With a global population in excess of six billion, childbirth is such a commonplace event that the complexities of human reproduction and potential for adverse outcome are often overlooked. Even with the best of medical care, there are inevitably a number of risks associated with pregnancy, childbirth and the postnatal period that run the gamut from the minor (e.g. nausea) to the severest consequences in the form of maternal or infant death.
In most industrialized nations, maternal mortality ratios average 5-6/100,000 live births. In less developed countries, the ratio may be as high as 1,000 or more maternal deaths for every 100,000 live births. The necessary medical precautions and care to ensure a safe and respectful environment for both mother and child are the main determinants of positive obstetric outcomes. And for those women whose lives are threatened by motherhood, the stakes are all too real.
Consider the situation in the West Bank and Gaza Strip. Babies wait for no one. Once they are on their way into the world, no tank, curfew or gunfire will stop them. With nearly 800 military barriers erected in the Occupied Palestinian Territories (OCHA Consolidated Appeal, November 2004) emergency obstetric care has become one of the most serious public health concerns and human rights issues. From the outbreak of the second Intifada in September 2000, the scale of violence and restriction on movement has had a severe and detrimental impact on the access of Palestinians to appropriate health services and care.
Palestinian Ministry of Health statistics show that essential reproductive health services, such as antenatal care have dropped from 82.4 percent at end 2002 to 71 percent at the end 2003. Deliveries at home have also risen, particularly in the West Bank, where numbers are not only higher but where the incidence of internal closures is also more important, notably because of the Separation Barrier that has isolated some 210,000 people. What poses a further risk is the threat of delivering in emergencies where no skilled attendant is available.
The time to reach health facilities as a result of this imposed fragmentation has also translated into increased delays, effort and funds (often with out-of-pocket family resources). With traditional support networks to women collapsing coupled with rampant poverty rates at 47 percent of the population in the West Bank and Gaza (Disengagement, the Palestinian Economy and the Settlements, World Bank Report; June 2004), it is likely that that women's health will deteriorate even further. Though it is arguable that any denial of access to appropriate health care is a breach of human rights, impeding a pregnant woman from such care is particularly insidious since the repercussions impact the mother, infant and family, based on the fact that mothers are the main caretakers in traditional societies such as in the Palestinian context. Loss of a mother to sickness or death will inevitably mean less care for existing children. Remarriage of the husband is also common and tends to upset the family dynamics when a stepmother is introduced, with negative consequences on gender equity concerns, though this is not within the scope of this article. Such has been the fate of at least 61 Palestinian women in the OPT in the last four years (Palestinian Ministry of Health statistics, Oct. 2004).
Let us take the case of Houria Miri (Birth at the Checkpoint; film by UNFPA, 2002). To listen to her story is to understand.
In 2002, Houria, then 40 years old, was in the eighth month of her sixth pregnancy when sudden complications arose and she began hemorrhaging. Alerted, her husband immediately rang the emergency medical services for an ambulance. The Yassins live in a village just outside of Jericho that is closed off by a checkpoint on the main road as well as a dirt mound barricade around their village. The Yassins were informed by the emergency services that an ambulance would be waiting outside the checkpoint on the main road, but that they were denied entry to the road itself and to their village; somehow, Houria and her husband would have to find a way to cross the distance to get to the ambulance.
They set out by car after crossing the dirt mound to their village by foot. Upon arriving at the checkpoint on the road to Jericho, armed soldiers confronted the couple with pointed guns even though it was obvious that the woman was pregnant and in distress. For over an hour, the husband pleaded with Israeli troops oblivious to the plight of Houria and despite her hemorrhaging. The couple could see the ambulance across the checkpoint but it remained a distant image as Houria's condition worsened by the minute.
Finally, Houria gave in from exhaustion. Infuriated and wrought with anxiety, her husband informed the soldiers that he would leave her to die at their feet and let them take responsibility. Only then did they finally consent to allow only Houria to pass through the checkpoint, and on foot.
Somehow she gathered her strength and slowly began walking the two kilometers to the ambulance, bleeding the entire way. She never made it and collapsed with Israeli troops watching. When she awoke hours later in hospital and after an emergency caesarian section, Houria was alive but in critical condition. The baby did not make it. Until this day, Houria suffers from depression and a slew of physical complaints.
Another woman, Fatima, was forced to give birth at a checkpoint in the Hebron area under the direct gaze of three Israeli soldiers after she waited for over an hour in labor in a private vehicle (Birth at the Checkpoint; film by UNFPA, 2002). Her placenta subsequently ruptured and she narrowly escaped death only through the heroic efforts of her family, medical practitioners and a four-hour surgery. Miraculously, the child, a girl, survived. The trauma to the mother, however, has left deep psychological scars in addition to the physical.
These are just two women's testimonies. In total, 61 births at checkpoints have been documented by the Palestinian Ministry of Health as of October 2004 (MOH statistics, Oct. 2004). For every recorded incident, it is likely that many more go undocumented. Women whose infants die on the road to hospital or where no skilled birth attendant is available at the time of delivery may not submit a birth and death certificate. Moreover, while maternal and infant deaths make newspaper headlines, there are less obvious but very powerful implications for women's tribulations in this respect.
Maternal morbidity, including psychosocial distress and illness in addition to any physical trauma, has an impact on the woman herself as well as her family. Since records are kept at health facilities, and many women do not have regular access to health facilities under the circumstances, much of the morbidity among women is thought to go unchecked until their situation is very severe.
It may seem as stating the obvious that without ending the Israeli occupation and allowing access to health facilities, no institutional response can address the issue at hand. However, and since access to quality health care is a basic human right, intermediate measures to alleviate the situation are warranted. Though 61 women may not seem like a large number, each and every woman represents a life that was not respected and put needlessly at risk of physical danger, degradation and psychological trauma. Efforts in partnering with agencies whose mandate is to protect civil and human rights such as Physicians for Human Rights, Mahsoum Watch and Amnesty International must be stepped up to create greater awareness of the inhumanity of allowing even a single childbirth at a military barrier, not to mention the 36 infant deaths and an undocumented number of maternal deaths, to happen.
As for health care system response, there are a number of actions that can be of assistance. UNFPA, as well as its partners and others in the field, have been involved in training health care providers (doctors, nurses and midwives) on community-based obstetric care. Because these professionals live in the communities they serve, responses to normal or emergency delivery are at hand. Moreover, these health providers are supported by community volunteers who have also been trained in emergency care. Another measure has been to link community providers with emergency medical services for quicker responses as well as setting up a hotline to provide further support.
Many argue that international agencies who provide such support really only alleviate the symptoms but not the disease, and are actually picking up the tab for the Israelis and thus diminishing the chance for a more holistic solution. This is a valid concern, but only to a degree. As with many humanitarian concerns, activists must find the balance between what is correct and what is humane. Should we allow more women or babies to die at checkpoints simply because a comprehensive solution to end the occupation is needed? Perhaps, as with any humanitarian concern, activists and professionals must question the need for balance between the ideal and the reality. Furthermore, working towards a comprehensive solution and meeting immediate needs should not be viewed as mutually exclusive. Rather, the two should go hand in hand. As proponents of human rights, we have a responsibility to women like Houria and Fatima not to allow this to happen again.
