gaza crisis : impact on reproductive health, especially ......gaza crisis : impact on reproductive...
TRANSCRIPT
: CrisisGaza
Impact on Reproductive Health, especially
Maternal and Newborn Health
and
Obstetric Care
Summary Report
9 February 2009
Prepared by:
United Nations Population Fund Programme of Assistance to the Palestinian People P.O. Box 67149 Jerusalem
2
(1) Background
Given the current population size and birth rate in Gaza, it is expected that there are around 41,000 pregnant women at any point of time. Approximately 170 deliveries take place every day including around 30 deliveries by caesarian section. Within such a small geographic area and fairly intensive network of primary and secondary healthcare facilities, antenatal care coverage was almost universal with 99% in 2007, and 99.1% of deliveries occur within hospital under professional supervision.
Healthcare services in Gaza have been affected by eight years of conflict and two years of strict closure to the outside world pre-ceding the 23 days of military operations which were launched on 27 December 2008. As a consequence of this crisis, the capacity and integrity of the system were severely affected in terms of (i) physical infrastructure, (ii) supplies and (iii) maintenance of continuity between primary and secondary levels of care.
During the crisis, 23 Primary Health Care Centers (PHCs) were directly hit and infrastructure damage occurred in all of them albeit at different scales (See detailed revised report about damage, Annex 1). These centers will require significant rehabilitation work to reestablish capacity to fully function. Primary healthcare services were halted in most of the 56 PHC centers, especially those in proximity to the military operations. According to Ministry of Health (MOH) data, 10 primary healthcare centers were transformed into emergency stations. They suffered, however, from (i) lack of sufficient equipment, (ii) staff able to reach their work stations and (iii) trained staff on assistance for normal delivery and basic emergency obstetric care (BEOC).
Isolated communities in Northern Gaza (Beit Hanun, Beit Lahia), the middle zone (Qarara, Khuza'a) and the area surrounding Rafah (Bani Suhaila) could not access services and, in many cases, were subjected to direct military operations and displacement.
With around 100,000 people being displaced into 58 UNRWA shelters as well as being absorbed by families mostly consisting of women and children, it is expected that around 25,000 women of reproductive age were subjected to the physical and mental distress associated with the conflict, further aggravated by the inability to satisfy their basic human needs and care within such shelters. Pregnant women in these shelters were especially vulnerable to physical and mental distress. In one of the shelters, 8 women from one family had miscarriages following an attack at Khuza`a village.
(2) Methodology
This report is based on a combination of qualitative and quantitative data collection approaches during the period from 26 January to 6 February 2009:
(1) Collection of monthly service records and rapid assessment of key maternal health of four major hospitals (Shifa, Al Aqsa, Naser, Rafah);
(2) Secondary analysis of MOH Operations Room reports;
(3) Qualitative feedback from key informants in UNRWA shelters, hospitals and communities in North Gaza, Rafah and Khan Younis governorates;
3
The assessment was designed to gauge the extent of damage to facilities, health service needs and whether services had to be suspended, changes in service demand, ability of the health facility to continue providing the service and whether the services were interrupted during the war.
To address the social dimension of the impact of the crisis, especially on women who could not access maternal health services, information was collected from Jabalia, Buriej, and Khan Younis. Analysis of quantitative data included calculating trends and projecting indicators whereas the qualitative analysis involved thematic categorization pertinent to access, quality of care and psychosocial impact.
The recommendations at the end of this report take into account above sources as well as the findings of an MOH/UNFPA supported health facilities damage assessment which had also been shared with the Ministry of Planning. The damage assessment report was revised and cross-checked by UNFPA’s sub-office in Gaza on 6 February 2009.
Limitations to this assessment included, (i) the unavailability of certain baseline data, (ii) time constraints, (iii) pressure on assessed facilities to respond to multiple assessment requests, and, hence, high burden on health staff, and (iv) conflicting figures from health facilities due to weak health records systems.
(3) Findings
(3.1) Access to care:
Many cases of maternal deaths were reported while trying to access hospitals (see Annex 2). For lack of safe mobility and difficult access to MOH hospitals especially in the North Gaza area, alternatively, NGO hospitals were utilized for delivery services.
In areas with no such hospitals, people relied on available human resources, which in this case could be elderly women in the family or in the displacement shelter. In one of those shelters in the Khan Younis area, 8 women delivered babies under the supervision of older women. One infant died in this shelter for lack of access to a hospital for the required neonatal care and resuscitation response.
In areas with limited capacity to move around, people used loud speakers to request medical assistance for women in labour. In one case reported from Karameh area, the woman and her child died while waiting for such assistance.
(3.2) Quality of care:
Major maternities and maternity hospitals in Gaza were transformed into surgical departments and hospitals to cope with the huge number of casualties. Priority was given to the transportation and/ or treatment of injured over any other kind of service including obstetric care. Examples of Caesarean sections postponed or avoided in favor of treatment of injuries were reported from Shifa and Rafah hospitals.
4
In most of the large maternities, women were discharged after 30 minutes of labour to vacate beds for potential needs during the emergency. Given the extreme living conditions in terms of lack of food, shelter and fuel, this meant an increased risk for both the mother and the newborn.
Recurrent electricity interruptions with reduced capacity of generators affected survival of newborns in need for intensive care.
