COMPLICATED DELIVERY The Yemeni mothers and children dying without medical care THE YEMENI MOTHERS AND CHILDREN DYING WITHOUT MEDICAL CARE 01 COMPLICATED DELIVERY 04 02 TAIZ HOUBAN MOTHER AND CHILD 08 HOSPITAL AND ABS HOSPITAL, HAJJAH 03 ACCESS TO MEDICAL CARE 14 04 THE IMPACT OF THE ECONOMIC 18 COLLAPSE ON MEDICAL CARE 05 SAFETY AND SECURITY WHEN 22 SEEKING MEDICAL CARE 06 MEDICAL CONSEQUENCES OF 26 IMPEDED ACCESS TO HEALTHCARE 07 CONCLUSION 30 CREDITS © 2019 Médecins Sans Frontières Médecins Sans Frontières Cover image © Matteo Bastianelli Plantage Middenlaan 14, Two premature twins closely monitored 1018 DD Amsterdam at the neonates department of the Tel: + 31 (20) 520 87 00 MSF run “Mother and Child”. Fax: +31 (20) 620 51 70 Taiz Houban. Yemen W: www.msf.org www.facebook.com/msf.english Art Direction & Design: Atomodesign.nl https://twitter.com/MSF Complicated delivery The Yemeni mothers and children dying without medical care 3 01 COMPLICATED DELIVERY After four years of conflict, the Today, the ability of Yemenis to access private or public medical and humanitarian situation healthcare has dramatically diminished, as the conflict has ravaged the economy and devalued people’s savings. in Yemen continues to deteriorate Receiving treatment in a private clinic was a significant and due to violent clashes, continuous widely affordable part of Yemen’s pre-conflict health system, airstrikes, political interference in aid but this is now out of the reach of all but a limited section of Yemeni society, leaving the vast majority reliant on a operations by warring parties, and hollowed-out public health service. an economic maelstrom in what The country is exceptionally dependent on imports of food was already the poorest country in and fuel. Before the escalation of the conflict, 80 to 90 the Middle East. percent of staple foods and an estimated 544,000 metric tons of fuel were imported each month.2 Currently, only around half of the fuel that Yemen needs is entering the For Yemenis living through this protracted crisis, getting hold of country, causing increased transport and energy costs. This the essentials of daily life is a constant struggle. This is especially has negatively affected all sectors of the economy, and hit the true of medical care, as Yemen’s public health system is far from poorest people hardest. meeting the needs of the country’s 28 million people. While medical needs are significant across all demographic In March 2015, the conflict in Yemen escalated when Ansar groups, those of mothers and children are alarming. Despite Allah (also known as the Houthi movement) took control weaknesses in Yemen’s public health system before 2015, over Sana’a and continued advancing south, then the Saudi there had been a steady decline in infant and maternal and Emirati-led coalition (SELC) started its campaign of aerial mortality. However, since the outbreak of the current conflict, bombardment in support of the internationally recognised these improvements have reversed.3 Government. The reduced number of functioning health facilities, the Since 2015, Yemen’s public health infrastructure has collapsed economic damage wrought by the conflict, and the physical under the strain of displacement, violence and health authority barriers of active fighting and shifting frontlines, all combine funding cuts, as well as the dissolution – and duplication – of to make reaching medical care a difficult and often dangerous state institutions. According to the World Health Organization, process. As a result, women and children often arrive so late at of the 3,507 health facilities it surveyed in 2016, more than medical facilities that their lives cannot be saved. 50 per­cent­were­either­non­or­partially­functional.­The­same­ survey reported just 6.2 hospital beds per 10,000 people were available – well under the recommended minimum of 10 per beds­per­10,000 people.­It­also­found­that­42­percent­of­the­ 1 districts surveyed had just two doctors, or fewer, present. 1 World Health Organization, Health Resources Availability Monitoring System (HeRAMS) – Yemen, November 2016, https:// The lack of functioning health facilities and public www.who.int/hac/crises/yem/sitreps/yemen-herams-infographic- november2016.pdf?ua=1 vaccination programmes has seen a resurgence of deadly 2 Yemen Economic Monitoring Brief – Winter 2019 (Accessed vaccine-preventable diseases such as cholera, measles and March 2019)https://reliefweb.int/report/yemen/yemen- diphtheria, while disruption to the movement of medical economic-monitoring-brief-winter-2019-enar and humanitarian aid is commonplace. 