Overwhelming needs as earthquakes hit south Turkey and northwest Syria: MSF scales up its response

Overwhelming needs as earthquakes hit south Turkey and northwest Syria: MSF scales up its response

Following the powerful earthquakes that hit the south of Turkey and northwest Syria on February 6th, Médecins Sans Frontières (MSF), already supporting the population of northwest Syria, has mobilized its team along with local partners to respond to the increasing needs in the area.

Unfortunately, one of our staff members was found dead under the rubbles of his house in Idlib, and others lost members of their families. “We are very shocked and saddened by the impact of this disaster on the thousands of people touched by it, including our colleagues and their families”, says Sebastien Gay, MSF Head of Mission in Syria. 

“Health facilities are impacted and overwhelmed, and the medical personnel in northern Syria is working around the clock to respond to the huge numbers of wounded arriving to the facilities. From the first hours, our teams treated around 200 wounded and we received 160 casualties in the facilities and the clinics that we run or support in northern Idlib. Our ambulances are also deployed to assist the population”
Sebastien Gay, MSF Head of Mission in Syria

MSF provided immediate support to 23 health facilities across Idlib and Aleppo governorates, by donating emergency medical kits and supporting them with medical staff to reinforce their teams.  

Moreover, our teams have donated blankets and essential life kits to the displaced populations in northwest Syria. The level of damage in the region has caused the destruction of hundreds of houses, leaving thousands homeless. It has been snowing the past three days and the population remains outside out of fear of further aftershocks that continued throughout the day. 

“The needs are very high in northwest Syria as this quake adds a dramatic layer for the vulnerable populations that are still struggling after many years of war”, adds Gay. “The massive consequences of this disaster will require an international aid effort that is up to the scale”. 

MSF remains in close contact with the local authorities in northwest Syria and with the authorities in Turkey to extend our support where it’s needed. We are currently assessing the situation and needs in Idlib, northern Aleppo and south Turkey to scale up our response accordingly, as the number of deaths and injuries is increasing by the hour.  

MSF Response to the earthquake on February 6, 2023.

Published on February 6, 2023

Yemen: Giving birth in the face of persistent obstacles in Taiz

Yemen: Giving birth in the face of persistent obstacles in Taiz

Nogood Mohammad Ahmed Shamsan was lying under the covers of her bed, exhausted. She rested her left hand on her belly trying to provide comfort while she drew long, slow breaths. Next to Nogood was her mother sitting in a chair, making sure that her daughter was comfortable and that she tended to her needs. However, both Nogood and her mother had their heads turned to the side looking towards where the other hand of Nogood was. Under Nogood’s right arm, one-day-old Ahmed was sleeping, grabbing on the nest of blankets that surrounded him.

Nogood was admitted to the post-operative ward of after delivering Ahmed through caesarean section at the maternity unit in the Al-Jamhouri hospital, in Taiz city, Yemen. Doctors Without Borders/Médecins Sans Frontières (MSF) and the Ministry of Health (MoH) have been running the maternal and neonatal services in the hospital together since May 2021. MSF provides technical support, financial incentives to the Ministry of Health’s staff, and medical and logistical supplies to run the maternity unit including services such as caesarean sections, antenatal and postnatal care, family planning, vaccination and neonatal care.

A nearly-collapsed health system and access obstacles

More than eight years of war in Yemen is taking a devastating toll on people in many ways, including the ability to reach quality and timely healthcare, which is becoming increasingly challenging. Fewer than 50 percent of healthcare structures in Yemen are functioning.[1] Most primary healthcare centres are only partially functioning due to lack of equipment, medical supplies, or medical staff. Since 2016, healthcare workers haven’t been paid monthly salaryies on regular basis, forcing many to find alternative employment to make a living. This situation drives people to seek available and free healthcare in the closest possible area – a task that is not always easy.

Like Nogood, many women travel long distances to deliver their babies at Al Jamhouri hospital. “I come from Bani Oman, a village,” said Nogood. “My financial situation is not that good, so I came to Al Jamhouri hospital to have my caesarean section, because it is free-of-charge. There is only one health centre in the village, but it is not good. It is not qualified because of the equipment that is not available there,” Nogood said.

“It took me two hours to come here,” said Bushra Khaleed Abdualrahman*, who is eight months pregnant. Bushra’s brother brought her to the hospital for emergency medical care hospital from Sabr Al Shaqeb area. “The roads are destroyed, and our route is mountainous,” said Bushra. “We live on a mountain, so after the rain the road becomes worse and worse. I was in pain and due to the arduous journey, I became so unwell.”

After many years of fighting, Taiz is still divided in two: Taiz city—controlled by the administration of the internationally-recognized government of Yemen—and the suburb of the city Al-Houban—which is in the Ansar Allah-controlled part of Taiz governorate. The frontline runs through the city is littered with landmines and guarded by snipers. To reach Taiz city, people must take the long, perilous journey through the mountains to avoid crossing the frontlines. Prior to the conflict, it took 10 minutes to reach Taiz city from Al-Houban—now it takes between five and eight hours. This is the route many people have to take to reach free, quality healthcare at the MSF-supported Al Jamhouri hospital.