While data from key maternities did not demonstrate significant variation in utilization of maternity services in the pre, during and post-crisis period, it is important to note the following from the surveyed facilities:
1- There was a 40% increase in miscarriage cases admitted to maternities
2- 50% increase in neonatal death (data from Shifa hospital maternity).
3- Increased prevalence of obstetric complications as reflected by increased C/S proportion to reach 32% and 29% in December and January respectively. Data from Gaza prior to the crisis showed an average of C/S deliveries to be at 15%.
4- Qualitative and anecdotal data coming from communities inform about severe impact of the crisis on mothers and infants not being able to reach care. Some of these data is available in the special attachment of this report.
5- Premature deliveries – it was reported that 5,000 deliveries occurred in January compared to 4,000 deliveries being the monthly delivery average prior to crisis. The excess number is explained by the increase in premature deliveries caused by stress and shock.
(4) Response:
The overarching theme in responding to the need in the post-crisis period is preserving and supporting the integrity and continuity of health care services from community towards secondary care facilities.
Two continua of care need to be taken into consideration:
1- Women to child continuum: safe pregnancy, delivery and care for the mother and newborn
2- Community to hospital continuum: ensuring that basic capacity for care is available at all and each of the three levels (community, primary care and referral hospital).
Programmatic areas on intervention:
1- Rehabilitation of damaged infrastructure to preserve the critical life-saving functions.
2- Supply equipment and medical supplies including essential drugs
3- Capacity building of staff along the continuum in areas pertaining to basic and comprehensive emergency obstetric care and neonatal care
5
4- Establish or strengthen existing logistic monitoring system to assure availability at all levels of health facilities and at least 6-9 month stock of reproductive health commodities at central level.
5- Assist the MoH to renovate/establish adequate storage facilities for medical supplies
6- Review of existing essential drug list to ensure the inclusion of all essential RH commodities as a part of the National Drug List.
Annex 1
Ta
ble of Health facilities damages and needs
Clin
ic
Damages Due to W
ar
Needs
Increase
/Decrease
of se
rvice Demand
Is the health
facility still
capable to
function
Was so
me of
services/staff
were transferred /
canceled
1.
Al Q
ud
s H
osp
ital-
Ma
tern
ity
De
pa
rtm
en
t
Ma
jor
infr
ast
ruc
ture
de
stru
ctio
n
an
d d
em
olit
ion
of
som
e
de
pa
rtm
en
ts
Da
ma
ge
to
fu
rnitu
re a
nd
m
ed
ica
l eq
uip
me
nt
suc
h a
s:
Ultr
a s
ou
nd
s
De
live
ry b
ed
s
CTG
mo
nito
r
Suc
tion
ma
ch
ine
s
Ve
ntil
ato
rs
Inc
ub
ato
rs
Re
co
nst
ruc
tion
of
the
b
uild
ing
P
rovi
sio
n o
f m
ed
ica
l e
qu
ipm
en
t a
nd
fu
rnitu
re
Inc
rea
se d
em
an
d
of
serv
ice
Y
es
N
o
2.
Al S
hifa
Ho
spita
l –
Ma
tern
ity
De
pa
rtm
en
t
Bro
ken
win
do
ws(
16
)
Da
ma
ge
to
eq
uip
me
nt
suc
h a
s U
ltra
sou
nd
an
d C
TG m
on
ito
r
De
ficie
nc
y in
bla
nke
ts(
700
)
De
ficie
nc
y in
be
d c
ove
r( 5
00)
D
efic
ien
cy
in p
illo
ws(
60)
D
efic
ien
cy
in b
ed
s’
ma
ttre
sse
s(50
)
40%
de
cre
ase
in n
um
be
r o
f n
urs
es
shift
s
20 %
de
cre
ase
in n
um
be
r o
f p
hys
icia
n s
hift
s
Re
ha
bili
tatio
n o
f d
am
ag
es
P
rovi
sio
n o
f m
ed
ica
l e
qu
ipm
en
t
20%
inc
rea
se in
se
rvic
e d
em
an
d
Ye
s
Ye
s , C
an
ce
ling
all
no
n u
rge
nt
op
era
tion
s.
3.
Al A
qsa
Ho
spita
l –
Ma
tern
ity
De
pa
rtm
en
t
Bro
ken
Win
do
ws
D
est
ruc
ted
wa
ll
Da
ma
ge
to
mo
st o
f th
e c
ha
irs
Da
ma
ge
to
ph
on
e n
etw
ork
Ma
inte
na
nc
e e
mp
loye
e w
as
kille
d d
urin
g t
he
wa
r
Re
pla
ce
bro
ken
win
do
ws
R
ec
on
stru
ctio
n o
f w
all
P
rovi
sio
n o
f w
aiti
ng
ch
airs
(5
0)
Pro
visi
on
of
pa
tien
t’s
ac
co
mp
an
y c
ha
irs (
60)
P
rovi
sio
n o
f p
ho
ne
s(30
)
Pro
visi
on
of
a f
ridg
e f
or
ph
arm
ac
y
Inc
rea
se o
f se
rvic
e
de
ma
nd
Y
es
N
o
4.
