28 July 2021
Wafa Dakwar, Medical Aid for Palestinians (MAP)’s Senior Programmes Officer in Lebanon, joined community midwife Zeina on her visit to Ein el Helweh refugee camp in the south of Lebanon. Here, she describes how MAP’s midwives have provided Palestinian mothers with breastfeeding advice, and other health and parental support amid the economic crisis in Lebanon.
Lebanon’s severe economic crisis is disproportionately affecting pregnant women, nursing mothers, and infants, who are among the most vulnerable groups. The local currency has lost more than 85 per cent of its value and inflation has reached an all-time-high.
The Central Administration of Statistics reported that food prices have quadrupled, leaving many Palestinian refugees unable to afford basic food supplies and skipping meals as a result. This leads to poor nutrition which can have harmful health effects, particularly on mothers and babies. Malnutrition is an underlying cause of almost half of the death rates for under-five-year-olds, and malnourished mothers are at higher risk of illness and complications during pregnancy and childbirth.
MAP supports mothers and babies through home-visits by a team of skilled midwives and nurses. These include health screenings, pregnancy follow-ups, and health and nutritional counselling. With the support of United Palestinian Appeal (UPA), MAP has also been able to provide much-needed multi-vitamins to pregnant women, which will help them meet their nutritional requirements during critical stages of pregnancy.
Recently, I accompanied a group of MAP’s community midwives to Ein el Helweh refugee camp, in the southern city of Saida, which was established in 1948 following the ‘Nakba’ (or catastrophe) when Palestinians were expelled from their homeland and sought safety in neighboring countries, including Lebanon. Today, this one square kilometre camp hosts around 80,000 refugees, despite its decaying infrastructure, over-crowding, and poor environmental, health and living conditions. After passing the Lebanese army checkpoints that control the entrance and exit of the camp, I joined midwife Zeina to visit the homes of Hasna* and Ghina* ‒ two of the 3,000 highly vulnerable expectant and new mothers that MAP works with.
Hasna is a twenty-nine-year-old Palestinian mother of three children, the youngest being a two-month-old baby boy named Ahmad. Hasna was married while still only a child, at just 14-years-old, and had her first baby at 15 and her second at 17.
Child marriage is common in Lebanon, especially among the most vulnerable population groups. A study by UNICEF in 2015-2016 reported that child marriage rates are as high as 12 per cent among Palestinian refugee women and 25% among Palestinian women displaced from Syria. The minimum legal age of marriage in Lebanon varies among religious sects, and girls as young as nine can be married off, although it rarely happens. In May 2021, steps were taken to try and combat child marriage with the minimum age of marriage raised to 18 years for Sunni Muslim communities and 15 years for Shiite communities.
Hasna suffered major complications during her first and second pregnancies, and almost died during the birth of her second child. Complications related to early pregnancy and childbirth are a leading cause of deaths for girls aged 15 to 19, and girls under 15-years-old are five times more likely to die during pregnancy and childbirth than girls aged 20 to 24.
“My pregnancy with Ahmad was different. I was able to take good care of myself. I used to follow the advice that midwife Zeina gave me, especially related to nutritious foods,” said Hasna. “I felt reassured and happy; it is probably because this time I am older and have more experience and knowledge. I will never let my daughter marry at a young age. She should enjoy her childhood and go to school.”
Zeina checked the health and growth of the baby and asked Hasna about signs of infections. She measured Ahmad’s height, weight, and head circumference and checked his reflexes. Zeina also asked Hasna if she took Ahmad to the vaccination appointments specified in his vaccination card.
Zeina was pleased with Ahmad’s growth and praised Hasna’s care and parenting skills. Hasna was very happy, and proudly said that she has been exclusively breastfeeding Ahmad, as the midwife advised. The World Health Organization recommends breastfeeding infants until they are six months old, and then introducing safe and appropriate complementary feeding with continued breastfeeding until two years and older.
Mothers sometimes do not comply with this recommendation because they are advised otherwise by health professionals who violate the code that prohibits the marketing of breast milk substitutes, or because they are discouraged by family members voicing traditional misconceptions and practices. “I am very glad that I don’t give my child formula milk,” said Hasna. “Mothers who give their babies artificial milk are now struggling because it is no longer available in pharmacies and, when found, it is extremely expensive.”