Pregnant women living in rural areas come to the hospital with high risk and/or complicated pregnancies that could have been avoided, stemming from a lack of consistent ANC antenatal and post-natal and PNC monitoring, either due to absence of the services or the necessary medical specialties and basic equipment, like ultra sound machines, to perform them. Between August 2021 and August 2022, MSF’s team in Al Jamhouri hospital assisted 6,739 deliveries, out of which 4,184 were normal deliveries; almost 29 percent required cesarean sections – an indication of the high number of complex pregnancies arriving to the hospital.

“The first time that I had pain I went to a doctor in my area and they just gave me first aid,” said Bushra.  “There is no equipment or machines and that’s the only thing they were able to do.”

It’s a challenge, some of the high risk pregnancies that come to antenatal care here in Al Jumhouri hospital are coming for the first time. Some of them are already in their eight or ninth month of pregnancy.
MSF's medical team leader in Taiz city, Mduduzi Chandawila

A lack of community health promotion

The nearly collapsed health system, compounded by access obstacles – mainly due to the insecurity and availability and affordability of health services – and the lack of community health promotion of healthy habits such antenatal and postnatal care that can be lifesaving, gravely impact the pregnancies of women and put their life and their babies’ at risk.

“Most of the women that are seen attending our services, for antenatal care for example, are presenting late or they are patients that are at high-risk pregnancies” said Chandawila. “These are women that have had some surgery before, like a cesarean section, some that have done the procedure two or three times. Others arrive with pre-conditions like eclampsia or pre-eclampsia—serious complications that need to be monitored closely and we need to carefully tend to patients that will not do normal delivery.”

MSF provides health promotion to spread awareness about the importance of antenatal and postnatal care. An MSF health promotion team shares information in the waiting areas of the maternity ward while and conducts broader community outreach.

“Through antenatal care, health conditions can be identified early in terms of way to deliver or the mode of delivery, what support they need, and what medication or treatment they need before they deliver,” said Chandawila. Postnatal care is also very important so that we can monitor the progress of the post-delivery period, we can monitor the surgical side, infections and other complications that may develop.”

The maternity unit at Al-Jamhouri hospital assists approximately 520 deliveries per month. After MSF began supporting the maternity unit, there was a sharp reduction in neonatal mortality and increase in antenatal and postnatal consultations. Between August 2021 and August 2022, neonatal mortality rate reduced from approximately 24 percent to 10 percent. Antenatal and postnatal consultations also increased, as in in August 2021, MSF in Al-Jamhouri hospital conducted 1,364 ANC consultations and 86 PNC consultations, whereas in August 2022 it remarkably rose to 1,795 ANC consultations and 527 PNC consultations.

While these numbers are encouraging, gaps remain. Timely access to primary healthcare is vital but remains a challenge, especially for pregnant women who should regularly monitor from the beginning of their pregnancies to avoid medical complications for them and their babies’ and in several cases, prevent maternal and neonatal deaths.

*name changed to protect anonymity

(1) Health Sector in Yemen – Policy Note, The World Bank, September 2021
  WHO – Yemen, HeRAMS report, 2020

MSF denounces Israeli plan to forcibly displace Palestinian residents from Masafer Yatta

MSF denounces Israeli plan to forcibly displace Palestinian residents from Masafer Yatta

Occupied Palestinian Territories, 19 January 2023 – Some 1,000 Palestinians are to be evicted from their homes in the Masafer Yatta area of the West Bank, according to a plan approved by the newly sworn-in Israeli government. The move has been strongly denounced by the international medical organisation Médecins Sans Frontières/Doctors Without Borders (MSF), whose teams provide medical care to the area’s residents.

This plan would mean the imminent forcible displacement of almost the entire population of Masafer Yatta. Where are all these families to go? This is completely unacceptable.
MSF head of mission David Cantero Pérez

In the 1980s, Israel designated Masafer Yatta, south of Hebron, as a military firing zone. In the decades since Palestinians living in 12 villages scattered across the region have seen their homes repeatedly demolished and have lived under the threat of forced displacement.

Their situation deteriorated yet further in May 2022 following a ruling by the Israeli Supreme Court which removed all legal barriers to the forced displacement of Palestinians from Masafer Yatta to make way for the military zone. Palestinian officials confirmed that, as of January 2023, most of the residents of Masafer Yatta had received demolition orders and are at imminent risk to be forcibly displaced.

Israeli authorities have put extraordinary pressure on residents of Masafer Yatta to leave the area. As well as demolishing people’s homes, they have installed checkpoints, confiscated residents’ vehicles, and enforced curfews and other movement restrictions. These measures, which have intensified in recent months, have severely impacted residents’ freedom of movement, mental health and ability to access basic services, including medical care, say MSF teams working in the area.  