Tal A
l Su
ltan
-El
Hila
l El E
ma
rati-
Bro
ken
gla
sse
s o
f th
e e
xte
rna
l c
linic
en
tra
nc
e
To r
ep
lac
e b
roke
n g
lass
R
ec
on
stru
ctio
n o
f In
cre
ase
on
se
rvic
e
de
ma
nd
Y
es
N
o
7
Ma
tern
ity
De
pa
rtm
en
t
De
stru
cte
d w
all
D
am
ag
e o
f m
ost
of
ch
airs
D
am
ag
e o
f p
ho
ne
ne
two
rk
Ma
inte
na
nc
e e
mp
loye
e
Mo
ee
n Q
an
na
n w
as
kille
d in
th
e w
ar
de
stru
cte
d w
all
P
rovi
sio
n o
f w
aiti
ng
c
ha
irs(5
0)
P
rovi
sio
n o
f c
ha
irs f
or
pe
op
le a
cc
om
pa
nyi
ng
th
e p
atie
nts
(60)
P
rovi
sio
n o
f p
ho
ne
s(30
)
Pro
visi
on
of
a r
efr
ige
rato
r fo
r th
e p
ha
rma
cy
P
rovi
sio
n o
f e
xte
rna
l ne
ts
for
win
do
ws
to p
rote
ct
fro
m in
sec
ts
5.
Al A
qsa
Ma
tern
ity
- -
Inc
rea
se o
f se
rvic
e
de
ma
nd
W
ith
Diff
icu
lty
Ye
s , s
erv
ice
s w
he
re t
he
re is
d
efic
ien
cy
in
eq
uip
me
nts
c
ap
ac
ity
6.
Al A
wd
a H
osp
ital
– M
ate
rnit
y D
ep
art
me
nt
Bro
ken
win
do
ws(
48)
with
d
iffe
ren
t si
zes
V
ario
us
da
ma
ge
s o
f 26
do
ors
(
size
120
*220
cm
)
Firs
t A
id O
ffic
er
Ara
fa A
bd
el
Da
yem
wa
s ki
lled
Fi
rst
Aid
off
ice
r A
laa
Sa
rha
n w
as
inju
red
D
rive
r K
ha
led
Ab
u S
ed
a w
as
ligh
tly in
jure
d
Tota
l de
stru
ctio
n o
f a
n
am
bu
lan
ce
du
ring
op
era
tion
.
An
oth
er
am
bu
lan
ce
wa
s se
vere
ly d
am
ag
ed
du
e t
o
isra
eli
bo
mb
ard
me
nt
A
ca
r th
at
wa
s p
ark
ing
in
ho
spita
l pa
rk w
as
targ
ete
d b
y tw
o a
ir m
isse
les
wh
ich
lea
d t
o
cra
cks
in t
he
dru
g s
tore
s.
Re
ha
bili
tatio
n o
f W
ind
ow
s a
nd
do
ors
P
rovi
sio
n o
f tw
o
am
bu
lan
ce
s
Re
co
nst
ruc
tion
of
the
w
all
of
dru
g s
tore
Sig
nifi
ca
nt
de
cre
ase
in c
lien
ts
of
the
ou
t p
atie
nt
clin
ics
bu
t th
ere
w
as
inc
rea
se in
c
ase
s o
f d
eliv
erie
s a
nd
ab
ort
ion
s
Ye
s
Ro
utin
e w
ork
wa
s c
an
ce
led
an
d
em
erg
en
cy
sta
tus
wa
s a
pp
rove
d.
7. North G
aza
Clin
ics
8.
Ab
u S
hb
ac
k C
linic
B
roke
n W
ind
ow
s’ G
lass
es
( 22
w
ind
ow
s)
Re
co
nst
ruc
tion
of
Win
do
ws’
Gla
sse
s (
The
re w
as
de
cre
ase
on
ye
s
No
8
est
ima
ted
co
st a
bo
ut
1000
NIS
/ 26
00$)
se
rvic
es
de
ma
nd
d
ue
to
co
ntin
uo
us
air
strik
es.
9.
Be
it H
an
ou
n
Ma
rtyr
s C
linic
B
roke
n W
ind
ow
s g
lass
es
an
d
fra
me
s.
De
stro
yed
Wa
ter
Ne
two
rks
A
ssis
tan
t P
ha
rma
cis
t(Ta
hse
en
A
hm
ed
wa
s in
jure
d in
his
left
Ja
w
Re
ha
bili
tatio
n o
f th
e
clin
ic(
est
ima
ted
co
st
4000
$)
The
re w
as
de
cre
ase
on
se
rvic
e d
em
an
d
du
e t
o a
ir st
rike
s,
lan
d in
vasi
on
an
d
de
stru
ctio
n o
f a
dja
ce
nt
bu
ildin
g
Ye
s
No
10A
l Ata
tra
Ma
rtyr
s C
linic
Th
ere
is m
ajo
r d
am
ag
e t
o t
he
b
uild
ing
in t
erm
s o
f c
olla
pse
d
wa
lls a
nd
co
lum
ns.
D
est
ruc
tion
of
mo
st o
f m
ed
ica
l e
qu
ipm
en
t
An
d f
urn
iture
.
