Reproductive Health Rights and Access to Healthcare in the Gaza Strip
Reproductive health rights contribute to ensuring that people have access to sex that is both secure and fulfilling as well as the freedom and ability to procreate as they see fit. According to the World Health Organization, reproductive health rights also give women access to high-quality medical care that can properly protect them during pregnancy and childbearing.1 Additionally, health rights are crucial markers of a woman's excellent reproductive health.2 Numerous studies show that since the First Intifada, the Gaza Strip has experienced significant obstacles to women's access to reproductive health care due to economic and mobility limitations. Such situations led to a significant reduction in the Gaza Strip women's access to healthcare facilities.3 Women in the Gaza Strip consequently suffered a broad range of challenges in their struggle to have reproductive health rights, including limited access to both antenatal and post-natal care, induced deliveries, and increased number of home births among others.4 The lack of donors' interest and their support withdrawal also substantially affected the Gaza women's access to reproductive health rights since such situations hampered the implementation of the National Reproductive Health Guidelines, as well as the sustainability and quality of the Gaza Strip's reproductive health services.5
Impact of Violence on Women's Sexual Health in the Gaza Strip
Besides, the Gaza women's limited access to reproductive rights, since the First Intifada, appears to be the most visible aspect of the effect of violence on their sexual health. This paper explores the access to reproductive rights by women in the Gaza Strip since the First Intifada, as well as what their experience means for gender in the idea of the Nation.
Ways in Which Women have Navigated Reproductive Health in the Gaza Strip since the First Intifada
Complicated emergencies always get linked with government crisis and translated into ever more deteriorating and deficient health systems as well as crumbling healthcare.6 The long history of the Palestinian territory fragmentation together with the military occupation have continually been forming the major factors hampering the establishment of coherent and sound health programs and policies in the Gaza Strip.7 An insight into the Israeli-Palestinian conflict's history is essential for a better understanding of the struggle to access to reproductive health rights by the women in the Gaza Strip since the First Intifada.8
The Israeli-Palestinian Conflict and the Fragmentation of Healthcare Systems
The origin of the Israeli-Palestinian conflict trace back to the year 1947 when the United Nations allowed for the division of the Western Jordan part of the Palestinian territory into an Arab state and a Jewish state.9
Occupation and Healthcare Responsibility
In the year 1948, Israelis established themselves as a Palestinian state, a situation which led to the outbreak of the first Arab-Israeli war. What followed were several years of conflict, and between 1948 and 1947, the West Bank fell under Jordan's direct rule while the Gaza Strip was under the jurisdiction of the Egyptian government. Consequently, both the administrations took control over the healthcare systems in their respective control areas.10
Role of UNRWA in Healthcare
A third health system got introduced in the year 1950 following the establishment of the United Nations Relief and Work Agency for the Palestine Refugees in the Near East (UNRWA). UNRWA held a particular role of offering relief services; especially those related to the health of Palestine refugees.11 In June 1967, the Israeli forces occupied both the West Bank and Gaza Strip as well as the East Jerusalem. As a result, the provision of healthcare in the occupied Palestinian territory became the Israeli Civil Administration's responsibility, specifically the Israeli's Defense Ministry.12 However, they did not put enough investment in health system development to appropriately deal with reproductive health needs of the growing women population.
The First Intifada and Its Impacts on Healthcare
The First Intifada, the rebellion of the Palestinians against the Israeli occupation, started in December 1987 and ended after five years following the signing of the Oslo Peace Accords on the 13th of September 1993.13 The signing of the peace accord led to the establishment of an interim self-ruling body in 1994 known as the Palestinian Authority.