Sick and elderly patients report being made to wait for hours at checkpoints and being forced to walk long distances to reach clinics. Residents’ movements are restricted even during medical emergencies. “You have to be on the point of dying to be allowed through the checkpoints,” one resident told MSF staff.   

“These measures have severely affected the residents of Masafer Yatta and made their lives unbearable,” says Cantero Pérez. “They live in constant fear. The mental health impact on residents, particularly on children, cannot be understated. In periods where more home demolitions occur, our mental health team receives more people with symptoms of depression and anxiety.”

One elderly woman described to MSF staff the moment that Israeli authorities came to demolish her home for the fourth time in two years: “I felt like I was suffocating, like I was blind, like my hands were tied. My children were in school when the demolition started, they came out to watch. They were in shock, in complete silence.”

Another resident told MSF: “They choose the winter for demolishing houses. Tonight, our family will sleep in the car, or in a tent in the cold. It’s going to be 5 degrees Celsius tonight.”

MSF teams run three clinics in the Masafer Yatta area, providing residents with basic healthcare. This includes mental health support and sexual and reproductive health services, with a focus on women, children and patients with chronic diseases. In 2022, the MSF team provided 3,066 medical consultations in the area.

MSF calls on Israeli authorities to bring an immediate halt to the eviction plan and to stop implementing restrictive measures that impede the ability of Palestinians in Masafer Yatta to access basic services, including medical care. MSF also calls on the international community to take all necessary measures to protect the population of Masafer Yatta and ensure that their human rights are upheld.

“The whole world should know what is happening to us,” one resident told MSF staff. “All we want is to live on our land, in our homes.”

All MSF staff acquitted in military tribunal in Cameroon

All MSF staff acquitted in military tribunal in Cameroon

Buea/Yaoundé (10 January 2023) – The international medical humanitarian organisation Médecins Sans Frontières/Doctors Without Borders (MSF) is extremely relieved at the acquittal of five of our staff, who faced trial in Cameroon, accused of complicity with secession. Four of the staff in question had to endure incarceration for many months.

MSF has categorically denied any complicity with armed groups or parties to any violent crisis or conflict. Our staff are guided by medical ethics – these accusations were groundless from the first instance, especially as the authorities knew exactly how we were providing medical support
Sylvain Groulx, MSF coordinator in central Africa

On 26 December 2021, an MSF nurse and ambulance driver were arrested in Nguti (South-West region of Cameroon), while transporting a patient with a gunshot wound to hospital. After being detained in prison for five months, for the charge of complicity with secessionists, both aid workers were provisionally released in May 2022.

Two other colleagues, a community health worker and assistant field coordinator, were detained in January 2022 under the same charge while another was accused in absentia.

On 1 November 2022, the Buea Military Tribunal ruled “no case to answer”, regarding one of the aid workers in question, citing a lack of evidence. The MSF staff member was released soon after the ruling, having spent 10 months in prison.

Finally, on 29 December, all remaining MSF staff members who had been detained were acquitted – the last of whom was released the following day. A judgement of acquittal was also declared regarding an MSF project coordinator who had been tried in absentia.

“We are enormously satisfied with the judgement that exonerates our five staff members – and, by extension, MSF as an organisation – of any wrongdoing,” says Sylvain Groulx, MSF coordinator in central Africa.

MSF deplores the fact that our staff were forced to endure almost a year of imprisonment, which caused untold distress and anguish for them and their families. 

“Accusing medical personnel for simply doing their job – treating patients in front of them – is simply against all medical and humanitarian ethics and laws,” says Groulx.

In May 2022, following the detention of MSF’s four staff members, our teams made the difficult decision to suspend activities in the South-West region of Cameroon. We are keen to restart our much-needed lifesaving services, but basic preconditions must be met to ensure that our medical activities can be conducted in a safe and secure environment, so that patients and staff are protected.

“Despite our attempts to open a channel of dialogue with the government, to ensure our teams can continue vital activities in South-West region, the government has been unresponsive. This has made it difficult to reach an agreement that ensures working conditions guarantee the safety of our teams and patients,” says Groulx.

“This prevents us from resuming critical lifesaving medical services, which are desperately needed in the South-West,” he says.

MSF teams must be able to provide medical care to every patient in need, in line with medical ethics and following the humanitarian principles of independence, impartiality and neutrality.

“We remain ready to continue discussions with the Cameroonian authorities to analyse the feasibility of restarting medical and humanitarian activities in South-West region under such preconditions.”

In December 2020, authorities suspended MSF medical activities in the North-West region following a series of allegations accusing MSF of supporting local armed groups, which MSF has consistently denied both publicly and in meetings with authorities. This suspension was never lifted and, here as well, MSF remains open to dialogue to restart its medical support for the population.