Re
co
nst
ruc
tion
of
the
w
ho
le b
uild
ing
an
d
pro
visi
on
of
me
dic
al
eq
uip
me
nt
an
d f
urn
iture
( e
stim
ate
d c
ost
ab
ou
t 12
1,0
00$)
Wo
rk a
t c
linic
c
om
ple
tely
st
op
pe
d d
ue
to
d
irec
t ta
rge
ting
a
nd
to
tal
de
stru
ctio
n)
No
Y
es,
pro
visi
on
of
all
serv
ice
s w
as
sto
pp
ed
11B
ait
Al M
akd
es
Clin
ic
Bro
ken
win
do
ws
gla
sse
s a
nd
fr
am
es,
da
ma
ge
to
th
e c
linic
d
oo
rs,
D
est
ruc
tion
of
wa
ter
tan
ks a
nd
n
etw
ork
s
Clin
ic’s
gu
ard
(Im
ad
H
am
do
un
a)
wa
s se
riou
sly
inju
red
an
d r
efe
rre
d f
or
tre
atm
en
t o
uts
ide
Ga
za.
Re
ha
bili
tatio
n o
f d
am
ag
ed
win
do
ws
, d
oo
rs ,
an
d w
ate
r n
etw
ork
s( e
stim
ate
d c
ost
60
00 $
)
The
re w
as
a s
ligh
t d
ec
rea
se d
ue
to
c
on
tinu
ou
s w
ar.
Ye
s
No
12O
ld B
eit
Lah
ia
Clin
ic
Da
ma
ge
to
th
e b
uild
ing
(a
n o
ld
bu
ildin
g),
ris
k o
f b
uild
ing
c
olla
pse
M
ed
ica
l eq
uip
me
nts
an
d
furn
itu
re o
f th
e c
linic
are
old
a
nd
co
nsu
me
d
Re
co
nst
ruc
tion
of
the
b
uild
ing
an
d p
rovi
sio
n o
f m
ed
ica
l eq
uip
me
nt
an
d
furn
iture
.(e
stim
ate
d c
ost
o
f a
bo
ut
190,
000
$)
De
cre
ase
in s
erv
ice
d
em
an
d d
ue
to
fe
ar
an
d
co
ntin
uo
us
air
strik
es
an
d la
nd
in
vasi
on
Ye
s
NO
13Ja
ba
lia C
linic
Bro
ken
win
do
ws
R
eh
ab
ilita
tion
of
win
do
ws
(est
ima
ted
co
st o
f a
bo
ut
3,00
0$)
No
Y
es
N
o
14C
en
tra
l Ja
ba
lia
Ma
rtyr
s C
linic
B
roke
n w
ind
ow
s
Re
ha
bili
tatio
n o
f W
ind
ow
s (e
stim
ate
d c
ost
a
bo
ut
600
0 N
IS/
1,50
0 $)
Inc
rea
se o
f se
rvic
e
de
ma
nd
du
e t
o
inte
rna
lly d
isp
lac
ed
p
eo
ple
fro
m
ad
jac
en
t a
rea
s a
nd
wo
rkin
g
Ye
s
No
9
aro
un
d t
he
clo
ck
du
ring
wa
r a
s e
me
rge
nc
y c
en
ter.
15
Al S
ha
ima
a(
Ne
w
Be
it La
hia
Ma
rtyr
s C
linic
)
Bro
ken
Win
do
ws
R
eh
ab
ilita
tion
of
win
do
ws(
est
ima
ted
co
st
1300
$)
De
cre
ase
of
serv
ice
d
em
an
d d
ue
to
fe
ar
an
d in
ab
ility
to
re
ac
h a
s it
loc
ate
s c
lose
to
bo
rde
rs in
a
dd
itio
n t
o
co
ntin
uo
us
wa
r.
Ye
s
No
16Iz
be
t B
eit
Ha
no
un
C
linic
B
roke
n W
ind
ow
s
Re
ha
bili
tatio
n o
f w
ind
ow
s(e
stim
ate
d c
ost
13
00 $
)
De
cre
ase
of
serv
ice
d
em
an
d d
ue
to
in
ab
ility
to
re
ac
h
an
d c
on
tinu
ou
s w
ar.
yes
N
o
Gaza
Governorate
17Sa
bh
a H
ara
zee
n
Clin
ic
De
stru
ctio
n o
f e
xte
rna
l fe
nc
e(
sou
the
rn a
nd
ea
ste
rn s
ide
s)
Bro
ken
win
do
ws
D
est
ruc
tion
of
ma
in w
ate
r n
etw
ork
an
d w
ate
r ta
nks
on
th
e
roo
f
Da
ma
ge
to
th
e e
lec
tric
ity
ne
two
rk in
th
e c
en
tra
l la
b.
D
am
ag
e a
nd
cra
cks
in w
alls
w
ith p
rese
nc
e o
f d
ee
ps
ho
les
in
the
clin
ic d
ue
to
air
bo
mb
ard
me
nt.
Re
ha
bili
tatio
n t
ha
t in
clu
de
s w
ind
ow
, wa
ter
an
d e
lec
tric
ity n
etw
ork
s a
nd
wa
lls o
f th
e c
linic
(
est
ima
ted
co
st o
f a
bo
ut
1000
0 $
)
De
cre
ase
se
rvic
e
de
ma
nd
du
e
ina
bili
ty t
o r
ea
ch
d
ue
to
air
strik
es
an
d t
arg
etin
g
ad
jac
en
t b
uild
ing
s.
