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Prevalence of Postpartum Depression in Occupied Palestine

Amneh Amro
University of Lynchburg

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Amro, Amneh, "Prevalence of Postpartum Depression in Occupied Palestine" (2022). Graduate
Dissertations and Theses. 47.
https://digitalshowcase.lynchburg.edu/etd/47

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Depression in Palestine 1

Prevalence of Postpartum Depression in Occupied Palestine

Amneh Amro, MPAS, PA-C

University of Lynchburg

School of Graduate Health Sciences

Department of Physician Assistant Medicine

Doctor of Medical Science Program

Bernard Toney, DMSc, MPAS, PA-C

PA962: Doctoral Project II

Final Manuscript

March 6, 2022
Depression in Palestine 2

Prevalence of Postpartum Depression in Occupied Palestine

In a world where everything has been modernized and progressively accepted,

has modern medicine kept up? With a growing population, is the accessibility to

healthcare service meeting the demand and without bias? More importantly, has the

growing population broken down the stigmas associated with medical conditions, like

postpartum depression? There has been a notable disparity in mental health treatment

worldwide, and even more so in Palestine and other third world countries of similar

nature.

In the United States, postpartum depression affects 1 in every 5 women but 1 in

every 8 seek treatment.1 It is reported that 10-15% of women are affected worldwide,

however, it is apparent that there are consistently higher rates among middle eastern

women.1 There are several contributory factors to these exponential rates with some

being stigmatized, financial deficits, poor infrastructure, limitations to medical

support, and high parity. The Edinburgh Postnatal Depression Scale (EPDS) is the

primary tool to assess depressive symptoms in antenatal and postnatal women and is

found to have a high sensitivity and specificity even when translated into their

respective languages.7 There are 10 questions with the highest possible score of 30.

The higher the score the more severe the symptoms.

According to the EPDS, any score above a 10 would be considered the cutoff for

PPD.7 Further classification of mild, moderate, and severe would be indicated as the

score rises. Although we can safely predict some risk factors and precursors for
Depression in Palestine 3

postpartum depression, it remains one of the top underdiagnosed and undertreated

illnesses. There are several reasons for this, however, the main reason could be

minimizing or underreporting.7

Partaking in cultural and religious practices is observed to naturally heal a

woman’s postpartum state.4 Bonding with the baby immediately following childbirth is

highly encouraged. In the Middle East, it is a cultural norm to take 40 days of solitude

and rest to allow a bond to form.5 Along with breastfeeding, the use of natural

supplementation and herbal remedies are started before delivery. There is a strong

religious coping mechanism with women of middle eastern origin. In many cases,

religion is looked at as a healing tool far stronger than any pharmaceutical.4 The

problem arises when PPD is progressively worsening beyond the data-driven 7-week

mark in Arab women followed by high parity and the need to offer the family a specific

gender.5

With regards to Palestinian women, in particular, compared to other women in

that region; there is a higher prevalence of PPD driven by ethnonational inequalities

and discrimination. The rates are quite staggering at 20% to 7% amongst Palestinian

and Israeli women, respectively. 5

HISTORY

Palestine is a country in the Middle East with a controversial history and an

uncertain future. In a country with 6019 km2, it is densely populated with

approximately 4.685 million people and continually growing.1 It is estimated that there
Depression in Palestine 4

are 400 births per day in Palestine.2 Furthermore, Gaza, a small strip within the

occupied territories is 360 km2, considered one the most densely populated cities in

occupied Palestinian territories with 1.88 million people residing there. Gazans are

unable to have access to any medical aid outside of the Gaza parameters. When a higher

level of care is needed Gazan residents, much like other Palestinians or Non-Israeli

residents, must request special permission to leave and pass through checkpoints.5

Without the Israeli government’s permission to pass through checkpoints, they are

confined to the territory they reside in. This is the same for medicine, food, and water

supplies.

Restrictive movement and curfews in occupied Palestine dates back to 1948.