MSF has worked in Cameroon since 1984 and in the South-West region since 2018. Since 2019, our medical teams in the South-West region have provided more than 400,000 medical consultations, and more than 68,000 consultations in health facilities that we support. In 2021, MSF-supported facilities also assisted 2,284 births. Our ambulance teams, the only emergency referral system in the South-West until activities were suspended, transported more than 8,000 patients for urgent medical care in 2021. 

Suffering and displacement in northwestern Syria

Suffering and displacement in northwestern Syria

The winter season remains a challenging period for the displaced people in northwest Syria. Every year, MSF witnesses the direct health impact of winter through its activities in the camps.

Published on January 11, 2023

Pakistan: Flood emergency is far from over

Pakistan: Flood emergency is far from over

Médecins Sans Frontières (MSF), also known as Doctors Without Borders, is seeing alarmingly high numbers of patients with malaria and children with malnutrition among flood-affected communities it assists in Sindh and eastern Balochistan provinces, Pakistan.Catastrophic flooding began in June, and the situation remains an emergency, with critical humanitarian needs. The current response is inadequate. The basic needs of people living in the worst flood affected areas such as access to essential food assistance, healthcare and safe drinking water, remain unmet.

MSF emergency response in Sindh and eastern Balochistan

In Sindh and eastern Balochistan, MSF teams are seeing high numbers of people needing treatment for malaria. Despite the colder season, when malaria rates would be expected to decline, we continue to see malaria positivity rates of 50% during December in patients screened in our mobile medical clinics and have treated more than 42,000 patients since October.

The floods have destroyed extensive areas of crops and livestock, which represent the main source of livelihood for many communities. In our mobile medical clinics in northern Sindh and eastern Balochistan MSF are already seeing alarming numbers of acute malnutrition. Since the start of our activities in these regions, we have screened a total of 28,313 children for malnutrition in our mobile medical clinics. Of those screened, 23% (6,489) had severe acute malnutrition and 31% (8,738) had moderate acute malnutrition, comprising more than half of the children who arrived at our clinics.

“We are still in an emergency phase”

‘We are months into this response and our teams in Sindh and eastern Balochistan still see people living in tents and makeshift shelters. In these winter months, people are becoming more vulnerable. While the focus is shifting towards recovery and reconstruction, a scaled-up humanitarian response to meet people’s immediate needs is absent. In December our medical teams continued to see high rates of malaria, acute malnutrition, and skin infections. Humanitarian organisations and government agencies involved in the response must not forget that the situation remains critical,” says Edward Taylor, MSF’s emergency coordinator in northern Sindh and eastern Balochistan. “In the areas where we are working, water has yet to recede, and the emergency medical and humanitarian needs remain high. People urgently need access to food assistance, safe drinking water, healthcare and shelter. We are still very much in an emergency phase.’  

MSF emergency teams are running mobile clinics and malaria teams that visit more than 50 locations per week in the Dadu, Jacobabad, and Shahadat Kot districts of Sindh and Jaffarabad, Naseerabad, Sohbatpur, Jhal Magsi, and Usta Mohammed districts in eastern Balochistan. So far, we have provided basic medical care to more than 92,000 people, mainly for skin diseases, malaria, respiratory tract infections, and diarrhoea.

Returning to destroyed homes and contaminated water sources

Those returning to their villages are finding destroyed houses and land, still surrounded by stagnant water. The devastating loss of homes and belongings impacts people’s mental health, as well as their livelihoods. MSF teams are providing psychological first aid and group counselling sessions to support people during this extremely difficult time.

Meanwhile, those remaining in camps and informal shelters are faced with the encroaching threat of winter. MSF continues to tailor its distribution of non-food items for the season with additional blankets for winter; in the past two weeks, 6,000 households have received these relief packages.

In Sindh and eastern Balochistan, many people whose villages are now accessible found that water sources are still contaminated and they must get drinking water from far away. Crops and food stores have been destroyed, livestock have died, and fields will not be ready for the next planting season, increasing the risk of further food insecurity. MSF teams are continuing to provide safe drinking water to rural communities, with more than 20 million litres provided so far. The teams have also helped to distribute 15,973 hygiene kits to families of remote flood-affected areas.

“Ensuring adequate food, water, sanitation, health care and shelter must be a priority for the international and national response to the catastrophic flooding in Pakistan,” continues Taylor, “many people in affected areas have immediate, urgent needs that cannot wait.”

About MSF in Pakistan

MSF began working in Pakistan in 1986 and now has 1,738 locally hired staff and 53 international staff providing quality medical care to people in Punjab, Balochistan, Khyber Pakhtunkhwa and Sindh provinces. In 2022, over 50 international staff were additionally sent to support the flood response. MSF has been committed to supporting affected communities in Pakistan and has responded to natural disasters over the years. Hundreds of Pakistani staff, including medical and non-medical specialists, have been at the core of this response to emergencies, making it possible to reach those in need.

