Refugee maternal mortality ‘alarming’
Death rate for Syrian women three times higher than for Lebanese in 2017
BEIRUT: Increasingly desperate economic conditions, high rates of teen marriage and the prevalence of cesarean section deliveries are driving a disturbing trend of deaths in pregnancy and childbirth among Syrian refugees in Lebanon.
Rates of maternal mortality are considerably higher among Syrian refugees than among Lebanese women, and they may be rising.
According to Health Ministry statistics from 2017, with 69,330 live births reported among Lebanese women, there were six reported maternal deaths as a result of pregnancy or childbirth.
Among non-Lebanese women, nearly all of them Syrian (Palestinian women are tracked separately), there were 55,267 births and 15 reported deaths.
That translates to a maternal death rate among Syrians of 27 per 100,000 births compared to nine per 100,000 births for Lebanese women.
According to World Health Organization figures, the average maternal mortality rate in developed countries was 12 deaths per 100,000 births in 2015.
“You have fewer Syrians delivering than Lebanese, but more Syrians are dying than Lebanese,” says Dr. Faysal El-Kak, a senior lecturer at the faculty of health sciences at the American University of Beirut and vice president of the International Federation of Gynecology and Obstetrics. Kak has been studying the issue of maternal mortality.
The ministry figures also show an apparent upward trend in maternal mortality among Syrian women and a downward trend among Lebanese. In 2015, the ministry reported 71,310 live births and 10 deaths among Lebanese women, a rate of 14 per 100,000. Among non-Lebanese, there were a reported 39,106 births and five maternal deaths, or 13 per 100,000.
The rate of reported deaths among non-Lebanese rose significantly from 2015 to 2016, reaching 30 per 100,000 births, then dropped slightly in 2017. Statistics prior to 2015 and for 2018 were not available, making it difficult to analyze the broader trend.
U.N. refugee agency spokeswoman Lisa Abou Khaled says that the UNHCR is “closely following the maternal mortality indicators with the Public Health Ministry” and “has not observed an increase in maternal mortality in recent years.”
Nevertheless, Kak called the higher rate of death among Syrians compared to Lebanese an “alarming sign.” He attributed the higher rate of deaths among Syrians in part to delays in seeking care during pregnancy due to fears of the expense.
Without early prenatal care, potential problems may not be identified, and women miss out on preventive measures including iron and folic acid supplements, he says.
“Probably and unfortunately, this is going to continue next year and the year after, because the conditions are the same,” Kak says.
“It’s even getting worse . ... The issue of stability of the money and cost of care is serious.”
The UNHCR covers between half and two-thirds of the hospital fees for delivery for Syrian refugees in Lebanon.
Women can also access subsidized prenatal care consultations, for a cost of between LL3,000 ($2) and LL5,000, Abou Khaled says.
But the share of the cost that the refugees are expected to pay for deliveries in most cases rose in July, when the UNHCR changed its funding formula.
Before, the agency would cover 75 percent of the cost of the delivery. Now, the refugee pays the first $100 and the UNHCR pays 75 percent of the remaining costs.
The changes were meant to reallocate resources to prevent refugees from facing massive costs in serious medical emergencies. The maximum payment the refugee can be expected to make is now capped at $800. But as a result, the out-ofpocket cost for less expensive operations like routine deliveries rose.
The family’s share of the cost now ranges from $150 to $200 for a normal birth and from $225 to $355 for a cesarean section, according to a UNHCR publication.
Practitioners note that refugees also often face added costs from hospitals for tests and other procedures, some of them unnecessary.
There are lower-cost options for some. The international NGO Doctors Without Borders (MSF) runs three birthing centers in Lebanon – two in the Bekaa Valley and one on the campus of Rafik Hariri University Hospital in Beirut’s southern suburbs – where deliveries are free of charge.
But their capacity is limited, and staff say that the prospect of continuing cutbacks in aid from other sources has them concerned.
“It’s very clear that we can’t serve everybody that needs access,” says Dr. Laura Rinchey, MSF’s project medical supervisor for south Beirut.
“The money’s a problem, the access is a problem.”
Rinchey pointed to some factors that put Syrian mothers at greater risk, including high rates of teen marriage and therefore teen pregnancy. Of about 3,200 deliveries at the NGO’s south Beirut birthing center last year, 440 were mothers under the age of 18, making up 14 percent of all deliveries.
Of those, 163 were under 16 and nine were under 13 years old.
“We know that the young adolescents are at a higher risk,” Rinchey says.
Teenagers, for instance, are more likely to develop preeclampsia, a condition characterized by high blood pressure and organ damage.
The prevalence of cesarean sections in Lebanese hospitals, along with the high fertility rate among the Syrian population, present other risks. With each subsequent cesarean section, there is a greater risk of complications, Rinchey says. “Many of these ladies have had a high number of previous pregnancies and C-sections, so they’re at a higher risk.”
Both the MSF staff and Kak say that educating women about family planning is key to preventing future pregnancies that could endanger the mothers. Access to birth control can also prevent women from resorting to illegal abortions, which Rinchey says is “one of the most dangerous procedures” for women. The MSF maternity program includes talking to pregnant women about family planning options for the future.
Fatima, a Syrian from Deir alZor who did not give her family name, was resting Thursday morning at the MSF birthing center in south Beirut, her yet-to-be-named newborn daughter swaddled in a pink blanket by her side. The baby was her first in Lebanon – she had four children in Syria before the family fled to Lebanon a year and a half ago. They now range in age from 2 to 8 years old.
Although she had wanted this baby, Fatima said that considering the expense of giving birth in Lebanon and the family’s financial situation, she had contemplated ending the pregnancy until she discovered the MSF maternity program.
Without it, she said, “I would have gotten an abortion, basically, because my husband doesn’t have much work. But when they told me that I could get treatment, I continued with the pregnancy.”
Now, however, Fatima said she plans to take measures to prevent another pregnancy. “This is my last child,” she said. “Five is plenty.”
‘We know that the young adolescents are at a higher risk’
The share of the cost that the refugees are expected to pay for deliveries in most cases rose in July, when the UNHCR changed its funding formula.