Ye
s
No
18A
l Fa
lah
Clin
ic
Bro
ken
win
do
ws
R
eh
ab
ilita
tion
of
win
do
ws
(est
ima
ted
co
st a
bo
ut
500
$)
No
Ye
s
No
19A
l Da
raj M
art
yrs
Clin
ic
Bro
ken
win
do
ws
R
eh
ab
ilita
tion
of
win
do
ws
( e
stim
ate
d c
ost
ab
ou
t 50
0 $
)
Inc
rea
sed
se
rvic
e
de
ma
nd
du
e t
o
de
ma
nd
fro
m
pe
op
le f
rom
oth
er
are
as
wh
o c
an
’t
rea
ch
he
alth
se
rvic
es
at
the
ir re
sid
en
ce
.
Ye
s
No
10
20A
l So
ura
ni C
linic
B
roke
n w
ind
ow
s (
20 w
ind
ow
s)
Cra
cks
an
d d
am
ag
e t
o c
linic
w
alls
P
ha
rma
cis
t R
aw
yea
Aw
ad
wa
s ki
lled
as
a r
esu
lt o
f b
om
ba
rdm
en
t o
f n
ea
rby
po
lice
st
atio
n (
wh
ile s
he
wa
s e
nte
ring
th
e c
linic
)
He
alth
insp
ec
tor
Aym
an
R
imla
wi w
as
inju
red
( in
th
e
ab
do
me
n a
nd
he
ha
d
sple
en
ec
tom
y)
Re
ha
bili
tatio
n (
est
ima
ted
c
ost
150
00$
)
The
clin
ic w
as
clo
sed
fo
r a
si
gn
ific
an
t p
erio
d o
f tim
e a
fte
r re
co
mm
en
da
tion
fr
om
se
cu
rity
du
e t
o
targ
etin
g a
dja
ce
nt
bu
ildin
gs
Ye
s , R
ec
en
tly
Ye
s , d
ue
to
d
est
ruc
tion
an
d
ina
bili
ty o
f w
ork
ers
to
re
ac
h t
he
c
linic
.
21Sh
aik
h R
ad
wa
n
Ma
rtyr
s C
linic
B
roke
n w
ind
ow
s
Bro
ken
do
ors
D
am
ag
e t
o b
ath
roo
ms
D
am
ag
e t
o d
rinki
ng
wa
ter
pro
ce
ssin
g s
tatio
n
Cra
cks
an
d h
ole
s in
th
e w
alls
Re
ha
bili
tatio
n (
est
ima
ted
c
ost
600
0 $)
In
cre
ase
du
e t
o
rec
eiv
ing
clie
nts
fr
om
oth
er
are
as
an
d d
ue
to
wo
rkin
g
aro
un
d t
he
clo
ck.
Ye
s
No
22A
ta H
ab
ee
b
Clin
ic
Da
ma
ge
to
te
lep
ho
ne
ne
two
rk
Ma
inte
na
nc
e (
est
ima
ted
c
ost
1,0
00$
)
No
Ch
an
ge
Y
es
N
o
23A
l Qu
bb
a C
linic
B
roke
n W
ind
ow
s
Re
ha
bili
tatio
n (
est
ima
ted
c
ost
1,0
00$
)
De
cre
ase
to
in
ab
ility
to
re
ac
h
the
clin
ic b
y c
lien
ts
an
d m
ed
ica
l sta
ff.
Ye
s
No
24A
l Mo
aq
ee
n
Clin
ic
Bro
ken
Win
do
ws
R
eh
ab
ilita
tion
(e
stim
ate
d
co
st 3
,00
0 $
)
No
Ch
an
ge
Y
es
N
o
25H
ala
Al S
ha
ww
a
De
stru
ctio
n o
f e
xte
rna
l wa
ll o
f th
e p
ha
rma
cy
D
est
ruc
tion
of
Dru
g s
tore
an
d
refr
ige
rato
r
Bro
ken
win
do
ws
B
roke
n d
oo
rs
D
est
ruc
tion
of
sta
irs r
oo
m
Cra
cks
in w
alls
an
d m
ain
do
ors
D
am
ag
e t
o w
ate
r ta
nks
an
d
ele
ctr
icity
ne
two
rks
D
am
ag
e t
o f
urn
iture
( c
up
bo
ard
s a
nd
ch
airs
)
Re
ha
bili
tatio
n f
or
win
do
ws
an
d d
oo
rs.
P
rovi
sio
n o
f d
rug
s ,
me
dic
al e
qu
ipm
en
t a
nd
fu
rnitu
re
Re
co
nst
ruc
tion
of
wa
lls
an
d s
tairs
ro
om
( e
stim
ate
d c
ost
30,
000
$)
Clin
ic w
as
clo
sed
d
urin
g t
he
wa
r an
d
wo
rk w
as
resu
me
d
rec
en
tly.
