On February 6, 2023, a magnitude 7.8 earthquake struck at 4:17 a.m. in southern Turkey and northern Syria. Many people were soon trapped under collapsed buildings, and the death toll in Syria alone soon rose to 5,900. Nineteen hospitals were fully or partially damaged by the earthquake, and most facilities were not able to provide services at all for a few weeks as their electricity was cut off and they did not have back-up generators.

At this time, Hiba, who asked that her last name not be used for safety reasons, was working as a midwife at Al-Rafah Specialized Hospital in Jindires, a town in northwest Syria. She was also eight months pregnant with her first child.

Hiba, fortunately, wasn’t hurt in the earthquake, and she gave birth to her baby without complications a month later in March. She now brings him to work at the hospital, where a private attendant watches him between Hiba’s breastfeeding breaks. But the trauma from the earthquake lingers on.

“Every day I come to the hospital, and I feel like maybe it’s the last day in my life,” Hiba shared with Direct Relief through a translator. “When I feel anything that reminds me of the earthquake, any tremor and anything else around me that makes it feel like there’s an earthquake again, I take my baby and go outside the building because the building is cracked and affected by the earthquake.”

New Trauma Added to War and the Pandemic

Hiba is one of around 500 midwives in northwest Syria who face tremendous challenges in their work and personal lives amidst the overlapping crises of the last few years—including not only the February earthquake but also war and Covid-19.

Syria’s protracted civil war has lasted over a decade, and more than 12 million people (half of Syria’s pre-war population) are refugees abroad or are internally displaced, and over 2 million people are living in Syrian tent camps with limited access to basic services.

The health needs here are immense, and almost all healthcare services for the 4.6 million civilians in northwest Syria are provided for by a patchwork of NGOs and UN humanitarian assistance, which makes health funding gaps inevitable.

Health facilities have also been actively targeted. Dr. Okba Doghim, a physician and the programs director at Syria Relief and Development, an NGO based in Syria and Turkey that Direct Relief has supported since 2018, said that many people, like Hiba, are afraid to enter hospitals due to the risk of an airstrike combined with infrastructure damage from the earthquake.

Medical staff also often choose to relocate away from risk, and the remaining personnel cannot meet the present health needs. This has translated to a decrease in the quality of care in safer areas as the health system’s capacity there has not been able to scale with the population growth caused by people fleeing danger. “And we already had a staff shortage after Covid-19,” said Dr. Doghim.

“If She Will Not Die, I Will Not Go to the Health Facility”

Women of reproductive age are especially vulnerable to inadequate healthcare, particularly in the more than 1,400 camps for internally displaced people, or IDPs, in the northwest of the country. 80 percent of IDPs are women and children, and although 40 percent of the population lives in camps, only 18 percent of all health facilities are in camp settings. Because of these gaps, it is particularly critical to know what to do and where to go in a health crisis, but unfortunately, many don’t have this knowledge.

“The conflict interrupted education about sexual reproductive health, as well as regular information about the need for sexual reproductive health services,” said Dr. Doghim. “And there is no public transportation. In some communities, they prevent women and girls from going to the services without being accompanied by a man.”

And male accompaniment is not always a given. Dr. Doghim and his team recently visited an IDP camp, and he asked a resident, “When your wife is pregnant, what do you do? Do you go to antenatal care?” He said, “If she does not die, I will not take her to the healthcare facility; it’s 35 kilometers from here.” Gas is scarce and costly, making it a significant factor in this decision.

Also, there are no family planning services offered in that camp. “Almost 100% of those girls are married under 18,” he said. “All those women, they cannot go to toilets at night because they are at risk of violence and rape. They take showers inside their tents—they use clothes to cover the place where they shower. So there’s a lot of risk for gender-based violence in that camp. And all the families depend on women to work in the field. They work all day to get almost 25 Turkish Lira, which cannot do anything because it’s less than $1 for the family.”

Midwives Provide Support, but They Also Need It

Hiba shared that most of the pregnant women coming to the hospital live in an IDP camp. Implementing medical advice there is difficult due to unmanageable temperatures, lack of proper food and lack of privacy for applying medication. The number of C-sections has doubled, which Hiba attributes to the stress of the war and earthquake. “Before the earthquake, there were typically four C-sections a day, but now it is usually seven or eight,” she said.

Hiba’s hospital, even though there’s been a rise in pregnancies and risks involved, does not have the resources to hire more midwives, and the current staff is overloaded. For example, just one midwife assists with the labor and delivery process on any given day.

“We at least want another midwife to stay with the doctor in the clinic so I can then go work with the midwife who is working in the labor room,” she said. “It is a tiring process and very hard for just one midwife.”

There is a parallel shortage of nurses, which also ends up affecting the midwives. Because it is common in Syrian culture for a man to refuse to let a male nurse assist his wife in any way, a female nurse is often called upon to assist the male nurse, and she asks for the midwife’s assistance if there is more than one emergency case.

Unsteady Access to Medicines

Medicines and medical staff are in short supply, and this issue is often exacerbated by the current system for allowing aid into the country.

Every six months since 2014, the UN Security Council must reauthorize the humanitarian border crossing from Turkey into Syria. The border crossing reauthorization negotiation most recently lasted from July 10 to September 20, causing a gap of over two months in supplies and UN funding for the NGOs that run health facilities in Syria.

And the flow of supplies often halts before the border crossing renewal times out. For instance, Dr. Doghim shared, the United Nations Population Fund (UNFPA) sends family planning supplies for the first quarter (three months) after reauthorization, and then in the few months leading up to the next reauthorization there is often another interruption as the parties begin to discuss the agreement and its renewal is again in limbo. According to Dr. Doghim, the effects on medical material supply have been detrimental.

“Since the earthquake in February, there was no distribution of reproductive health kits, and many health facilities complain of supply shortages, including some critical items like oxytocin, which is given after each delivery to prevent postpartum hemorrhage.”

Fortunately, Direct Relief has recently been able to send 35 midwife kits to Syria Relief and Development during this most recent UN supplies lapse. Each kit contains the 61 essential items a midwife needs to perform 50 facility-based safe births.

“These are the best kits we receive,” Hiba said. “The contents are all there, like the scales and other delivery tools. And especially in the cases of emergency delivery attempts, everything is there, and we don’t have to buy any additional items to be prepared.”

A Sign of Hope, and a New Challenge

Despite all the challenges for families in northwest Syria, Hiba and her colleagues have seen a sign of hope: a significant increase in the number of women who want to have more children.

“Many women lost one, two, or three children [in the earthquake], and now they are coming to the hospital pregnant or trying to get pregnant, even though in many cases they are over 40 years old. This is a risk for them,” Hiba said. “And this is a new thing for us [the hospital staff]. These women didn’t want to become pregnant anymore before the earthquake, but now they are hoping to become pregnant to compensate for the loss.”

“Also, before the earthquake, when women were asked to return to the hospital for a follow-up appointment during their pregnancy, they mostly were not coming. But now, after the earthquake, most of them are committed to come and sign up for additional appointments to help implement what advice they were given,” Hiba said. “They are even now more cheerful about themselves and their children.”

“Those who live in the camps find difficulties in applying medical advice, but now they want to.”

Since 2010, Direct Relief has supported Syria Relief and Development with more than $28.2 million in medical and financial support, including for midwifery.