New decree obstructs lifesaving rescue efforts at sea and will cause more deaths

New decree obstructs lifesaving rescue efforts at sea and will cause more deaths

We, civil organisations engaged in search and rescue (SAR) activities in the central Mediterranean Sea, express our gravest concerns regarding the latest attempt by a European government to obstruct assistance to people in distress at sea.

A new law decree, signed by the Italian President on 2 January 2023, will reduce rescue capacities at sea and thereby make the central Mediterranean, one of the world’s deadliest migration routes, even more dangerous. The decree ostensibly targets SAR NGOs, but the real price will be paid by people fleeing across the central Mediterranean and finding themselves in situations of distress.

Since 2014, civilian rescue ships are filling the void that European States have deliberately left after discontinuing their state-led SAR operations. NGOs have played an essential role in filling this gap and preventing more lives being lost at sea, while consistently upholding applicable law.
Despite this, EU Member States – most prominently Italy – have for years attempted to obstruct civilian SAR activities through defamation, administrative harassment and criminalising NGOs and activists.

There already exists a comprehensive legal framework for SAR, namely the UN Convention on the Law of the Sea (UNCLOS) and the International Convention on Maritime Search and Rescue (SAR Convention). However, the Italian Government has introduced yet another set of rules for civilian SAR vessels, which impede rescue operations and put people who are in distress at sea further at risk.

Among other rules, the Italian Government requires civilian rescue ships to immediately head to Italy after each rescue. This delays further lifesaving operations, as ships usually carry out multiple rescues over the course of several days. Instructing SAR NGOs to proceed immediately to a port, while other people are in distress at sea, contradicts the captain’s obligation to render immediate assistance to people in distress, as enshrined in the UNCLOS.

This element of the decree is compounded by the Italian Government’s recent policy to assign ‘distant ports’ more frequently, which can be up to four days of navigation from a ship’s current location.

Both factors are designed to keep SAR vessels out of the rescue area for prolonged periods and reduce their ability to assist people in distress. NGOs are already overstretched due to the absence of a state-run SAR operation, and the decreased presence of rescue ships will inevitably result in more people tragically drowning at sea.

Another issue raised by the decree is the obligation to collect data aboard rescue vessels from survivors, which articulates their intent to apply for international protection, and to share this information with authorities. It is the duty of states to initiate this process and a private vessel is not an appropriate place for this. Asylum requests should be dealt with on dry land only, after
disembarkation to a place of safety, and only once immediate needs are covered, as recently clarified by the UN Refugee Agency (UNHCR).1

Overall, the Italian law decree contradicts international maritime, human rights and European law, and should therefore trigger a strong reaction by the European Commission, the European Parliament, European Member States and institutions.

We, civil organisations engaged in SAR operations in the central Mediterranean, urge the Italian Government to immediately withdraw its newly issued law decree. We also call on all Members of the Italian Parliament to oppose the decree, thereby preventing it from being converted into law.

What we need is not another politically motivated framework obstructing lifesaving SAR activities, but for EU Member States to finally comply with existing international and maritime laws as well as guarantee the operational space for civil SAR actors.

Signing SAR organisations:
Iuventa Crew
Mare Liberum
Médecins Sans Frontières/Doctors Without Borders (MSF)
Open Arms
ResQ – People Saving People
Salvamento Marítimo Humanitario
Sea Punks
SOS Humanity
Watch the Med – Alarm Phone

Co-signing organisations:

Borderline-Europe, Menschenrechte ohne Grenzen e.V. Human Rights at Sea

1. UN High Commissioner for Refugees (UNHCR), Legal considerations on the roles and responsibilities of States in relation to rescue at sea, non-refoulement, and access to asylum, 1 December 2022, available at: https://www.refworld.org/docid/6389bfc84.html.

How Lebanon’s financial troubles have delivered a surge in demand for midwives

How Lebanon’s financial troubles have delivered a surge in demand for midwives

Eva Mousa had always planned to give birth in hospital.

But after the 19-year-old housewife’s husband Mohammad ended up being admitted himself following a motorbike accident, the pair were left financially depleted and indebted. The young, previously middle-class family — newly impoverished, like many in the financially struggling country of Lebanon — have been forced to think of alternative options for childbirth.

With only five months to go until the arrival of their daughter, the young mother said the prospect of incurring further debt influenced their decision to have the pregnancy attended to by a midwife rather than an obstetrician.

They had borrowed from friends and family to afford the cost of Mohammad’s week-long hospital stay and an operation on his leg. It broke them so much financially that Mrs Mousa was left wondering “how on earth could we afford to have a family?”

Following the advice of a cousin who had recently given birth at a midwife-operated clinic in the mountain town of Aley, Mrs Mousa decided to carry her pregnancy to term under the watch of the same midwife.

Her anxiety over deviating from the norm of giving birth in hospital vanished after her first check-up.

