As we mark 12 years of the Syrian conflict, a new report documents how targeted violence against healthcare personnel and infrastructure has impeded vital sexual and reproductive health (SRH) care, resulting in far-reaching tolls on the health and wellbeing of women, girls, and healthcare professionals.

The devastating earthquake that struck southern Türkyie and northern Syria in February 2023 has compounded already precarious access to healthcare in the region, contributing to the collapse of the fragile healthcare system in northwest Syria.

“She Pays the Highest Price: The Toll of Conflict on Sexual and Reproductive Health in Northwest Syria,” co-published today by Physicians for Human Rights (PHR), the International Rescue Committee (IRC), Syria Relief & Development (SRD) and the Syrian American Medical Society (SAMS), details how ongoing conflict and targeted attacks on hospitals and healthcare professionals have fueled a crisis in northwest Syria, limiting the availability and access to life-saving SRH services.

Informed by interviews with over 260 healthcare workers and patients in northwest Syria conducted in 2022, the study shines a light on the barriers women and girls faced, even before the earthquake, in accessing SRH services such as maternal and newborn healthcare, family planning, gender-based violence services, post-abortion care, and sexually transmitted infection treatment and care.

For example, in northwest Syria years of attacks on healthcare facilities have forced women and medical providers to opt for riskier caesarean sections over vaginal birth, partly to reduce the time spent inside a health facility, which are subject to armed attacks and can be hazardous to all involved. The average in-facility C-section rate in 2021-2022 was 23% of the total deliveries - higher than the pre-conflict rate. Patients also avoided prenatal care visits to limit exposure to potential attacks. A health worker in Idlib, Syria, told researchers:

“When health facilities were targeted, we saw pregnant women [only] during labour, instead of four or six times throughout their pregnancy. When we asked them why they didn’t come for medical care earlier, they said, ‘Who would dare visit the hospital when it’s being targeted? We would be crazy to stay in the hospital.’”

Damage from the earthquakes that hit Syria and Türkiye on 6 February has only worsened the humanitarian crisis in northwest Syria, increasing the need for health services and intensifying pressure on medical staff, medical facilities, and health resources. The surge in displacement, destruction of roads, fuel shortages, and limited health services, medicine and medical equipment will likely impact as many as 148,000 pregnant women, 37,000 of whom are due to give birth in the next three months, according to the report.

“In Syria’s devastating war, women pay the highest price. The fundamental human right to health - including being able to deliver a baby safely, to bring new life to the world - has been routinely violated in northwest Syria, where bombs have rained down on hospitals, and healthcare workers have been persecuted,” said Dr. Houssam al-Nahhas, Middle East and North Africa (MENA) Researcher for PHR and co-author of the report. “12 years of impunity for attacks on health care have exacerbated a sexual and reproductive health crisis in Syria. The UN system, Member States, and aid agencies must meet their obligations to provide SRH care to the millions of people who lack access in the region. The need is even more urgent in light of the horrific earthquakes and aftershocks that have killed and injured thousands and leveled countless buildings.”

The report outlines the stark gap between the availability and demand of SRH services. Of the 367 functioning medical facilities in northwest Syria, only 7% offer comprehensive maternity care. Outpatient reproductive  ealthcare services exist in fewer than 40% of facilities. Despite efforts to provide free delivery and newborn care, overcrowding at hospitals causes significant gaps in maternal and newborn services. Violence in the region has  lso contributed to the overall lack of skilled care providers, especially midwives and gynaecologists, the report finds. Particularly in frontline areas, healthcare providers have moved their operations away from the fighting,  imiting the number of accessible facilities despite sustained need.

"Rampant attacks on health magnified by the earthquakes’ devastation have contributed to a dire shortage of health facilities and workers, leaving the most marginalised - including women and girls - without adequate access to essential sexual and reproductive health services,” said Dr. Okba Doghim, programmes director at SRD, SRH technical working group co-lead, and contributor to the report.

“Economic downturn, poverty, and shifting donor funding have further exacerbated this crisis, barring Syrians from accessing lifesaving care. Improved transportation, increased information and resources, and broader coverage of reproductive health services delivery are critically needed to meet the urgent needs of millions in northwest Syria."

“The bombing of facilities like al-Atareb Hospital and al-Shifa Hospital has reduced access to essential reproductive and neonatal care consultations, putting mothers and newborns at even greater risk. Pregnant women have given birth in their cars on the way to healthcare facilities because of the distance, and others were forced to deliver at home during heavy shelling. Many who suffered miscarriages were unable to access facilities  or care,” said Dr. Amjad Rass, president of SAMS. “Years of violence have already severely limited access to sexual and reproductive health services. In the aftermath of the earthquake, rapid protection assessments  onducted in affected areas underscore what we’ve learned from over a decade of conflict: that women and girls are being disproportionately affected by the escalation of needs.”

The report offers recommendations to the international aid community, donor governments, NGOs, Syrian governing entities, and intergovernmental bodies to support the availability of and access to sexual and reproductive health care in northwest Syria, including:

‘After more than 12 years of conflict the healthcare system in northwest Syria now finds itself on life-support. The strain it is under has only been exacerbated by the recent earthquake that once again saw thousands displaced, health centres damaged and supplies of medicines and vital equipment temporarily disrupted’ said Tanya Evans, Country Director for IRC Syria. ‘This report demonstrates the disproportionate impact the conflict continues to have on women and girls in northwest Syria, and reaffirms the need to ensure that those most vulnerable are protected from both conflict and its reverberating effects .’

Download the report.