After the war, Israel put in place a Defense Emergency Regulation.12 This regulation

restricted the freedom of movement and required permits to cross between cities or

towns. Ultimately, these regulations became part of military law and were enforced in

what are now known as checkpoints. Between 1967- 1972, occupied territories became

known as closed military areas severely restricting movement to those that resided

within.12 By 1991, Israel had required military permit approval to enter Israel or move

between the West Bank, Jerusalem, or Gaza.12 This became part of the Oslo Accord (a

peace agreement between Palestine and Israel) and what is now affecting immediate

and emergent healthcare to the residents of occupied palestine.12

Depression in Palestine 5

According to the World Health Organization (WHO), 61 women have given birth

at a checkpoint between 2000-2004.11 36 babies have died as a result of delayed medical

access.11

BIRTHING RIGHTS

Home Births

For many years, prior to the occupation, palestinian women birthed at home.

They were evaluated by unlicensed midwives, known as Dayas in Arabic. These

midwives have a very holistic approach to health and disease.16 It is ingrained in their

practice that stress and emotion directly affect the physical state of the mother.16

Dayas move fluidly between traditional, western, and spiritual medicine to ease the

child birthing process on the mother. By 1994, there was a big push by the Palestinian

government to encourage hospital births and reduce the risks associated with home

birthing.15 The push for medicalization of the birthing process was set in motion.

However, the women residing in occupied Palestinian territories preferred the home

birth route because of the familiarity and support. Social and economic stressors were

not a factor when Palestinian women delivered at home. Women did not have to worry

about complications of birthing associated with checkpoint closures, laboring through a

two hour security clearance with Israeli Defense Forces, or worse, fetal demise due to

lack of access.16 Although fetal demise is still a risk in home births, many women

reported preference to home births because their human rights and basic needs were

met.15 The midwife would continue to care for the mother after delivery and help
Depression in Palestine 6

support her with the child as a part of her continuity of care.16 Having that deep

understanding of the culture and the socioeconomic struggle supported their mental

health needs at the time and would make the transition from antenatal to postpartum

much smoother.16

Hospital Births

At the turn of the 20th century, the rate of home births among Palestinian

women declined significantly. In 1996 18% of pregnancies in occupied Palestinian

territories happened at home.11 However, by 1999 that declined to 8%.11

With this decline came much negligence and complaints from Palestinian

women. Oftentimes while women labored, family was not allowed in the room for

support. Women reported being yelled at, being left alone for extended periods, lack of

privacy, and lack of empathy from health care workers. Due to the lack of space in

government funded hospitals, oxytocin is utilized to speed up labor. The idea is to

reduce time spent in the hospital to free up beds for the next patient. However,

research has shown that the use of unnecessary oxytocin increases the risk of

stillbirths. WHO recommends no physiological intervention in the childbirth process

unless absolutely necessary, especially in moments of limited resources and restrictive

movement.11

After delivery, women are expected to leave the hospital within hours. There is

no postpartum care follow up. This gap in maternity care, particularly towards

Palestinian women, opens the door for unserved and missed mental health needs.
Depression in Palestine 7

Women birthing in an already war torn country with severe inequalities develop high

levels of anxiety and depression.

Palestinian women are required to have medical visas approved by the Israeli

military for medical or hospital visits. In cases where intensive care is needed for the

newborn, the palestinian mother must leave back to her home and reapply for an

extension. About a third of those applications are denied on the first attempt. Another

portion of applications are placed under review for an obscure amount of time.

Palestinian women have reported being seperated from their newborn for six months.

Essentially, given access to pick up their infant to take home or to bury. These mental

health disparities are worse because of the life they now have responsibility over and

little supportive care depending on their circumstances.

STATISTICS

According to the Health Ministry report, there are currently 117,600 pregnant

women residing in Palestine.9 Of those, 17,460 are enduring difficult or complicated

pregnancies.9 Inadequate medical access or care is the third leading cause of death

amongst Palestinians.

