AMMAN — “There is this misconception about us people living in the camps, that we do not work and do nothing all day but have children. This is not true,” Jihan, a Syrian aid worker and mother of three, told Syria Direct.
Jihan’s resentment was sparked by comments made by the Syrian artist Rasha Rizk on Facebook, asking humanitarian organizations to provide birth control rather than aid to displaced Syrians. Rizk allegedly referred to displaced parents as “criminals” for bringing children into an unsafe country.
But Jihan, like thousands of displaced Syrian women, simply strives to make her own choices against the backdrop of a conflict that has severely eroded women’s access to reproductive health.
The disruption of women’s health
Before the 2011 revolution, the fertility rate in Syria was 3.4 children per woman, according to World Bank data. An estimated 53% of women of reproductive age were using a contraception method, and only one-third of pregnancies were unintended, compared to a global average above 40%.
However, a study of Syrian refugees and vulnerable women in Lebanon and Iraq, conducted from 2014 to 2015, revealed a 66.7% unplanned pregnancy rate among women who delivered a child in the previous year. Although the study’s findings are not easily generalizable to other contexts, the stark contrast between the figures highlights a well-known fact: displacement can dramatically affect women’s access to reproductive health services.
Through her work as a midwife in Idlib, Nahla (a pseudonym) observed a growing number of home abortions in past years, a worrisome indicator that reproductive health needs are not met. “Most women use contraceptives because they are unable to bring another responsibility into their lives,” she told Syria Direct. “If pregnancy occurs, some resort to household means to terminate the pregnancy, because abortion is forbidden in religion and cannot be accessed in the health centers unless the woman suffers from dangerous conditions.”
Obstacles to access contraception
In northwest Syria, the last stronghold of the opposition, contraceptives were reported to be “widely available” – compared to other medicines – by the women who spoke to Syria Direct. They are often able to obtain contraceptives for free from community health centers or purchase them from pharmacies and private clinics. However, Huda Alawa, Director of Development at NuDay, a Syrian organization providing women’s health services in the area, told Syria Direct that “contraceptives are hard to come by on a steady basis, and women who request contraceptives are limited in options.”
Yet, availability does not imply widespread access. “Living conditions and access to basic necessities are tough,” Alia (a pseudonym), who lives in Idlib, told Syria Direct. “Most women rely on free health centers, which are overcrowded due to their limited number.” Not everyone can afford “$3-4 required for pills outside the health centers,” recognized Alia, “forcing some women to rely on traditional methods.” Further, transportation can also be an obstacle for women seeking healthcare.
When people are displaced and health systems disrupted, women can lose access to their contraception. For this reason, Dr. Hasnaa Hamdan, a gynecologist working in Idlib, favors intrauterine device (IUD) implants. These prevent pregnancy for several years, whereas the pill – the most commonly used contraceptive, according to Dr. Hamdan – needs to be taken daily, leading to a greater risk of interruption.
Growing health risks
Women in northwest Syria also face increased risks of maternal death and high-risk pregnancy. According to a Syrian American Medical Society (SAMS) report, there are large gaps in maternal health services, including a scarcity of doctors, equipment, medical supplies and insufficient resources to provide pregnant women with adequate prenatal care. The report records a one-third increase in child and maternal mortality over the past seven years in Syria.
“Miscarriages definitely increased due to overcrowded living conditions, poverty, homelessness and lack of awareness,” Dr. Hamdan said. “The most common problem faced by pregnant women,” midwife Nahla added, “is iron deficiency anemia, and most cannot afford medicines due to their high prices.”
At the same time, “the war has generated emergency priorities for medical workers and patients. As a result, health knowledge and awareness have lagged behind,” according to the SAMS report. This includes knowledge on contraception, which is still associated with various stigmas, such as lessening fertility.
The issue is compounded by growing rates of early marriage, with girls under 18 representing 12-15% of the deliveries taking place in Syria, according to the OCHA’s 2019 Humanitarian Needs Overview. To cope with the high cost of living, some families marry their daughters earlier, hoping they will be provided for. However, early marriage is associated with inadequate knowledge and awareness about family planning and more high-risk pregnancies.
Women’s free choice
Women of reproductive age account for 25% of the Syrians in need of humanitarian assistance in Syria and the MENA region, according to the United Nations Population Fund (UNFPA). Their specific needs are often deprioritized in the face of other emergencies, as recognized by the UNFPA, noting that the sexual and reproductive response has generally been underfunded.
Still, women’s health organizations like NuDay identified an increase in requests for contraceptives over the years. “The dynamics of family life have slowly shifted, as more women assume the role of the main breadwinner,” Halawa said. “Contraceptives empower these women by giving them control over their bodies – and this in itself is priceless.”
For Jihan, freedom to make her own choice is part of her dignity. “We are not animals who just think about food, water and reproduction. We want to live a normal life that goes beyond the war and all the problems,” she said, “to have children according to our own preferences.”
This report is part of Syria Direct’s project promoting gender equality, supported by the Canadian Embassy to Jordan’s Canada Fund for Local Initiatives (CFLI).