"She is one of us, and in her job, she is leading"

The north-east of Syria is a very complicated area for everyone who lives in it: it has suffered from the conflict since so many years now, it is a mosaic of populations, some women are living in camps whilst more are living in their communities, all of which are in very hard living environments. Many men work far from home for long periods, and women are left alone with their children. Regarding the possibility for women to seek health care, it depends on where they live so as their religion and clan system, which is often different for Arabic or Kurdish people. In the north east, some women have the same freedom as women living in western countries, others are dependent on their family, cultural or religious patterns, which gives them less room for manoeuvre.

Women have a lot of health concerns, there is a high number of diseases, mainly because of 2 factors. The first one is the over-medicalization around birth: for example, a lot of women have caesarean-section, which I think technically it’s over-medicalization. Secondly, women do not receive sufficient medical care. Most of their specific problems, like period pain or irregular bleedings, are treated by female midwifes because women prefer to see other women for those issues. And if you are a male medical doctor, you often don’t have anything or very little in your training about women’s health: this is almost a discrimination for the men, they are not able to learn or experience how to treat specific female issues, unless they are obstetrician or gynecologist.  

My role is to train health care providers, to make sure that midwives- mostly female- and obstetrician gynaecologists- half of whom are women but fewer in number than midwives- improve their capacities. It’s also about empowering midwives especially regarding what they are allowed or not to do, and about who decides that. It’s not that all women do need a C section. If we offer patients better care during childbirth, C section could be reduced significantly. But this is not an option till now because the labour room environment is neglected. Till now, the health system is still not set up to support vaginal birth and improving it is one of the focus of HERNES program.

When we do conduct some training workshops, there is a lot of communication and respect. With female health workers, we immediately feel at ease. Maybe it’s possible because most of us have children and have similar health concerns. Maybe health is a neutral topic around which you can empower and support women.

Gender based violence (GBV) is a particularly difficult topic to tackle: there are limited opportunities for women to report this or to seek support. We discuss how to address GBV during the training workshops, under the umbrella of reproductive health. The majority of GBV concerns intimate partners’ violence: this is something we at least have introduced a screening tool for a part of ante-natal care. According to World Health Organization (WHO) guidelines, women can be screened during their pregnancy if psychosocial support is in place. We can ask them about their marital and family situation, whether they have been physically or verbally abuse, and about their mental health. Midwives now feel able to ask those questions. The ministry of Women’s Affairs and its partners are also trying to establish safe houses and propose various awareness-raising activities to the community to try to address the problem of GBV.

They are at least 3 areas where our program does make a difference. Firstly, we are paying attention to take care of all aspects of maternal and reproductive health as a team, doctors and midwives together, looking for solutions to improve the availability and quality of health services. Often, health care providers don’t receive any kind of support except criticisms. Sometimes, people think they can improve quality by sending external inspectors to sit next doctor or midwife, observing what he/she is doing and telling him/her what is incorrect. We have to change this approach: we are all learning together, we practice as a multi-disciplinary team together and we self-assess and learn together to improve our care .

Secondly, we provide coordination in this chaotic environment. When I started in Syria, my first job was to produce a mapping of healthcare facilities and what women’s health services they provide. It was very difficult to access the information and most people worked in isolation. Expertise France now works in close collaboration with humanitarian and stabilisation partners. Through this program, we are no longer working in silos, we try to make sure that, together, we ensure all women everywhere have a better environment for delivery and can receive better healthcare.

Finally, we have improved data processing. Up until then, data was almost exclusively used at for management purposes, and was hardly every used at service delivery level. We have tried to changed that, working across 10 pilot healthcare facilities, trying to look what’s really happening. How many times of the day is your neonatal resuscitation table ready for use? Do you have all the equipment you need? Health care workers collect their own data, they look at them and they decide how to use them to change their practice.

I started working for this program in 2020. Most of my time, I work from United Kingdom or in the office in Erbil and, when I am allowed, I go to Syria. I enjoy working in the field, I can understand the problems better. It’s a bit scary I don’t have any humanitarian experience, the environment is quite intense. I am aware that I am a foreign woman in a situation which I don’t belong, and that I’m a possible target for kidnapping, I know that, but once I start working, I forget about it.

It’s new for me working in the middle east. It is certainly an advantage to be a bit older. It took a while for the men to respect what I say. I think they are more used to work with senior men than senior women. Whenever I make any mistake, I know they notice it. But over time, I have learned to earn their respect.

I am also aware that, for the midwives and the female obstetrician-gynecologists, I am a sort of a role model: I don’t want to be, but they say to themselves “She is one of us, and in her job, she is leading”.