In September 2020, I started to volunteer as a health educator in sexual and reproductive health and rights with mobile clinics of the Palestinian Medical Relief Society, reaching marginalized communities in the Occupied Palestinian Territories (OPT). I worked in the villages of two cities in the West Bank — Jenin and Qalqilya. Through this experience, I learned how to “educate” — how to speak to people in a language they can understand and reformulate the solid science I learned in medical school into simpler terminology.
My serendipitous journey to this volunteering opportunity began in August of 2019, when I joined Y- peer as a member and later trainer for youth in schools and universities. Y- Peer is an international group working to improve sexual and reproductive health rights for youth around the globe. To better explain my experiences in the mobile clinics, I would like to first contextualize my story by sharing some of the statistics and evidence on sexual and reproductive health and rights in Palestine.
According to the Palestinian Central Bureau of Statistics, 95% of women aged between 15 and 49 years old received antenatal care at least four times by a health care provider during their pregnancy, and 73% of women in the same age group received health care eight times or more during pregnancy in 2021. Most births in Palestine — 99% to be exact — occur in health institutions. Of all live births recorded, about 100% were attended by skilled health staff.
A majority of the research conducted on Palestinian reproductive and sexual health is observational, with most publications covering topics related to antenatal care, labor and delivery. On the other hand, I could not find research articles on menopause, preconception and psychosocial services. Unsurprisingly, research on the quality of sexual and reproductive health services provided is limited. In a study conducted on adolescent access to health services in fragile and conflict-affected contexts, participants highlighted the main challenges to access as absence of preventive adolescent health initiatives, limited information on sexual and reproductive health, shortage of medications, costly treatment and inappropriate interactions with service providers.
In a 2020 online survey of 861 Palestinian youth, more than 90% of respondents were in favor of including age appropriate comprehensive sexual education in school curricula. The findings suggested that although education on sexual and reproductive health, including on menstruation, has been incorporated into the school curriculum, its implementation remains unclear.
The link between Israeli involvement in the occupied Palestinian territories and women’s reproductive health (RH) is most evident in diminished access to health care during times of heightened violence. In the West Bank, barriers to health care can be related to closures and military checkpoints controlling movement within and between Palestinian cities and villages. For example, restrictions on mobility can cause an increase in induced and home deliveries or deliveries at checkpoints. In the bombardment of the Gaza Strip in 2014, we saw access to RH services and their availability were severely affected due to closures and overload of hospitals treating war-related injuries. Consequently, pregnancy complications, preterm deliveries, neonatal mortality and maternal mortality seemed to increase during that period. This showed the consequences of reduced access to antenatal and postnatal care.
Studies of marginalized communities such as those where I used to go with mobile clinics need to take into consideration political determinants of reproductive health. One study examined residents of the Kufr ‘Aqab neighborhood and found that Israeli biopolitics in East Jerusalem could be barriers to accessing maternal health services. Women have to pass military checkpoints to be able to reach hospitals located in Jerusalem to give birth and ensure their children’s eligibility for permanent residency – a required document for Palestinians to live in Jerusalem.
Data indicate that only eight percent of all births took place at home in 1999, compared with 33% in 2002. Women have to deal with uncertainty and delays when prevented from getting to a hospital because of checkpoints. Their coping mechanisms in reaction to the fear of being unable to reach hospitals on time include acceptance of non-hospital settings for childbirth, with reduced standards of care and increased risks to them and their babies.
In 2022, health care access is still a struggle for pregnant women, who must get regular checkups at the Salfit MoH Directorate – the only governmental health care center in the area with an ultrasound machine. Their head of nurses, Reem Abu Higleh, said “I see many pregnant women canceling their appointments due to access issues, where the Israeli army closed the gate of their village or settlers attacked cars on the roads.” She continued, “I also know of some cases of pregnant women who had to deliver their babies on the side of the road as they were unable to get to the hospital on time.”
With this background, I hope you will be better able to visualize what experiences I had as a clinic volunteer. At first, I used to travel with the clinic but not to participate in taking a history or physical exam. In my role as a health educator, I would travel with the mobile clinic and introduce myself to people seeking medical help, saying something along the lines of “Hello, I am Duha Shellah and am available to answer your questions on reproductive health and rights.” After a couple of minutes, people would line up to ask their questions. These ranged on a number of topics, from menstrual cycle abnormalities, pregnancy, breastfeeding, puberty, teenager’s’ health and mental health support.
This whole experience affected me as a medical student and formed who I became as a junior doctor. My vision of health education, services and the system in my homeland changed as I had conversations with people of different ages and backgrounds, and they shared with me their concerns and thoughts about their reproductive health and rights. I realized how important it is to research the reproductive health of women, both within and outside of reproductive age, in addition to men and adolescents. Through my many conversation with those seeking care, I saw a need to better address the reproductive health needs of specific community subgroups within the service provision system.
My duty during my time with the mobile clinics was primarily raising awareness and providing health education about reproductive health; this topic remains a big challenge in the region for many health care providers. Ways for improvement are highly needed at the content, dissemination and utilization levels. In my opinion, a continuous professional development system for health professionals is essential. This system would ensure that all are up-to-date on the quality of reproductive health services provided. During my time volunteering, I also saw a need to sensitize and mobilize the community with regards to its different reproductive health needs and services. In addition, I would advocate for designing and implementing conflict-sensitive and age and gender appropriate adolescent services.
My experience volunteering had its effects on me as a person in addition to impacting my professional identity as a physician. By listening to people’s concerns and providing them with information about the field of sexual and reproductive health and rights, I became more flexible, resilient and understanding. My character changed to a level that I can express my thoughts and feelings more freely and, more importantly, it grew my ability in leadership and advocacy.
Image courtesy of The Palestinian Medical Relief Society and UNFPA Palestine Youth Focal Point. The photograph, taken in 2020, shows one of the mobile clinics in action, with health care workers offering primary health care services.