The WHO reported that 61 women had given birth at checkpoints with 36 fetal

demise between 2000 and 2004.11 In 2000, 31 pregnant women delivered at checkpoints

resulting in 17 fetal demises.9 By 2004, the numbers decreased to 8 women giving birth

at checkpoints 5 of the babies died. The United Nations Relief and Works Agency

reported a woman transported via ambulance was held at checkpoint for 1 hour while
Depression in Palestine 8

trying to get to the hospital for complications at 6 months of pregnancy.9 She

ultimately aborted inside a Palestinian Red Crescent Service (PRCS) ambulance.9 It is

safe to say that the increase in fetal demise in the early 2000s is linked to

medicalization of childbirth. While the decline of fetal demise is in part due to

Palestinian women choosing to birth at home for safety reasons.

Maternal Morbidity vs Mortality in Palestine

A comprehensive hospital based analysis was conducted in 2011 over the course

of 3 months.14 This analysis was done to observe the complications associated with

Palestinian women delivering in government based hospitals. Maternal morbidity was

found to be exceptionally high between the ages of 16-48 among Palestinian women.14

Of the 1558 women assessed, 15 were found to have survived life threatening

complications.14 61 women delivered via cesarean section and 110 experienced

postpartum complications.14 Hemorrhage was found to be the most common

complication amongst these women.11 However, rational use of cesarean section,

reduction of unwanted pregnancies, and elimination of unwarranted medicine can

prevent antenatal and postpartum complications.14

Maternal Morbidity vs Mortality in Israel

In contrast, a 23 year comprehensive review of maternal care in an Israel hospital

showed better outcomes. The rate of mortality averaged about 3 deaths per every

10,000 women.11 In this review the complication leading to maternal mortality was

vascular damage during cesarean section. Cesarean section was the route of delivery in
Depression in Palestine 9

almost one third of all cases ending in either fetal demise or maternal demise, followed

by infection, then sepsis.14 In recent years, there has been a sharp decline in maternal

mortality with the implementation and liberal use of antibiotics and aseptic

techniques. Home births in Israel are frowned upon due to the push for medicalization

of the birthing process. An Israeli Jewish woman is offered the highest standard of care

in childbearing, child birthing, and postpartum care.11 Israel is known as one of the

leading countries in reproductive technologies and offers its citizens subsidized fertility

treatment for up to two children.11 During pregnancy, women are offered various

ultrasounds and tests over the course of their pregnancy to ensure healthy fetal

development.11 Unfortunately, the cesarean section rate in Israel is about 19%,

surpassing the WHO recommendation of 10-15%.14

CONCLUSION

There are an estimated 4 million people currently residing in the occupied

Palestinian territories with an estimated 400 births per day.2 A mother averages about

4 children during her lifetime within the occupied territories. However, there is a

failure in the healthcare system when a woman transitions into motherhood. Although

the evidence is staggering, postpartum depression has not been the focus of care due to

a number of socioeconomic factors and political conflicts causing constraints to access

to care. Israel’s Ministry of Health has established a state of the art health care system

since its establishment in 1948. The health care system and continuity of care is

comparable to other developed nations, if not better. While just a stone's throw away,

in neighboring occupied Palestine, the health care system is severely deficient and
Depression in Palestine 10

operating in constant crisis. A woman cannot be expected to bring a child into this

world without having her basic needs met. The lack of security, reassurance, and a

supportive healthcare system will undoubtedly trigger postpartum depression.2 PPD,

although easily managed in developing countries, is a complex issue to treat in

Occupied Palestine due to the current political circumstances. It is not only

depression, but trauma, fear, and trust that needs to be addressed in this population. It

is a transitory diagnosis after child birth but requires ongoing treatment for years after.
Depression in Palestine 11

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Provider Discussions About Perinatal Depression - United States, 2018. MMWR Morb

Mortal Wkly Rep. 2020;69(19):575-581. Published 2020 May 15.

doi:10.15585/mmwr.mm6919a2

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Depression in Palestine 12

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Depression in Palestine 13

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Published June 29, 2021.