Clin
ic is
pa
rtia
lly
wo
rkin
g ,
it w
ill b
e
fully
op
era
ted
a
fte
r c
om
ple
tion
o
f re
ha
bili
tatio
n
Cu
rre
ntly
, c
linic
is
pa
rtia
lly w
ork
ing
C
lien
ts w
ho
ca
n’t
b
e s
erv
ed
at
the
c
linic
are
re
ferr
ed
to
th
e c
lose
st
he
alth
fa
cili
ty
26A
l Ho
rryy
a C
linic
B
roke
n w
ind
ow
s
Re
ha
bili
tatio
n (
est
ima
ted
N
o C
ha
ng
e
Ye
s
No
11
De
stru
ctio
n o
f w
ate
r a
nd
ph
on
e
ne
two
rks
c
ost
500
0$)
27Za
ito
un
Ma
rtyr
s C
linic
D
est
ruc
tion
of
ph
on
e n
etw
ork
D
est
ruc
tion
of
sate
llite
ne
two
rk
Dr.
Iha
b E
l Ma
dh
ou
n w
as
kille
d
du
ring
his
wo
rk in
pro
visi
on
of
first
aid
to
inju
red
pe
op
le.
N
urs
e H
am
da
n M
ala
ka w
as
inju
red
du
ring
at
his
wa
y to
w
ork
.
Ma
inte
na
nc
e o
f p
ho
ne
a
nd
sa
telli
te n
etw
ork
s
No
Ch
an
ge
Ye
s
No
28Sh
ate
Ma
rtyr
s C
linic
B
roke
n w
ind
ow
s
De
stru
ctio
n o
f n
ort
he
rn w
all
of
the
clin
ic
De
stru
ctio
n o
f o
ne
ro
om
D
est
ruc
tion
of
the
ph
on
e a
nd
e
lec
tric
ity n
etw
ork
s
De
stru
ctio
n o
f th
e la
b
eq
uip
me
nts
Re
co
nst
ruc
tion
of
de
stru
cte
d r
oo
m a
nd
w
all.
M
ain
ten
an
ce
of
ph
on
e
an
d e
lec
tric
ity n
etw
ork
s
Pro
visi
on
of
lab
e
qu
ipm
en
ts.(
est
ima
ted
c
ost
is a
bo
ut
1800
0$)
No
Ch
an
g
Y
es
N
o
29Middle Area
Governorate
30W
est
ern
Nu
seira
t C
linic
B
roke
n w
ind
ow
D
am
ag
e o
f fu
rnitu
re
Re
ha
bili
tatio
n o
f w
ind
ow
s a
nd
re
pla
ce
me
nt
of
da
ma
ge
d
furn
iture
(est
ima
ted
co
st is
a
bo
ut
3,0
00$
)
No
Ch
an
ge
Y
es
N
o
31A
l Kh
aw
ald
a
Clin
ic(
Al
Saw
arh
a)
All
clin
ic’s
win
do
ws
we
re b
roke
n
Re
ha
bili
tatio
n o
f w
ind
ow
s( e
stim
ate
d c
ost
8,
000
$)
No
Ch
an
ge
Y
es
N
o
32N
use
irat
Ma
rtyr
s’
Clin
ic
Bro
ken
Win
do
w
Re
ha
bili
tatio
n o
f w
ind
ow
s (e
stim
ate
d c
ost
ab
ou
t 1,
000
$)
No
Ch
an
ge
Y
es
N
o
33A
l Za
hra
a C
linic
B
roke
n w
ind
ow
s
Da
ma
ge
of
wa
ter
tan
ks
Da
ma
ge
of
wa
ter
ne
two
rk
De
stru
cte
d c
linic
’s w
all
Re
co
nst
ruc
tion
of
clin
ic
wa
ll
Ma
inte
na
nc
e o
f w
ate
r n
etw
ork
R
eh
ab
ilita
tion
of
win
do
ws(
est
ima
ted
co
st
is a
bo
ut
7500
$)
Wo
rk w
as
sto
pp
ed
d
urin
g t
he
wa
r an
d
it w
as
resu
me
d
aft
er
ce
ase
fire
.
yes
Se
rvic
es
of
pre
ven
tive
m
ed
icin
e d
ue
to
in
ab
ility
to
mo
ve
as
a r
esu
lt o
f c
on
tinu
ou
s b
om
ba
rdm
en
t
34Jo
hr
El D
eik
Clin
ic
Bro
ken
win
do
ws
D
est
ruc
tion
of
wa
lls a
nd
R
eh
ab
ilita
tion
of
win
do
ws
an
d r
ec
on
stru
ctio
n o
f W
ork
wa
s st
op
pe
d
du
ring
th
e w
ar a
nd
Y
es
N
o
12
pre
sen
ce
of
ho
les
in t
he
wa
lls
wa
lls(
est
ima
ted
co
st o
f a
bo
ut
250
0$).
it
wa
s re
sum
ed
a
fte
r c
ea
sefir
e
35N
ew
Bu
riej C
linic
B
roke
n W
ind
ow
s
Cra
cks
in t
he
ce
ilin
g a
nd
se
riou
s d
am
ag
e t
o t
he
wa
lls o
f th
e
clin
ic
Lab
eq
uip
me
nt
we
re d
am
ag
ed
D
am
ag
e in
dru
gs
sto
re
Re
ha
bili
tatio
n o
f w
ind
ow
s ,
R
ec
on
stru
ctio
n o
f w
alls
a
nd
ce
ilin
g
P
rovi
sio
n o
f la
b
eq
uip
me
nts
an
d d
rug
s(
est
ima
ted
co
st is
ab
ou
t 40
,00
0$)
De
cre
ase
in s
erv
ice
d
em
an
d d
ue
to
fe
ar
an
d
co
ntin
uo
us
wa
r.