Challenges Faced by the Palestinian Health Ministry
The Palestinian Authority got charged with limited responsibilities, which included health, while over 59 percent of the Civil control remained under Israeli rule.14 After its establishment, the Palestinian Health Ministry had challenges relating to a weak health system which depended on politicized and inexperienced administration and had to deal with a broad range of health care providers.15
The Impact of Donor Support on Reproductive Health Services
Since its foundation, the Gaza Strip's Health Ministry has depended substantially on the support from various external donors that get driven by their agendas and mandates as opposed to the concern for creating a sustainable reproductive healthcare system for the Gaza Strip women.16 The donor support in the Gaza Strip has always been making use of the strategies applied in humanitarian interventions such as the pursuit of short-term outcomes and short-term commitments instead of getting concerned with developing an environment of sustainable reproductive health for the women. Such an approach has an adverse impact on the establishment and implementation of effective reproductive health policies.17 The donor support has been emphasizing a narrow focus on services relating to family planning as opposed to addressing the underlying quality reproductive health determinants such as the improvement of the quality of family planning services in various overburdened and weak healthcare facilities.18
Mobility Restrictions and Their Impact on Women's Access to Reproductive Health Rights
The primary issues surrounding the Israeli-Palestinian peace process, however, remained unresolved. Such a situation sparked the beginning of the Second Intifada in September 2000.19 The effects of the Second Intifada still get felt among the Gaza women, and has the characteristic of an increasingly harsh regime of extreme mobility restrictions imposed on the Gaza population by the Israeli occupying forces.20 The present situation in the Gaza Strip can get described as a crisis of access and mobility and has led to a significant decline in the Gaza Strip women's overall access to reproductive health services.21 According to the recent United Nation's report, the number of women in the Gaza Strip attending post-natal care services offered by UNRWA represents a reduction of over 52 percent.22 Additionally, the Union of Palestinian Medical Relief Committees' ambulances, as well as those of the Palestinian Red Crescent Society, got forced to wait for several hours or denied the passage at the Israeli military checkpoints. As a result, several patients, especially the women in labor, had to deliver in their residential areas, which is a much riskier practice to their reproductive health.23
Impact of Mobility Restrictions on Access to Reproductive Health Services
Since the outbreak of the Second Intifada, the access to reproductive health services has become a big problem for the women in the Gaza Strip.24 Since March 2002, the United Nations together with the humanitarian organizations no longer have an entitlement to their privilege status of acquiring the permissions to deliver reproductive health services to the areas under curfew or closure. Such a situation significantly continues to deny the women in the Gaza Strip their rights to access various reproductive health services.25
Challenges in Supplying Contraceptives and Medical Equipment
Furthermore, the maintenance of the supply of contraceptives, drugs, and medical equipment to various healthcare facilities in Gaza is both complicated and time-consuming, a situation which further makes it difficult for the women in the Gaza Strip to access reproductive health services.26 In fact, one public health facility that provided counseling and family planning services, as well as both the antenatal and postnatal services, became unattended by any physician following the repeated curfews in the Gaza Strip imposed by the Israeli forces.27 Besides, the presence of several checkpoints made it more challenging and almost impossible for the women in Gaza Strip to reach the health centers for essential reproductive health services. Such situations forced several women in the Gaza Strip to seek the help of the local midwives as well as the assisting nurses who could only offer some general follow-up services to the mothers and their newborns.28
Increased Risk and Complications in Childbirth
The number of deliveries in the Gaza Strip's referral hospital during the curfew periods got reported to have reduced by an average of five deliveries per day to three, and such a decrease indicated a growth in the number of home births among the women.29 Cases of caesarean sections increased among the women due to the high rate of pregnancy complications caused by reduced access to antenatal care.30 Additionally, several health facilities in Gaza experienced a rising number of pre-term births since the women, in most cases, asked for labor induction due to the fear of getting trapped by curfew, a situation which could prevent them from reaching the health centers in time.31
Challenges in Postnatal Care and Delivery
Due to curfew reasons and security problems, the women in Gaza also preferred getting discharged immediately after delivery, a situation which made it difficult for them to access postnatal care.32 The birth records kept by the international organizations indicate several cases of stillbirths and the death of women during delivery at various military checkpoints because the security officers at such checkpoints denied the women the passage to reach the health facilities.33 According to one of the international organizations' report, there have been approximately thirty-three deliveries and nineteen stillbirths at the Gaza Strip's military checkpoints since the beginning of the Second Intifada. Another report from one of the international organizations in the Gaza Strip indicates about thirty-six cases of women who delivered at various checkpoints including four stillbirths and three that resulted in maternal deaths.34
Emergency Measures and Home Health Services
In response to the worsening condition of the women's reproductive healthcare in the Gaza Strip, the international organizations developed various emergency measures. One of such measures was to ensure that the health staff at the referral hospital's maternity unit stayed at the hospital throughout the periods of the curfew so as to secure attendance for the pregnant women already present at the facility.35 Moreover, the non-governmental organizations established a network of volunteers and a hotline to offer home delivery assistances, as well as quickly identify and reach the doctors or midwives who could attend to the women in labor in their areas of residence.36 Some of the humanitarian agencies had to employ additional health staff, and the doctors together with the midwives provided exceptional home health services, especially in very remote areas that lacked qualified health workers.37
Call for Improved Training and Data
The women's limited access to reproductive health rights also made some international agencies to begin organizing training sessions for the midwives on home deliveries. In fact, they also got supplied with proper delivery kits.38 The mobility restrictions imposed on the pregnant women in the Gaza Strip created a stressful situation and deterioration of the women's reproductive health as it significantly denied them their right to access health services.39
Impact of Reproductive and Sexual Health Programs and Policies