“Immediately I was more comfortable than if I had gone to the hospital,” Mrs Mousa said of the quality of care she received. Her daughter Mariam is now a healthy six months old, cooing and smiling under a bundle of blankets.

“I felt like the qabila” — the Arabic term for midwife — “knew exactly what to say and how to act and she was more personable than a doctor.”

The delivery procedure cost the family about 2 million Lebanese pounds or the equivalent of $45 on today’s market rate. By comparison, the average cost of childbirth in a Lebanese hospital is $350 to $500, although some private hospitals charge thousands of dollars.

The cost of childbirth — not to mention pre and postnatal care — has become almost insurmountable in Lebanon’s crumbling economy. Now in its fourth year, Lebanon’s financial meltdown has pushed two thirds of its population into poverty. Inflation is at an all-time high, and the local currency is worth a mere fraction of what it once was. The average public sector employee makes less than $50 a month.

A rise in demand for midwives

A midwife is a qualified and accredited clinical professional who provides specialist care to mothers and newborns. They work with women in labour to enable childbirth, in addition to working with mothers in the prenatal and postpartum stages.

Medical studies on midwifery-led models say the benefits include lowered rates of unnecessary and potentially harmful medical procedures such as Caesarean and labour inductions, higher rates of breastfeeding and significantly increased rates of satisfaction in women when it came to quality of care before, during and after birth.

Most patients cite financial reasons as a major reason for their decision to give birth accompanied by a midwife, Dr Rima Cheaito, head of the Order of Midwives in Lebanon told The National.

The order recorded a “definite increase” in midwife-enabled births following Lebanon’s economic severe downturn, Dr Cheaito said.

Births delivered through midwives in private clinics more than doubled in the first three years of the economic crisis: from 2,095 in 2019 deliveries to 4,800 last year.

It’s a comprehensive service free of charge and open to whoever wants to give birth in the area so long as they fit the criteria
Charlotte Massardier, MSF's advocacy manager

Marginalised and limited despite surging popularity

In Beirut’s Rafic Hariri University Hospital, Lebanon’s largest government hospital, Batoul Al Hamad cradles two day old Yousef. He is her second child to be born with the aid of a midwife.

“Women I knew, neighbours and friends, had told me about their experiences and advised me. But I still had reservations because it’s a different way of giving birth than we’re accustomed to,” the 27-year-old Syrian mother told The National.

“Back then I took their advice and tried it. And here I am again for Yousef, because I’m comfortable here.”

The midwife birthing centre in Rafic Hariri hospital — run by medical NGO Medecins Sans Frontieres (MSF) — became the only hospital-based, midwife-led birthing unit in the nation when it relocated from the Shatila camp for Palestinian refugees in 2018.

According to Public Health Minister and previous director of RHUH, Firas Al Abiad, hosting the unit in a government hospital was partly an initiative to empower the midwife-led model in Lebanon and answer its detractors.

The majority of patients at the birthing centre are Syrian and Palestinian refugees, and domestic migrant workers.

“It’s a comprehensive service free of charge and open to whoever wants to give birth in the area so long as they fit the criteria,” said Charlotte Massardier, MSF’s advocacy manager.

She said MSF staff had witnessed an increase in the number of economically vulnerable Lebanese patients coming to the centre since the start of crisis in 2019.

But with the resources of the Health Ministry and various international aid organisations stretched thin, Dr Al Abiad said there was no capacity to expand the midwife-led model to other hospitals.

“We are looking at how we can even preserve the current model, never-mind expand it, because we’re not sure for how long MSF can maintain it,” he said. The Health ministry was studying ways to independently support the birthing centre, he added.

Aside from the MSF unit, women who desire the care of a midwife must make appointments in private clinics — a significant point of contention for advocates of the practice who say midwives are marginalised in Lebanon’s healthcare system.

Midwives v the system

“As a woman in Lebanon you don’t have many options,” said Dr Tamar Kabakian, a reproductive rights expert and associate professor at the Department of Health Promotion and Community Health at the American University of Beirut. “You have a choice between a midwife clinic and a hospital with an obstetrician.”

Technically and according to Lebanese law, midwives are permitted to be the primary birth attendant in charge of delivering a baby.

But in practice — in part due to Lebanon’s highly decentralised and mostly privatised health sector — critics say midwives have been sidelined, with hospitals regarding them as little more than obstetric assistants.

“The midwife is only permitted to see the mother before and after the birth,” said Dr Cheaito. “And not during deliveries. They’re limiting our role.”

Dr Al Abiad echoed her concern that midwives in Lebanon had “taken a backseat” to physicians, citing numerous studies that found women perceived midwife-led deliveries to be higher quality.

Health experts and advocates of the midwife-led model argue that its numerous economic and health benefits outweigh those of the dominant obstetric model.

In Dr Cheaito’s view, obstetricians and midwives should be working in tandem, with midwives delivering low-risk pregnancies and obstetricians the high-risk.

