August 07, 2013

“I was seven months pregnant when I came to Lebanon,” said Maryam, 18, a Syrian refugee from Aleppo. “Many of my relatives were killed back home. I was terrified. I had to walk for hours before crossing the Lebanese border and suffered a hemorrhage. I feared miscarriage.”

In April 2013, Médecins Sans Frontières (MSF) teams in Lebanon opened a reproductive health care project to respond to the needs of refugees in the Bekaa valley, the main entry point for Syrians crossing into Lebanon.

“Many women arrive here by themselves, without their families or husbands who have been left behind or killed in the war,” said Marjie Middleton, an MSF midwife in charge of the project.

“Some are pregnant and haven’t been able to see a healthcare provider during their pregnancies. They don’t know whether their babies are okay or not because they haven’t had access to antenatal care. They’re extremely anxious, and the combination of psychological and physical stress is very dangerous for their pregnancies.”

Lack of access to safe and affordable delivery

Many refugees don’t know anyone in Lebanon, so it’s hard to find help within the community. “Pregnant women often have no idea where to go,” said Middleton. “We’ve heard stories of women who were left to deliver on their own, in a tent.”

Cost can be an issue as well. Antenatal care is very expensive in Lebanon, even for Lebanese women. “A woman will have to spend the equivalent of $20 US just to see a doctor and pay for vitamins and transport,” Middleton noted. “This is often half or more of a worker’s weekly wage.”

The United Nations High Commissioner for Refugees (UNHCR) covers 75 per cent of the delivery costs for Syrian refugees. UNHCR used to cover the whole bill, but recently reduced its commitment to 75 per cent due to a shortage of funds.

But even that 25 per cent can be more than many refugee families can afford, and there are only six hospitals in the Bekaa valley sponsored by UNHCR where women can deliver.

A normal delivery costs US $50 and a caesarean is US $200. “If the refugee cannot afford to pay, she might be refused access to the hospital or have her refugee card confiscated, which often means no access to food vouchers until she can pay off the hospital bill,” Middleton said.

Poor living conditions put pregnancies at risk

There are considerable risks associated with delivering without a skilled birth attendant. The risks are greater in the places most refugees are settling, where living conditions are often cramped and unsanitary. Watery diarrhea has been reported, for instance.

“We are also seeing lots of infections among our patients, partly because they’ve had no access to care during their pregnancies and because of their poor access to water facilities and hygiene,” said Middleton.

Infections are one of the leading causes of premature delivery. Poor diets are another problem. “In many cases, refugee women cannot afford basic food, which makes it harder for a baby to grow and for a woman to maintain her own health during her pregnancy. I’ve seen cases of malnourished newborns.”

In accordance with World Health Organization (WHO) standards, MSF aims to provide four antenatal visits per pregnancy and, in case of concern or complication, refers women to a gynecologist for free treatment.

In addition to providing antenatal consultations in its clinics, MSF helps women recognize possible signs of danger and establish birth plans, so they know what to do and where to go when labour starts, or if they have problems.

Postnatal care and family planning to respond to the needs

After birth, both the baby and the mother are still at risk. MSF offers postnatal care and family planning options.

“We try to get the women to come back in the first week, and then again at six weeks for a final check and to start them on contraception if they wish,” said the midwife. “Many women want to have babies, but many others would rather not get pregnant.”

MSF is responding to a high interest and demand for family planning services amongst refugee women. “My husband and I don’t want at all to have another child for the time being, because the situation has become unbearable in Syria and we feel very insecure in Lebanon,” said a woman who came with her two-month-old baby to the MSF clinic to get contraceptive medication.

MSF also provides general women’s healthcare for refugees suffering from infections, sexually transmitted diseases and any other women’s health problems.

MSF’s reproductive healthcare for Syrian refugees

MSF has been running three reproductive healthcare clinics in eastern Lebanon’s Bekaa Valley since April 2013. The clinics have performed nearly 850 consultations up until the end of June.

In Tripoli, Lebanon’s second largest city, MSF ran a reproductive healthcare program in its clinic at Dar al Zahraa hospital, providing more than 450 consultations to Syrian refugees. In January 2013, MSF also started offering family planning services, providing 118 consultations until late June.