Refugee ma­ter­nal mor­tal­ity ‘alarm­ing’

Death rate for Syr­ian women three times higher than for Le­banese in 2017

The Daily Star (Lebanon) - - LEBANON - By Abby Sewell

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.

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