The women's reproductive health has been of great concern in the Palestinian health system since the establishment of the Palestinian Health Ministry. For example, in the year 1995, the Women's Health and Development Directorate got established with the sole aim of focusing on family planning.40 Additionally, the Palestinian Ministry of health, through the support of UNFPA, created the National Unified Reproductive Health Guidelines and Protocol with the idea of integrating comprehensive reproductive health services into all primary health care systems.41 However, the implementation of such guidelines got extremely hampered by the geographical separation of Gaza and the West Bank, and the situation worsened by the imposition of severe mobility restrictions.42 Also, the officials from the Ministry of Health in Gaza had no permission to organize various meetings aimed at enhancing the women's access to reproductive health care.43
Dependence on External Funding and Donor Support
The delivery of reproductive health services to the women in Gaza was substantially dependent on external funding. However, the ease of access to reproductive health became a none-priority for the donors due to the ever-increasing political violence in the area.44 The lack of sustainable family planning and other reproductive health programs in Gaza resulted in the increased donor fatigue, poor donor coordination, as well as the lack of donor interest in various sexual and reproductive health programs.45
Reduction in Reproductive Health Services for Refugees
Before the Second Intifada's outbreak, the Palestinian refugee women had good access to a broad range of reproductive health services including education, information, and sensitization regarding sexually transmitted infections and family planning.46 Since the year 2000, the international donors have been cutting back most of their programs aimed at enhancing the women's access to reproductive health in Gaza. As a result, there had been a significant reduction in the services delivered to the women refugees to the restricted minimum of family planning services and mother and child health.47 Consequently, the various health agencies had to reconsider the delivery attendance policies that aimed at replacing the traditional birth attendants by the trained midwives. That was because there was no any other better alternative than reintegrating the traditional birth attendants for both the post-natal visits and home deliveries despite some of them not having received any midwifery-related training.48 The withdrawal of the donor funding adversely affected the quality of the women's reproductive health services in Gaza since it discontinued the health staff training sessions as well as the monitoring and supervision of the pregnant women.49
Cultural and Social Determinants and Gender Roles
There was a call for more female reproductive health specialists by both the Palestinian Authority and the international organizations due to the prevailing cultural norms among both the Christian and Muslim populations. That was because both the religions had great value for motherhood and fertility.50 Such rules also got reinforced by the harsh political scenario, which further created a huge barrier for women to take part in professional careers such as health specialists.51 Also, the several deaths caused by the political situation in Gaza, the firm cultural norms on sexuality, and the call by the Palestinian Authority for the women to bear many children as their Intifada contribution led to a high sensitivity around the issues relating to sexual and reproductive health. Such a situation further hampered the implementation of the reproductive health policy in the Gaza Strip.52
Promotion of Family Planning and Challenges
The promotion of family planning during the home visits by the traditional birth attendants became challenging as the households aggressively reacted and rejected those programs. Such a situation forced the traditional birth attendants to embrace the use of modern contraceptives to control birth spacing.53 Numerous international organizations in the Gaza Strip alongside the Palestinian Authorities continue to point to the urgent need for an up-to-date, reliable data regarding the women's reproductive health to create a strategy for improving the women's access to their reproductive health rights, as well as protecting them against various sexually transmitted infections.54
Impact of Mobility Restrictions and Economic Crisis on Women's Livelihoods
In the Gaza Strip, mobility restrictions alongside insecurity and violence, and economic crisis became the women's normative experience while economic well-being, peace, and the women's freedom of movement became the exception. Such circumstances affected the majority of women in the Gaza Strip with about 60 percent of the women population living in hostile conditions, and the pregnant women denied the right to access health centers.55 The mobility restrictions and the economic collapse in the Gaza Strip caused significant destructions to the Gaza Strip women's livelihoods in matters relating to their reproductive health as well as the well-being of their children.56
Challenges in Communicating with International Organizations
The circumstances created by the violence and the restriction of movement made it difficult for the women in the Gaza strip to communicate with the international organizations concerning the best way to save the situation of the women's maternal health. The mobility restrictions imposed by the Israeli soldiers in Gaza is what led to the collapse of the Gaza Strip's economy, a situation which intensified the women's reproductive health crisis in the area.57 Therefore, despite the mobility restrictions and violence in the Gaza Strip having severe direct impacts on the women's reproductive health, their indirect economic effects to the Gaza population appears to have more widespread and far deeper long-term implications. One of such impacts relates to the bias in gender roles in Gaza as well as the disparity in life opportunities for the future young women in the Gaza Strip.58
Conclusion
The women's limited access to reproductive health rights in the Gaza Strip since the First Intifada creates a need for gender equality in the context of the health services delivery to the Nation's population. The Gaza Strip's political leadership together with the international community has to consider ensuring equal and adequate access to healthcare for its entire population, in particular for the pregnant women, who need close and regular reproductive health services. The use of modern contraceptives in the Gaza Strip remains minimal, and, therefore, there is a necessity for the government and the international organizations to put more effort to provide the women with adequate access to reproductive health care. The solution to primary healthcare issues faced by the women in Gaza, such as family planning, has certain political implications due to its potential influence on the Gaza Strip's demographic growth. However, the failure to ensure women's equal access to health services, especially those relating to reproduction would adversely affect the Gaza Strip's female gender, thereby creating a situation of gender-based discrimination in the delivery of health services. Thus, there is a need for the international organizations in the Gaza Strip to go beyond their technical interventions and short-term approaches so as to accomplish their international commitments of protecting and fulfilling the women's rights to access reproductive health care. The various reproductive health programs in Gaza should get developed beyond the perspective of medical and public health. They should equally address the underlying cultural and social determinants such as gender-based violence. Besides, the limitation of the women's rights to access reproductive health services is both social-culturally and politically unacceptable.
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