US funding cuts and the impact on Syrian refugee women

Zaatari, Jordan – For many women living in the Zaatari refugee camp, the large sign by the entrance of the only maternity clinic is a familiar sight.

It reads, Women’s and Girl’s Comprehensive Center, and features two digital display boards: one reflecting the current date, and the other indicating the number of babies safely delivered in the clinic, now approaching the 8,000 mark, all without a single maternal death.

Also printed on the sign is a flag – with stars and stripes, red, white, and blue – a tribute to the country that first made this clinic a reality for thousands of women and girls in the world’s largest Syrian refugee camp.

The United States provided the vast majority of the clinic’s funding when it opened its doors in Zaatari five years ago and continued to support it through contributions to the United Nations Population Fund (UNFPA). That was up until this past April when the Trump administration announced a total and immediate withdrawal of US funding to UNFPA.

Months later and the US flags are still dotted throughout Zaatari’s maternity clinic: on doors, walls, staff uniforms – even medical equipment. The clinic in Zaatari represents everything the UNFPA has worked towards since its inception in 1969: providing healthcare services to vulnerable women and girls around the world – be it maternal care, gender-based violence response, advocacy against child marriage, or safe access to contraceptives.

Formerly the second-largest donor to the UN agency, the US provided 80 percent of the start-up costs for the clinic in 2012 and continued to help sustain it until the Trump administration’s decision to completely withdraw support on April 3.

That decision was based on the claim that the UNFPA “participates in the management of a program of coercive abortion or involuntary sterilisation in China”. In the same letter, addressed to the Senate Foreign Relations Committee, the State Department also acknowledged there is no evidence that directly links UNFPA to any coercive abortions or involuntary sterilisations in China.

UNFPA denies these allegations and asserts its work “promotes the human rights of individuals and couples to make their own decisions, free of coercion or discrimination.”

The UN agency explained how US contributions have “saved tens of thousands of mothers from preventable deaths and disabilities,” in a statement released in April.

With the support of the US, UNFPA prevented the deaths of 2,340 women during pregnancy and childbirth in more than 150 countries in 2016 alone, it said. The Zaatari clinic, in particular, treats more than 100 women every day and delivers an average of 80 babies per week.

“What is most disturbing to me is the fact that a country that represents democracy, a country that represents civil rights, a country that others take note from is suddenly taking a stance that gives others a free license to bash the women’s agenda,” said Laila Baker, UNFPA’s representative in Jordan, at her office in Amman.

After the US funding cut, UNFPA was left with a gaping budgetary hole and only enough funding to sustain Zaatari’s maternity clinic for the remainder of 2017.

‘God, please don’t leave’

Although the clinic doesn’t open until 9am, the line outside its doors begins to form at 6am. By the time the name of the first patient echoes through the clinic’s loudspeaker, the queue of pregnant women waiting to get routine tests, scans and screenings has already exceeded the entrance to the general waiting area. 

In the delivery room on the opposite side of the clinic, three or four women at a time can be found lying on adjacent beds, tucked behind the veil of a thin pink curtain that cuts through the middle of the room. As midwives and nurses scurry passed the curtains, they offer soft words of encouragement, all muffled in between labour screams from women and girls across the room, some as young as 14.

“God, please don’t leave me now. Please don’t leave me here,” yelled one young woman, clenching the sheets beneath her on a recent summer afternoon in the delivery room. She affectionately referred to one of the midwives, Amoon, by her nickname, “Amooneh”, and pleaded with her to stay at her bedside in the moments before she delivered her baby.

“We had a simple, small beginning. It was essentially one caravan, one midwife, and one doctor,” said Rima Diab, the leading gynaecologist at the clinic.

When Diab was first offered the job five years ago, she decided she needed to see what it was like in Zaatari before making a final decision.

There was much to consider. She had been working at the same place, the Jordanian Ministry of Health, for eight steady years; she lived in the Jordanian city of Irbid, which is an hour and a half away from Zaatari by car, and she had no experience working in a refugee camp. But after spending just two days there, she decided to take the offer.

“It felt [it was] absolutely necessary,” said Diab.

When she first started working in the refugee camp, her husband was not initially supportive of her decision. “I have to be available 24/7, even if it’s 2 or 3am,” she explained, her phone going off every few minutes, with consistent knocks on her office door from the other doctors, nurses, and paediatricians she oversees.

“Mentally, I’m always here,” she continued, “so it kind of took me away from my life at home. Since I took this job, whenever I have friends or family over, they make me surrender my phone for the duration of their visit,” she said with a laugh.

READ MORE: Syrian refugees mark 5,000th birth at Zaatari clinic

Despite seeing dozens of patients every single day, Diab maintains a close relationship with many of them. She described an incident in which one of her patients, a 16-year-old girl who was eight months pregnant at the time, was redirected to another hospital after suffering violent convulsions. Diab, who suspected the patient was suffering from a case of pre-eclampsia, a pregnancy complication that can sometimes be fatal, asked the medic to stay on the phone to monitor her patient’s status.

“I knew they were missing something and I couldn’t get it out of my head,” said Diab. It wasn’t until the patient’s husband came running to the clinic, pleading with her to come see his wife that she decided to pack her medication, get into a car and drive to the other hospital. When Diab arrived, she confirmed the patient was indeed suffering from pre-eclampsia and treated her accordingly at the hospital. A month later, both the patient and her newborn baby made a full recovery.

“I feel personally responsible for following up on every case, and the same goes for every doctor in this clinic,” said Diab.