MAP’s midwives provide extensive breastfeeding counselling and advice starting with visits before childbirth. Over the years, the midwives have been successful in improving breastfeeding rates. For example, last year the breastfeeding rates among the mothers MAP supports was 87 per cent after the first month of childbirth, and 80 per cent after three months ‒ a much higher rate than the national average.
During the visit, Hasna raised some concerns she had related to breastfeeding, particularly whether it will be sufficient as Ahmad continues to grow. Zeina reassured her that Ahmad will get all the nutrients and liquids he needs from the breast milk and that there is no need for additions until he is six-months-old.
Zeina also gave Hasna nutritional advice – which is particularly important, with many foods becoming unaffordable to most families in the camp. Countless families have reported reducing the number of meals they eat, or their portion size, or replacing protein-rich foods with carbohydrates, which puts them at risk of malnutrition in the long-term.
“We are not able to buy many types of foods such as meat. We are relying mostly on vegetables and pulses; we buy them in the evening because their prices become cheaper at the end of the day,” explained Hasna. “My husband works 12 hours every day, and he is paid 1,000,000 Lebanese pounds (LBP) which used to be equivalent to $667 US dollars but is now worth only $58. We can barely buy anything anymore with this amount and with how high the current prices are.”
Throughout the visit, Hasna was listening carefully to Zeina and asking many health and parenting- related questions. She was very pleased with the midwife’s visit and thanked MAP for helping her and other mothers in the camp.
Ghina is a Palestinian mother of three children who lives in Ein el Helweh Palestinian refugee camp in south Lebanon. When MAP first started to support Ghina, she suffered severe anemia and was concerned that she might need blood transfusion during childbirth, as in her previous pregnancy. Like many other pregnant women, Ghina was also worried about getting COVID-19 and, in turn, causing harm to her unborn child. This was putting her under a lot of stress and preventing her from leaving her house, even for medical consultations.
According to the Head of the National Order of Midwives, this was a common issue among pregnant women during the early period of the pandemic, as many lacked sound information about the pandemic and were worried about the consequences of testing positive for COVID-19. “Many pregnant women were staying home all the time and forgoing medical consultations,” said Zeina. “Sometimes they were experiencing serious complications and health problems – such as gestational diabetes, hypertension or anemia – but were not aware of it as they were not attending pregnancy routine consultations or doing essential tests. Thus, reaching out to these pregnant women during the pandemic and providing them with evidence-based information and pregnancy care through community-based midwifery has never been more important,” she added.
Ghina was very happy to see the midwife at her door; she welcomed us with a big smile and invited us in. Zeina started by asking Ghina about her pregnancy, different signs and symptoms, and the results of the last tests she did. Zeina also examined her, checked her blood pressure, tested her for urinary tract infections, checked her hemoglobin blood test results, and listened to her fetal heartbeat.
“Listening to the baby’s heartbeat is the mothers’ favourite part; it is when you can see their eyes shine,” said Zeina. Ghina was able to overcome anemia with the help of nutritional advice and supplements. Many nutritious foods, such as meat, are no longer affordable for most of the families in the camp, so the midwives give advice on alternatives and less expensive nutritious foods during their visits.
Ghina also benefited from the distribution of high-quality multi-vitamins donated by UPA, that will help her stay healthy during her pregnancy. “The multi-vitamins you provided are excellent. I checked with my doctor before taking them, and he said they are safe and good for me. They do not cause any stomach discomfort like some other types of multi-vitamins,” said Ghina. “The bottle is enough for six months which is great because food supplements have become very expensive, like everything else in the country. The cheapest bottle of vitamins now costs around 100,000 Lebanese pounds [approximately 66 US dollars].”
Ghina asked the midwife about possible, more permanent family planning options as she has heard about tubal ligation which she can ask the doctor to do during childbirth. Zeina explained to her the different modern family planning methods, highlighting the advantages and possible side effects of each method. She explained to Ghina the procedure she is interested in by drawing it, so Ghina could better understand it.
Zeina also emphasised the importance of involving Ghina’s husband in decision-making, especially for the more permanent choices. She also advised about exclusive breastfeeding to support the mothers’ newborn feeding decisions. At the end of the visit, Ghina thanked MAP and UPA for their support.
To support the work of MAP's midwives and Palestinian refugees in Lebanon, please consider donating today.
*Names has been changed to protect identity.
Top photo: MAP midwifes during a visit to Ein el Helweh refugee camp in the south of Lebanon. (Credit: Wafa Dakwar).