3 Naseeb Qirbi and Sharif A Ismail et al.; Health Policy and Planning (2017) https://academic.oup.com/heapol/ article/32/6/911/3591753 4 Complicated01 delivery The Yemeni mothers and children dying without medical care Complicated delivery The Yemeni mothers and children dying without medical care 5 MSF IN YEMEN METHODOLOGY AND LIMITATIONS MSF has scaled up its work Methods in Yemen since the conflict Information was collected between November 2018 and February 2019. escalated in 2015. Today, MSF 10 semi-structured individual interviews with patients, caretakers and runs 12 hospitals and health medical staff in MSF’s Taiz Houban mother and child hospital in Taiz centres across the country. governorate, and 10 semi-structured individual interviews with patients and staff in an MSF-supported hospital in Abs, Hajjah governorate. MSF also hospitals governorates: Abyan, provides or health Aden, Amran, Hajjah, Additional information support to facilities Hodeidah, Ibb, Lahj, Saada, more than across Sana’a, Shabwah and Taiz. Health data and indicators from MSF medical reports from these 20 11 facilities were collected between 2016 and 2018. From March 2015 to December 2018, MSF teams performed As of 2019, MSF has Patient sampling Convenience sampling of patients and caretakers was used in the neonatal, maternal and paediatric departments within the two hospitals. 2,200 Limitations and potential bias international and locally-hired staff The locations were chosen on the basis of MSF’s presence at the facility. in Yemen It was not possible to access the wider community to assess their 81,102 barriers to accessing healthcare. The issues raised cannot be said to be representative of the challenges facing mothers and children across the entire country. The report also cannot conclude which barriers to surgical interventions healthcare had a greater impact on mothers’ and children’s ability to Provided treatment to reach the MSF facilities compared to others. Although this report focuses specifically on MSF’s work in both the Taiz and Hajjah governorates, the conclusions and recommendations of this report 119,113 are drawn from MSF’s operational experience throughout the country. patients with injuries related to war and violence Having interviewed solely those who managed to access an MSF-run/ Delivered supported facility, this report likely underestimates the scale of the and provides incentive payments to challenges facing those who never make it to an MSF facility. As the facilities chosen were analysed with a focus on the provision of care to 68,702 mothers and children, it has not been possible to compare their access newborn babies to healthcare to that of adult males. 700 and cared for more than Ministry of Health staff across Participants were also aware that the interviews were being conducted the country. by MSF, which possibly led to some social desirability bias in the findings. 116,687 suspected cholera cases. 6 Complicated delivery The Yemeni mothers and children dying without medical care Complicated delivery The Yemeni mothers and children dying without medical care 7 02 TAIZ HOUBAN MOTHER AND CHILD HOSPITAL AND ABS HOSPITAL, HAJJAH Taking a look at two facilities where Taiz Houban mother and child hospital provides MSF is providing free healthcare – the free healthcare to children under five and women of reproductive age, including the management of complicated MSF-run Taiz Houban mother and deliveries, neonatal care and a therapeutic feeding child hospital and the MSF supported programme. Since opening, demand for these services has hospital in Abs – offers an insight been high and has increased year on year – doubling from 4,100 deliveries in 2016 to 8,443 deliveries in 2018. In into some of the challenges facing 2018 alone, the hospital saw 6,915 inpatient admissions and mothers and children in Yemen. admitted 1,432 malnourished children to its therapeutic feeding programme. MSF established its Taiz Houban mother and child hospital In the district where the hospital is located, there is no in late 2015, converting a local hotel into a 130-bed public hospital for a population of approximately 263,871. hospital and trauma centre to try and address some of the Given the lack of public hospitals, the number of referrals healthcare needs in Taiz governorate. Houban is a suburb made by MSF from Taiz Houban to private hospitals has of the city of Taiz, which has been divided by an active also been increasing year on year since 2015. In 2018, MSF frontline since 2015. Fighting has left many health facilities referred 3,322 patients to private health facilities to receive out of operation or out of reach and displaced many care that it lacked the capacity to provide. healthcare workers from the city. Those facilities that still Returning from a recent visit to Taiz Houban, Christian function often lack vital drugs and staff. Katzer, MSF’s operations manager for Yemen described Health facilities themselves often come under attack. the experience of one patient: “I was particularly touched On­2 Decem­ber­2015,­an­airstrike­by­the­SELC­hit­the­ by the story of one heavily pregnant woman. This woman immediate vicinity of an MSF tented clinic located in came from some distance away and had spent a lot of Houban. The attack injured nine people including an MSF money on transport to reach MSF’s mother and child health educator and a guard.