Ye
s
No
36K
ha
n Y
ou
nis
G
ove
rno
rate
37K
ha
n Y
ou
nis
M
art
yrs
Clin
ic
Bro
ken
win
do
ws
22
of
clin
ic d
oo
rs w
ere
bro
ken
M
ain
do
ors
of
the
clin
ic w
ere
d
est
roye
d
Re
ha
bili
tatio
n o
f w
ind
ow
a
nd
do
ors
of
the
clin
ic.(
e
stim
ate
d c
ost
is a
bo
ut
1573
0 $
)
In e
arly
da
ys o
f w
ar,
clin
ic s
erv
ice
s w
ere
mo
ved
to
an
a
dja
ce
nt
pla
ce
as
imm
un
iza
tion
sp
ot,
la
ter
on
wo
rk
resu
me
d.
Ye
s
Ye
s, a
ll se
rvic
es
exc
ep
t im
mu
niz
atio
n (
w
hic
h w
as
mo
ved
to
an
oth
er
pla
ce
) w
ere
sto
pp
ed
d
ue
to
ta
rge
ting
a
dja
ce
nt
pla
ce
s a
nd
ina
bili
ty o
f w
ork
ers
to
join
w
ork
.
38K
hu
zaa
Ma
rtry
rs
Clin
ic
Serio
us
da
ma
ge
to
th
e c
eili
ng
o
f th
e b
uild
ing
re
sulti
ng
fro
m a
n
art
ille
ry s
he
ll
Re
ha
bili
tatio
n a
nd
re
co
nst
ruc
tion
(est
ima
ted
c
ost
is a
bo
ut
5000
$)
De
cre
ase
in s
erv
ice
d
em
an
d d
ue
to
fe
ar
an
d in
ab
ility
to
re
ac
h t
he
clin
ic
yes
N
o
39R
afa
h
Go
vern
ora
te
40C
en
tra
l Ra
fah
M
art
yrs
Clin
ic
Bro
ken
win
do
ws
( 25
win
do
ws)
D
am
ag
e o
f d
oo
rs
Re
ha
bili
tatio
n o
f w
ind
ow
s a
nd
do
ors
.(e
stim
ate
d
co
st is
ab
ou
t 4,
000
$)
At
ea
rly p
ha
se o
f w
ar d
ec
rea
se in
c
lien
ts d
ue
to
c
on
tinu
ou
s a
ir b
om
ba
rdm
en
t
Ye
s
Pre
ven
tive
se
rvic
es
we
re
sto
pp
ed
du
e t
o
co
ntin
uo
us
bo
mb
ard
me
nt
an
d m
ove
me
nt
diff
icu
ltie
s
13
41Ta
l El S
ulta
n
Ma
rtyr
s C
linic
B
roke
n W
ind
ow
s (1
0 w
ind
ow
s)
Re
ha
bili
tatio
n o
f w
ind
ow
s(e
stim
ate
d c
ost
3,
000
$)
De
cre
ase
du
e t
o
sec
urit
y si
tua
tion
a
nd
isra
eli
bo
mb
ard
me
nt
Ye
s
Pre
ven
tive
se
rvic
es,
mo
the
r a
nd
ch
ild s
erv
ice
s w
ere
influ
en
ce
d
du
e t
o c
on
tinu
ou
s b
om
ba
rdm
en
t ,
ab
sen
ce
of
som
e
wo
rke
rs a
nd
in
ab
ility
to
re
ac
h
clin
ic.
42
El S
ho
uke
h C
linic
Se
riou
s d
am
ag
e in
ma
in g
ate
B
roke
n w
ind
ow
s
Cra
ck
in t
he
clin
ic’s
wa
lls
spe
cia
lly f
rom
ea
ste
rn s
ide
Tr
ea
sury
bo
x w
as
lost
in a
dd
itio
n
to s
tam
ps
an
d a
su
m o
f tw
o
hu
nd
red
NIS
.
Re
ha
bili
tatio
n o
f w
ind
ow
s, d
oo
rs
R
ec
on
stru
ctio
n o
f d
est
ruc
ted
wa
lls
(est
ima
ted
co
st 9
,000
$)
Sig
nifi
ca
nt
de
cre
ase
th
en
st
op
pin
g w
ork
du
e
to la
nd
inva
sio
n.
No
, wo
rk s
top
pe
d
du
e t
o p
rese
nc
e
of
Isra
eli
forc
es
in
ad
jac
en
t p
lac
es
ne
ar t
he
airp
ort
.
