The Daily Star - Easing the burden: maternal health care in Palestinian camps, May 5 2012

By Martin Armstrong

SIDON, Lebanon: Sitting in a dark, cramped living room in the Palestinian refugee camp of Ain al-Hilweh, Sawsan, 24, tenderly rocks her three-month-old son Bayan on her knee, whispering sweet-nothings to calm the agitated baby.

As his crying subsides, Sawsan gingerly hands Bayan over to Zeina, one of five midwives and nurses employed in Ain al-Hilweh by the non-governmental organization Medical Aid for Palestinians (MAP), as part of its maternal and child health care program. Zeina takes the child and smiles affectionately at him while gently wrapping a blood pressure cuff around his delicate arm.

“I don’t know what I would do without her,” says Sawsan of Zeina. “There would be no one to help.”

Sawsan is severely anemic and suffers from Thalassemia, an inherited blood condition for which she has received three blood transfusions. She has already lost one child; Hasniya was born premature – as was Bayan – and died shortly after birth.

“I lost everything when I lost her,” says Sawsan quietly, grief threatening to overwhelm her composure. “In those times Zeina supported me like a sister.”

Midwives have traditionally provided crucial care for mothers in Lebanon and around the world. Their contribution is celebrated on International Day of the Midwife on May 5. MAP inaugurated its own maternal and child health care program in 2008 following the 2007 conflict between Fatah al-Islam and the Lebanese Army in the Nahr al-Bared camp. It operates in Nahr al-Bared and Beddawi camps outside of Tripoli in addition to Ain al-Hilweh in Sidon, and employs a total of 15 midwives and nurses who visit beneficiaries in their homes.

According to Dr. Ali Dakwar, MAP’s project coordinator, the program “fills a gap in resources.” Working in conjunction with the United Nations Relief and Works Agency (UNRWA), it provides services that complement those delivered by the U.N. body.

In Lebanon’s Palestinian camps, factors such as overcrowding, lack of fresh water and nutritious food, and a socio-cultural predilection for big families leave mothers and their newborn children vulnerable to bouts of diarrhea, viral hepatitis, fevers, intestinal infestations and other illnesses.

Anemia caused by a lack of nutritious food is a major problem. Marta Petagna, MAP’s director of programs, says that over 30 percent of pregnant women supported by MAP suffer from anemia. Among children under 1 year of age the figure is as high as 80 percent in certain areas.

The consequences are severe. Pregnant women suffering from anemia are six times more likely to suffer complications over the course of their pregnancy and during childbirth, and the condition stymies both the physical and cognitive development of newborn children.

UNRWA clinics struggle to cope with the demand. In a recent MAP briefing paper, Dr. Suleiman, senior medical officer at one of two UNRWA health clinics in Ain al-Hilweh, articulates the difficulties the clinic faces in treating an average of 140 patients a day.

“Our record is 200 for a shift that lasted [fewer] than eight hours,” observes Suleiman. “Ideally, we should be treating only 50 patients a day maximum, and I feel guilty that I cannot spend proper time with people.”

Dakwar, whose family was forced to emigrate from Palestine to Lebanon during the Nakba in 1948 when he was only 2 years old, explains that this is where MAP steps in: “Due to small numbers of staff, UNRWA are unable to do home visits or give enough time to patients in their own clinics.”

Each MAP midwife makes around five or six visits a day, carrying with her the equipment necessary to check blood pressure and fetal heartbeats, as well as conduct urine samples to test for protein and nitrate levels. Additional health care education and psycho-social support is also provided. At the end of each day, the results of the home visits are recorded and compiled at the MAP clinic. MAP additionally empowers 20 “community mothers” to reinforce key health messages while the Lebanese NGO Naba’a (Development Action Without Borders) has contributed four social workers to the project.

Lamise and Nadine, two of MAP’s midwives working in Ain al-Hilweh, explain that the frequency of visits to a beneficiary depends on the case. Normally, MAP midwives pay calls on a mother-to-be four times over the period of her pregnancy and then every two months after the child is born. If the child is healthy, these visits stop after six months. In high-risk cases, the midwives visit the beneficiaries every week during pregnancy and after birth if the child’s birth weight is low. In extreme cases, visits are made every day.

Since the home-visit initiative was established in 2008, results have been positive. Last year, the program provided outreach nursing support to over 3,400 people, with over 1,800 home visits. MAP’s consultative nurse Maggie Kent reports that mothers have generally complied with calls to practice exclusive breastfeeding and ensure the passage of at least 18 months between pregnancies.

“Both [developments] bode well for the health of mothers and their babies,” says Kent over a cup of coffee at MAP’s headquarters in Ras al-Nabaa, Beirut. In another encouraging sign, levels of anemia have fallen.

The home-visit system also enables MAP midwives and nurses to transcend the strictly medical impetus of their visits and forge stronger relationships with beneficiaries, sometimes even becoming their confidants. The creation of such bonds increases the likelihood that vital health-related advice will be taken to heart.

“I have had great help from [MAP] both medically and in terms of support; they have helped many women in our community,” says Sanaa, a 22-year-old. “I feel comfortable opening up and saying what I want; they will hear me,” she adds, while cradling her son Imad in her left arm.

Lamise echoes the sentiment. “We are always communicating via phone calls and text messages and they tell us about other pregnant women in the community ... our relationship is like a friendship,” she explains, while employing fancy footwork to avoid a particularly perilous open drain off Ain al-Hilweh’s main thoroughfare. Nadine nods in agreement while Zeina interacts animatedly with a group of children congregating nearby.

Lamise, Nadine and Zeina admit that their work is upsetting at times. Nadine describes the most difficult situation she has faced working for MAP as involving the antipathy of a woman toward the child of one of her husband’s other wives.

“She was not in a good state of mind,” Nadine says. “She would leave out knives and sharp objects so that the baby might accidentally hurt himself.”

Lamise concurs that “it is upsetting when you see mothers and their children suffering.” But then she brightens and adds: “Every day we work with lovely people. Our difficulties compared to theirs are nothing, and this is our job.”