Iraq

Iraq: Five years after the battle of Mosul, women still struggle to access health care

Undeterred by the stormy weather, a line of women formed outside the Doctors Without Borders/Médecins Sans Frontières (MSF) Al-Amal maternity center, located in the Al-Nahwaran neighborhood of Mosul, the second largest city in Iraq.

Maram is three months pregnant. She is expecting her third child, but this is the first time that she’s visited this center. “I came here because my relatives told me about [it],” she says. “My sister-in-law came here before, and she recommended it.” Many other women here also heard about the center through word of mouth, and patient numbers have increased in recent months.

Al-Amal offers routine obstetric care, newborn care, family planning, and mental health support. The MSF team also conducts health promotion. Thirty midwives and five midwife supervisors work in the facility, which is open 24 hours a day, seven days a week.

The team assists between 10 and 15 deliveries daily, but a busy day can see up to 25 births. “Unfortunately, we still can’t cover all the needs,” said Rahma Adla Abdallah, an MSF midwife supervisor. “We help most women who come here, but we have to have admission criteria to maintain the best possible level of care within the limits of our own resources.”

A long road to recovery

In June 2014, Mosul fell to the Islamic State group. In October 2016, a military offensive led by an alliance of the Iraqi security forces and an international coalition was launched to retake the city. The battle of Mosul lasted for more than 250 days and was described as one of the deadliest urban battles since World War II.

Almost five years after the city was officially declared retaken by Iraqi authorities, many medical facilities damaged in the fighting have yet to be fully renovated and are not fit for use. “What has mainly been done is to [temporarily] install containers next to destroyed facilities until they are rebuilt,” said Adla Abdallah. “But the containers are often not properly equipped for receiving patients. Right now, especially [with] COVID-19, the needs are too big for hospitals in Mosul to handle.”

On top of this, there are still shortages of medical supplies, and thousands of families in Mosul and surrounding areas still struggle to access quality affordable health care.

Filling the gaps

In response to the high level of unmet needs after the conflict, MSF opened a specialist maternity unit in Nablus hospital in West Mosul in 2017 to provide safe, high quality, and free health care for pregnant women and newborns. In July 2019, a second MSF team opened the Al-Amal maternity unit within Al-Rafadain primary health care center, also in West Mosul. Last year, MSF teams in both facilities assisted the births of almost 15,000 babies.

“We first opened this maternity unit because there were significant needs in the city when it came to access to health care in general, and even more so in the field of sexual and reproductive health care,” said Loay Khudur, MSF’s assistant project coordinator. “Three years later, many women still need to come here because the city’s health system is far from functional.”

“Women in this community not only need access to physical health care, they also need full mental health support,” said Adla Abdallah. “Gender-based violence is an issue we sometimes witness. Some of our patients have experienced it but they very rarely talk about it.”

Iraq’s Directorate of Health has set up dedicated health services in the city to provide care for survivors of gender-based violence. But stigma continues to prevent many women from seeking this care.

“Most of the time, it’s the people who live with them who bring [the patient] here,” said Adla Abdallah. “The women themselves don’t speak because they feel scared. Gender-based violence is still very taboo and is an additional challenge we face when treating women here.”

Barriers to accessing care

Stigma is not the only barrier women face to accessing care. “The environment is particularly complicated here,” said Bashaer Aziz, an MSF midwife supervisor. “A significant number of women cannot access health care either because they do not have the means to pay for it, or because they face other challenges, such as not having official administrative document due to the recent conflict or being displaced from their homes.”

MSF offers free care in all its facilities. “When patients come to our facility, they are generally very grateful to receive good medical and obstetric care,” said Aziz. “They don’t have other places to go, they cannot afford to pay for services at hospitals or private clinics. Our maternity unit makes a big difference to them.”

“Before this maternity unit existed, nothing was available and we used to deliver at home,” said Mahaya, 50, who traveled more than an hour with her pregnant daughter-in-law to come to the clinic. “A midwife would come, deliver the baby, and that would be it. There wasn’t even a hospital we could go to. This maternity unit is a big improvement in our lives.”

“There is still a long way to go before proper access to both physical and mental healthcare can be guaranteed in Mosul,” said Adla Abdallah. “But I focus on the little wins to keep on going. One day a patient left us a note to thank us for the services we provide, but also for the human approach we take at the maternity unit. Her thanks meant a lot to me.”