The urgent health struggle of mothers and children in the occupied Palestinian territory

March 04, 2009

Maternal and child health in the occupied Palestinian territory (OPT) faces challenges that are common to many low-income and middle-income countries, such as poverty, poor nutrition, and an overburdened public-health system, as well as unique challenges of military occupation and continued warlike conditions. Access to unrestricted 24-hour emergency care and other services, though vital for effective provision and protection of maternal and child health, is complicated by the living conditions there, especially the Israeli-imposed system of several hundred checkpoints. These issues and others related to maternal and child health trends and services are discussed in the second paper in The Lancet Series on Health in The Occupied Palestinian Territory, written by Dr Hanan F Abdul Rahim, Birzeit University, Birzeit, OPT, and Qatar University, Doha, Qatar, and colleagues.

Roughly 40% of the Palestinian population are women of reproductive age and children under 5 years. Fertility rates in Palestinian women are among the highest in the world, at 4.5 births per woman (Israel figure is 2.8). Around 28% of Palestinian women are married to a first cousin, which can have adverse health implications for children.

The authors analyse maternal and child health in the OPT with reference to Millennium Development Goals 4 and 5 (MDG4 / MDG5)*. They discuss how, following decades of improvement, infant mortality in the occupied Palestinian territory has not fallen much since 1990, nor has mortality in children under 5 years. In the occupied Palestinian territory, interventions that are fairly simple to schedule and deliver have high coverage. These include antenatal care, skilled attendance at birth, and childhood immunisations. Those that require a well-functioning health system 24h a day--such as emergency obstetric care--have lower coverage.

There can be no time more delicate and crucial than labour for a pregnant woman. But between 2000 and 2006, the Ministry of Health reported 69 cases of Palestinian women giving birth at Israeli checkpoints. 10% of pregnant women in labour were delayed for 2�� h on the road to the maternity facility, whereas the average time without roadblocks to reach health facilities was 15�� min. These numbers do not reveal women's anxiety throughout the pregnancy about reaching a place of birth and returning home safely. The rate of caesarean sections has risen from 6•8% to 15•0% of all births in the past decade. The rise in the rate of caesarean sections is cause for concern because of deteriorating health service conditions.

Gaps in the quality of health service provision are partially due to interactions between restrictions on mobility and the legacy of occupation which has stifled the development of good governance and the culture of accountability. Maternal and child health services in the public sector are perceived to be of lower quality and are not always in accordance with best evidence. Human resources are scarce in some specialisations, such as neonatology and paediatric surgery, but there is also a problem of ineffective use of human resources.

The authors make a range of recommendations, some immediate and some long-term, to improve maternal and child health in Palestine. They conclude: "Lives cannot be saved without access to 24 h curative services to deal with unpreventable complications. Such an achievement requires a political solution of unrestricted mobility, ensuring access to services. Availability of emergency obstetric care and high-quality birth attendance for all depends on a strengthened health system, which can only be achieved through a concerted effort and the commitment of the Palestinian National Authority, donors, and political decision makers to overcome the external and health-system constraints."
Dr Hanan F Abdul Rahim, Birzeit University, Birzeit, OPT and Qatar University, Doha, Qatar. T) + 970 2298 8654 E)

Notes to editors: *MDG4: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate. MDG5: Reduce by three quarters the maternal mortality ratio and achieve universal access to reproductive health.

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