‘These things happen’

Growing up, Usool al-Atmeh never imagined she would spend her honeymoon in a refugee camp in Jordan. al-Atmeh, who was 16 when she got married in her hometown of Daraa in Syria, was celebrating with her family and friends when she mistook deliberate gunfire for celebratory shots, which are common at Syrian weddings. As the sounds became louder, guests started to leave, and the wedding came to a halt. Al-Atmeh recalls sitting in her white dress at home with her new husband, staring blankly at the dead air of a television broadcast, wondering why it had stopped airing. Weeks later, as the Syrian civil war intensified, al-Atmeh and her husband headed for the border towards the Zaatari refugee camp.

When al-Atmeh became pregnant with her first baby, Ahmed, at 17-years old – she quickly realised how grateful she was for all the services provided by Zaatari’s maternity clinic. But it wasn’t until her second pregnancy, when she experienced her first miscarriage, that she realised she wasn’t just grateful for the midwives, nurses, and doctors – she depended on them.

“I was four-months pregnant, and I came in for a check-up. Then they told me my baby had no pulse. Then I just walked back home.”

Al-Atmeh was standing in her kitchen when she first started to bleed. At first, she didn’t know what it was, but then she saw little hands and little feet the size of her palm. She already had a name picked out for him, Abdullah, and she wept quietly before she wrapped him in a white cloth, muttered a prayer, and buried him. After that, she made her way back to the clinic, where the concerned staff took the time to console her.

“They told me not to worry, that these things happen, that I’ll be able to have another baby,” said al-Atmeh as she rocked her 10-day-old baby girl, Fatima, back and forth in her arms. Fatima is her third healthy baby, and al-Atmeh was passing by the clinic to pick up birth control pills – another service offered by the clinic free of charge. “It’s hard not to have a mother or a sister here in the camp with me, but that is exactly what these people are to me.”

Emotional trauma

Besides the maternal health care services offered at the clinic, the sister programmes they provide include therapy for victims of domestic violence, legal counselling, awareness sessions where counsellors work with parents to advocate against early marriage, and recreational programmes where women can knit, paint, and even practice yoga together.

In the five years she has spent in Zaatari, Fatima Abu al-Shareef, 36, lost many family members who stayed behind in Syria – the most painful being the death of her mother. She became a patient at the clinic after two failed pregnancies, both of which resulted in a miscarriage seven months down the line.

“I had to deal with a lot of emotional trauma,” said al-Shareef, her voice trembling. “To think about where we used to be back in Syria and how we are now. The lifestyle. The finances. It was a hard thing to fathom.”

After a year of counselling and support, al-Shareef found solace in “just being able to connect” with other women about what they had gone through and how their lives had changed. The time she spent chatting as she knitted a new sweater, or just breathing between yoga positions, brought back a sense of normalcy to her life. “I found a new family here,” said al-Shareef.

Another woman, 33-year-old Jude al-Hassan, came to the clinic after years of domestic abuse at the hands of her husband. Back in Syria, she moved away from her husband, but the war forced her to move back in with him as a refugee in Zaatari.

“When I first got here [Zaatari] I would speak to no one. I locked myself at home and totally isolated myself,” she said.

A year ago, al-Hassan woke up to the sound of a knock on her door. It was an outreach agent from the clinic, who stood there, smiling, happy to explain the services offered at the clinic. Al-Hassan decided to give it a shot and has been involved with the clinic ever since.

Back in her UN Amman office, Baker explained that typically, after a significant withdrawal of funding, the first thing to go is the number of outreach agents working on the ground. This could mean a failure to reach victims of domestic abuse who are too afraid to come forward, women who may be pregnant but have not followed up with doctors, or mothers who don’t bring their babies to the clinic for postnatal check-ups, which is essential for newborns in a refugee camp.

Currently, the clinic has a system in place where women who miss appointments receive home follow-ups. But following the US defunding, the future of this service, and many more like it through UNFPA, is unclear.

“Without active outreach, neonatal death almost always occurs more often,” explained Dr Diab. “Women sometimes try to treat newborn illnesses with home remedies, like garlic or sugar, and they don’t understand that they need to bring them here to the clinic. That’s why these follow-ups are so important.”

Stepping up

In the wake of the US funding cut, Sweden increased its contribution to UNFPA by $11m. Canada has also pledged up to $20m to fund global family planning initiatives to fill the US gap. Just days after the cut was announced, a group of private American citizens that call themselves the “Friends of the UNFPA” raised $100,000 and sent in a cheque specifically devoted to the maternity clinic in Zaatari.

While enough was made to cover the clinic for the remainder of the year, Baker said there is still a lot of uncertainty over the future of the clinic and other UNFPA programmes in Jordan.

“It’s just too big of a financial gap,” she said. “So the UNFPA is going to have to do one of two things: We can either draw down the number of services, or we draw down on the type or the scale. It’s going to be a difficult year on the humanitarian front.”

READ MORE: Syrians at Zaatari camp – ‘We can’t live here forever’

Back in the clinic, Dr Diab had a few more minutes to spare before going to see her next patient. The medical staff don’t have time to worry about funding issues, despite the fact they will deal with the consequences first-hand.

Diab breathed in deeply and with a tired smile sat back in her chair and stared at a poster on the wall with the American flag printed on it.

“This place is the cradle of the whole camp. It carries two souls – the mother and the baby,” she said speaking slowly.

“To want a healthy birth, a healthy baby, and a healthy mother. That is all that really matters, isn’t it?”