in accounting for the pressures of refugees on health systems whilst recognising the availability and quality of care to protect the rights of refugees and the host population.  

The Global Strategy for Women's, Children and Adolescents Health (launched to aid the pursuit of Sustainable Development Goals) recognises the intersectionality between poverty and health (UN, 2015). The strategy helps us to envision the reduction of OOP expenditure and increase free universal care as paramount to the provision of equitable care.  Furthermore, the strategy highlights a key message that women face considerable interrelated health challenges, underpinned by poverty, inequality and marginalization. Thereby, efforts to improve access to care requires a multifaceted approach, considering wider health determinants and gendered challenges.  

Alongside protecting women's lives, efforts to mitigate the barriers of accessing care will impact the ending of extreme poverty, promote development and achievement of sustainable development goals. 

No matter how much money they hold, every woman deserves the right to maternity care.  

References

Alnuaimi, K., Kassab, M., Ali, R., Mohammad, K. and Shattnawi, K. (2017) Pregnancy outcomes among Syrian refugee and Jordanian women: a comparative study. International Nursing Review. 64 (4), 584– 592. Available from: https://doi-org.ezproxy.is.ed.ac.uk/10.1111/inr.12382 

Brown, H., Giordano, N., Maughan, C. and Wadeson, A. (2019) Vulnerable Assessment Framework, Population Study 2019 Jordan. The UN Refugee Agency (UNHCR). Available from:  https://data2.unhcr.org/en/documents/details/68856   

El Kak, F., Harb, H., Daouk, S., Nassar, A. and Kabakian-Khasholian, T. (2021) Maternal mortality in Lebanon: Increased vulnerability among Syrian refugees. International Journal of Gynecology and Obstetrics. (Online) 00, 1– 7. Available from: https://doi-o rg.ezproxy.is.ed.ac.uk/10.1002/ijgo.14063

Karasapan, O. (2018) The Challenges in Providing Health Care to Syrian Refugees. Brookings. Available from: www.brookings.edu/blog/future-development/ 2018/11/15/the-challenges-in-providing-health-care-to-syrian-refugees/ 

Mazhar, M. (2015) The Impact of Jordanian Health Care Policy on the Maternal and Reproductive Health Care Seeking Behavior of Syrian Refugee Women. Independent Study Project (ISP) Collection, Paper 2057. Available from: http://digitalcollections.sit .edu/isp_collection/2057

Tappis, H., Lyles, E., Burton, A. and Doocy, S. (2017) Maternal Health Care Utilization Among Syrian Refugees in Lebanon and Jordan. Maternal and Child Health Journal. 21(9), 1798–1807. Available from: https://link.gale.com/apps/doc/A501633 098/AONE?u=ed_itw&sid=bookmark-AONE&xid=a46de8c5 

Turkay, Ü., Aydın, Ü., Salıcı, M., Çalışkan, E. et al (2020) Comparison of pregnant Turkish women and Syrian refugees: Does living as a refugee have an unfavorable effect on pregnancy outcomes? International Journal of Obstetrics and Gynaecologists. 149 (2), 160-165. Available from: https://doi.Org/10.1 002/ijgo.1 3117 

United Nations (2015) The global strategy for women's, children's and adolescents’ health (2016–2030). United Nations, Every Woman Every Child. Available from: https://www.everywomaneverychild.org/global-strategy/ 

Vulnerability Assessment of Syrian Refugees (VASYR), (2019).  Vulnerability Assessment of Syrian Refugees in Lebanon. The United Nations Children’s Fund (UNICEF), United Nations High Commissioner for Refugees (UNHCR) and the United Nations World Food Programme (WFP). Available from:  http://ialebanon.unhcr.org/ vasyr/#/  

Vos, A. (2020) A Decade in Search of Work A review of policy commitments for Syrian refugees’ livelihoods in Jordan and Lebanon. International Rescue Committee. Available from: https://www.rescue-uk.org/sites/default/files/document/2265/adec adeinsearchofworkfinal.pdf 

World Health Organisation (2016) Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva, World Health Organisation. Available from: http://ap ps.who.int/iris/bitstream/10665/250796/1/9789241549912-eng.Pdf?ua=1 

World Health Organisation (2018) Recommendations on Intrapartum Care for a Positive Childbirth Experience. Geneva, World Health Organization. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513809/