“If it’s a normal pregnancy and we have highly qualified professionals who can conduct deliveries for a lower cost, why not allow them to work?” she asked.

Midwifery v obstetrics

The obstetric model remains dominant in Lebanon’s vastly privatised healthcare sector.

Dr Kabakian explained that the marginalisation of midwives in Lebanon’s health sector was a “systemic issue” that stems from the struggling Health Ministry’s inability to impose national guidelines and standards of care on the mostly decentralised — not to mention deteriorating — health sector.

As a result, “hospitals have their own standards and practices. It’s different according to each provider and physician,” Dr Kabakian said.

Compounded by Lebanon’s worsening economic crisis, the large gaps and lack of regulation in the healthcare system have conjoined to create an environment where obstetric violence — the mistreatment and abuse of women during childbirth by their care providers — has become a matter of routine.

This includes “interventions that are not medically necessarily and may even be harmful to the mother and child, but are done almost routinely to women in Lebanon,” said Dr Kabakian, “such as episiotomies” — the process of cutting the perineum during childbirth to move the foetus through the vaginal opening more easily — “and caesarean sections. Women don’t know when they don’t need C-sections and care providers do it because it’s faster.”

Lebanon has one of the highest rates of caesarean sections in the world, hovering at about 50 per cent according to the World Health Organisation. They are not needed nearly as often as they are prescribed but are faster than normal deliveries and therefore more convenient for obstetricians. The procedure also incurs additional fees, which means more revenue for the hospital or doctor.

Overwhelmed physicians who are paid per-service and cash-strapped hospitals have little incentive to advance the midwife-led model, instead maintaining an obstetric model that priorities the needs of the doctor over the patient.

“This is a private, fee-for-service healthcare system,” said Dr Al Abiad of the challenges of bringing midwifery to the foreground in hospital settings. “Physicians are obviously not very happy to give up that route. At the end of the day, this is a source of income for them.”

By contrast, midwives attend to and prioritise the woman’s needs, “leading to an improved quality of care,” said Dr Kabakian. “It’s the healthier option, scientifically-speaking.”

Health advocates argue that a strong midwifery-led model might be able to reduce the impact of the economic crisis on patients.

“We could have higher value deliveries at lower cost to the patient,” said Dr Abiad. “This economic crisis is an opportunity for us to rethink our care delivery.” He added that he was eager to dispel perceptions that “midwife-led delivery is lower quality because it’s more affordable. That is not the case.”

But for mothers such as Mrs Moussa and Mrs Al Hamad who were driven to using midwives for financial reasons, it is also the comfort and quality of care which will keep them loyal to midwives.

“She was with me before and after I had Mariam,” Mrs Mousa told The National. “She told me how to care for her in the first few weeks. That I should stay warm and drink natural juice to maintain my body’s nutrients while breastfeeding.”

“I’ll definitely go to her if I get pregnant again.”

*First published in The National News

MSF supports Haitian health authorities in cholera vaccination

MSF supports Haitian health authorities in cholera vaccination

Port-au-Prince, 20 December 2022 – Médecins Sans Frontières (MSF) teams in Haiti are supporting the cholera vaccination campaign launched by the national health authorities. This campaign is the latest effort in response to the resurgence of the disease, which has affected more than 15,000 people and caused more than 300 deaths in the country since the end of September. On 12 December, the Ministry of Public Health and Population (MSPP) received 1.17 million doses of cholera vaccine from the International Coordinating Group, a mechanism to manage and coordinate the provision of emergency vaccine supplies to countries during outbreaks.

“We support the vaccination campaign in Cité Soleil, one of the most cholera-affected areas of Port-au-Prince”, says William Etienne, MSF emergency coordinator. “Our teams are helping with the transportation of the vaccine doses and other items, facilitating the movement of the MSPP vaccination teams, distributing soap and other hygiene items, and taking care of waste management.”

The ongoing cholera resurgence comes at a time when the population is already facing enormous difficulties in accessing health care. Fuel is becoming progressive available after weeks of extreme scarcity due to the blockage of the main oil terminal, but insecurity and violence combine with an unprecedented economic and social crisis to make access to basic services extremely complicated.

“Though the pace of contamination has apparently slowed down recently, vaccination remains a very useful tool in a fragile health context such as this” says William Etienne. “Haiti has been hit by a major cholera epidemic in recent past”. MSF teams have been part of the cholera emergency response since the first few patients were identified. We quickly opened several cholera treatment centres in Port-au-Prince and in the Artibonite province, work to provide access to clean water and run health promotion activities.

Lebanon’s ailing health system grapples with cholera outbreak near Syrian border

Lebanon’s ailing health system grapples with cholera outbreak near Syrian border

In a freezing classroom in Arsal, an isolated Lebanese town perched 1,500 metres above sea level near the Syrian border, one by one children line up for their cholera vaccine — taken orally, a quick gulp down the throat.