Wo
rk w
as
sto
pp
ed
du
e t
o
lan
d in
vasi
on
43A
l Sh
ab
bo
ura
C
linic
B
roke
n W
ind
ow
R
eh
ab
ilita
tion
of
win
do
ws(
est
ima
ted
co
st
7500
$)
De
cre
ase
in s
erv
ice
d
ue
to
b
om
ba
rdm
en
t.
yes
N
o
Page 14 of 15
Summary of qualitative data
(9 February 2009)
Source Residence Event Denied
Access
Low
Quality of
care
Psychosoci
al impact
1. JWHC Jabalia Inability of woman to easily access hospital √ √ √ 2. JWHC Jabalia Traumatizing experience of woman during labor
for her eight baby √
3. JWHC Jabalia Woman with difficulties to access hospital, traumatizing experience
√ √
4. JWHC Jabalia Woman, difficulties to access hospital; traumatized due to loss of three family members killed in the war
√ √ √
5. JWHC Jabalia Woman, delivered in the street of Hala under shelling and war environment
√
6. JWHC Jabalia Delivery of child during the war; baby only immunized after end of war
√ √ √
7. JWHC Jabalia Woman, unable to breast-feed her baby (born before the war) due to fear.
√
8. JWHC Jabalia Miscarriage due to state of extreme fear due to bombing of adjacent house
√
9. JWHC Jabalia Woman, delivery under shelling and sounds of war; obstructed labor; baby only immunized after war ended
√
10. JWHC Jabalia Woman, delivered her fifth child ten days after her husband got killed on the first day of the war
√
11. JWHC Jabalia Woman, 18 years, pregnant, lost her husband during the war
√
12. JWHC Jabalia Woman, delivered her baby three days prior to the start of the war, problems in breast-feeding due to fear, compensated by using baby formula
√
13. JWHC Jabalia Woman, 21 years, miscarriage of two fetuses due to extreme fear.
√
14. JWHC Bedwen Village
Woman, 19 years, pre-term delivery in 28th week of pregnancy through assistance of a nurse visiting the area
√ √ √
15. JWHC Jabalia Woman, 27 years, had to walk on foot to hospital where she had induced labor; traumatized with what she had seen; couldn’t find cotton and antiseptic to disinfect umbilicus of her baby
√ √ √
16. JWHC Gaza,Saftawi area
Woman, delivered on last day of the war after extreme difficulty to reach hospital; caesarian section; experienced lack of care
√ √ √
17. Jabalia Atatra Woman, on the way to hospital to deliver, got shot at and had to have both limbs amputated
√ √ √
18. Jabalia karameh A pregnant woman and her three companions were targeted by a rocket and got killed.
19. Jabalia Jabalia Woman had difficulty to move outside and had to deliver at home
√ √ √
20. Jabalia Jabalia Woman had difficulty to reach hospital and had to deliver at home
√ √ √
21. Jabalia Jabalia Woman was fired at on the way to the hospital for delivery and sustained injuries to her legs
√ √ √
22. Jabalia Jabalia Woman was shot at and fainted, when she reached the hospital she was delivered through C/S
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23. Jabalia Gaza,Tal El Hawa
Woman was not able to reach hospital and had to walk a long distance to reach the Red Cross where she finally got transport to the hospital
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24. Jabalia Jabalia Woman could not reach hospital for long time; finally ambulance took her to Al Awda hospital but had to be transferred onward to Shifa
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hospital for delivery, since Al Awda prioritized war casualties.
25. Jabalia Jabalia Woman, hit by a rocket and her lower limbs had to be amputated; delivered in the ambulance on the way to the hospital; transferred to be treated abroad.
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26. Jabalia Jabalia Woman, started labor at school (after evacuation) and was transferred to hospital by an ambulance
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27. Jabalia Jabalia Woman, delivered in the first week of the war; later, IDF forced her out from her house informing her that the house and the whole area would be bombarded.
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28. CFTA Buriej Woman, 25 years old, displaced, reached hospital under very horrifying circumstances; she delivered her baby at the hospital but did not receive satisfactory health care; at the shelter, she could not meet most basic conditions in terms of hygiene and sanitation.
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29. CFTA Buriej Woman, 30 years, gave birth to her child in a crowded hospital where she didn’t receive satisfactory health care and was discharged immediately after delivery in the middle of the night where she had to witnessing random bombardment on her way back.
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30. CFTA Buriej Woman, 25 years, delivered her baby through the assistance of a neighbor midwife; newborn baby suffered from hypoxia and died later due to lack of equipment to treat her deteriorating condition
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31. CFTA Buriej Woman, 35 years, pregnant in her third trimester and suffering from chronic asthma was denied access to primary health care to have physical examination and receive medication. This led to deterioration of her medical condition.
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32. CFTA Johr El Deik
Woman, 30 years, injured on her way to hospital during bombing of a nearby house; difficulty to be transported to hospital; needed blood transfusion, but was not available; after delivery, she was immediately discharged.
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33. CFTA Buriej Woman, 25 years, delivered her baby before the war; lost her husband during the first day of the war while trying to get the baby’s birth certificate. Moving to a shelter with broken windows, she had very difficult times trying to keep her baby warm due to recurrent electricity cuts
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34. CFTA Johr El Deik
Woman, 34 years, had C/S delivery in her eighth month; baby was put in an incubator and mother was immediately discharged
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35. CFTA Buriej Woman, 23 years, lost three family members; delivered baby under very distressing situation which impacted on the family’s care of her and her new-born
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36. CFTA Buriej Woman, 20 years, lost her uncle; difficult access to hospital with low quality of care
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37. CFTA Buriej Woman, 22 years, lost her husband’s brother; difficulty to access hospital and had to deliver at home under the assistance of a nearby midwife.
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