The teacher marks their hands with a pen, and now the jacket-clad children have an extra layer of protection against Lebanon’s first cholera outbreak in three decades.

Arsal, a largely Sunni Muslim town in the north-eastern reaches of the Baalbek-Hermel governorate, is one area of Lebanon that has been a focal point of the cholera spread — and efforts to fight the disease.

A poor, overcrowded town where informal settlements sit alongside houses, it’s the perfect place for the disease to take hold.

And while Lebanon is — at the moment largely successfully — countering cholera, there are fears that the looming winter could isolate Arsal, where the proportion of Syrian refugees is double that of the Lebanese population.

By the end of November nearly 450,000 vaccines had been administered. Since the outbreak in early October, there have been about 4,600 suspected or confirmed cases and 20 deaths.

The cholera strain found in Lebanon is similar to the one in neighbouring Syria, itself struggling with a much larger outbreak.

The World Health Organisation describes cholera as “an acute diarrheal disease that can kill within hours if left untreated”.

It can be easily treated with oral rehydration salts but in severe cases immediate medical attention is needed.

Lebanon’s economic crisis means the country lacks a sufficient supply of medicine, clean water and electricity.

Organisations such as Medicines Sans Frontiers, which recently opened a cholera treatment unit in Arsal, are going door-to-door in a bid to get people vaccinated.

One of those to take the vaccine was the family of Salah, a middle-aged Lebanese man from Arsal who lives near one of the small refugee camps that merge with the older homes.

Normally the family gets their water from lorries and a nearby well.

“You never know. Waste management is not properly functioning, so you never know if this water is clean or if the water in the well is clean,” he said.

Salah said waste management and infrastructure were already in a bad state before a series of crises hit Lebanon, including a devastating economic crisis that first became apparent in 2019 and an influx of refugees fleeing the war in nearby Syria that began more than a decade ago.

“It became worse with overcrowding but it was already bad,” he added.

For now, suspected and confirmed cholera cases are somewhat stable — and are even potentially going down slightly, according to government statistics.

The focus has been on prevention — whether through awareness or efforts to ensure that the water is safe — and on treating those who fall sick.

While cases have largely not been as severe as initially predicted, fears remain that cholera could be around in Lebanon for longer. It is also believed that Lebanon’s health system would struggle to tackle a larger or more serious outbreak. So, the focus is on ensuring that it does not become an epidemic, said Farah Nasser, medical co-ordinator for MSF Lebanon.

“If we want to describe [the situation] it would be we are still in control, as the cases are still mild to moderate. The phase we are in now, we still have the hospitals prepared, there are still places in the hospitals. So it is still under control,” she said, contrasting the current situation to that when cholera first broke out in Lebanon when authorities and humanitarian organisations had to rapidly mobilise.

“But now it is controllable and we are having the time to really work on the prevention arm of the outbreak. The idea is we should focus really on prevention. If we really worked on prevention, then we will be in a good place.”

Lebanon’s economic capitulation has been described as one of the worst in modern history by the World Bank, with much of the population plunged into poverty. It has led to shortages of vital medicine, a lack of clean water and hospitals impaired by power cuts.

“The health system is under the burden of all the crises,” said Ms Nasser. “We had a good health system, which was mostly private plus what the Ministry of Public Health was working on as primary healthcare centres.

“And then with the economic crisis, it put a huge burden on that system, which is near collapse. They are not getting what they need [financially] and it’s a huge burden on the patients themselves.”

All of Lebanon’s eight governorates have detected cholera, but it is most prominent in the areas neighbouring Syria, where the border between the two countries is porous. While Akkar to the north-west of Arsal has recorded more cases, the latter is bereft of a public hospital — although MSF does operate a clinic — and relatively isolated.

Akkar and Arsal, which briefly came under the control of ISIS in 2014, have particularly weak infrastructure and their residents have particularly poor access to clean water.

Winter is expected to be grim in impoverished Arsal — previous years have seen refugee camps covered in blankets of snow amid below freezing temperatures.

One family The National spoke to said they were forced to burn plastic to fuel their heater, despite the fact that it would likely worsen a heart condition of one of their young children.

Recent flooding, blamed on blocked pipes, was yet another issue to hit the area.

One of those affected was Raida, a mother of five who lives in a Syrian refugee camp in Arsal that was flooded. She was in an isolation unit and had taken her youngest — only three months old — to the MSF clinic when she had diarrhoea, a classic symptom of cholera.


“Two days ago I realised I was changing her diapers more than usual,” Raida said.

For now, Lebanon’s embattled health system is responding — but a wider, more serious outbreak could prove too much.

“With a bigger outbreak, I think we would be not in a good place,” said Ms Nasser. “The efforts since day one to prepare government hospitals to accept patients … most of the hospitals were prepared within the first two weeks of the outbreak.

“But if we had a really large outbreak, as we’ve seen in other countries, that would be a super-big burden on our health system.”

* First published in The National News