Abstract
This research paper explores the relationship between maternal health and conflict, specifically looking at the situation in occupied Palestinian territories. The framework used, situates health outcomes within broader structures of settler colonialism and political violence. The biopolitical control Israel exerts over Palestinians has shaped their health since 1948 and has worsen after the blockade placed in Gaza from 2007. Issues such as requiring permits to access hospital care to restrictions at checkpoints leading to avoidable deaths all of which exacerbates health disparities for Palestinians and reinforces colonial dynamics. Using a structural violence framework, the research evaluates how Israeli-imposed mobility restrictions and geographical fragmentation contributes to systemic barriers in accessing maternal care.
Contrary to assumptions that conflict settings led to underutilisation of services, findings reveal higher
institutional birth rates and rising caesarean sections with stagnant infant mortality rates in Palestine, driven by
international aid and policy pressures. However, these trends obscure deeper issues of autonomy and the
Westernisation of policies in the Global South without addressing population needs. This research paper argues
that dominant, top-down interventions often replicate Western biomedical models without addressing the
unique political and cultural context of Palestine.
It calls for a shift towards community-led maternal health policies that centre Palestinian women’s voices
restoring birth agency and recognising health as a site of resistance. With reclaiming health sovereignty and
decentralising health systems, Palestinians can challenge dependency frameworks to assert resilience within the
settler colonial context. This work contributes to the growing discourse on decolonising global health and
reimaging care in conflict settings.
Introduction
Maternal and neonatal health (MNH) refers to care
provided to women during pregnancy, childbirth and
postpartum as well as to newborns in the first weeks of life (3)- which is a longstanding public health
priority.Maternal mortality (death within 42 days of
pregnancy) rises during conflict due to a multitude of
factors which include restricted access to maternal
services, safety concerns, financial constraints and geographical barriers (4). Neonatal mortality (death
within the first 28 days of life) remains higher than
universal standards, particularly in conflict settings where
there are significant gaps in healthcare and lack of
specialised services (5). While much of the literature
includes logistical and health system challenges, there is
limited understanding of the geo-political barriers that
shape access to care. This makes outcomes more
complex and context-specific which is essential for
developing targeted interventions in conflict zones.
When examining the case of Palestine, ongoing
occupation and repeated escalations of violence has
created a multitude of complex barriers. MNH is an
important element regarding health in the oPt as women
of reproductive age and children under five make up
approximately 39% of the population according to the
2010 Family Survey (6). Settler colonialism is
fundamental in preceding all economic, social, and
political determinants of health in Palestine (7).
Addressing barriers to accessing MNH services in
Palestine requires more than just health system
strengthening, it demands political solutions to achieve
quality care (8). This research paper will discuss and
connect these components of health to address a wider
reality to Palestine, reorienting the focus to root causes.
How does political instability in opt affect health infrastructure and the availability of services?
3.1 Epidemiology of maternal care in the Opt
Within the occupied territories of Gaza and the West
Bank, women of reproductive age make up
approximately 22% of the population with a high fertility
rate of 3.3. By 2002, the maternal mortality rate (MMR)
in Palestine was estimated to be 24 (9, 10). While
maternal and newborn mortality rates in the oPt have
decreased since the 1960s, across all maternal child
health(MCH) indicators, the oPt preforms worse than
Israel and surpasses Jordan in only MMR value (11).
There is considerable under-reporting by the Palestinian
MOH with regular audits and near-miss investigations
not being done- the death registration system is often
unreliable with data for maternal complications often
missing (10).
A study on coverage of antenatal care(ANC) in Palestine
discovered that 72% of women met the WHO
recommended visits but with variations across the region
33% in the Southwest Bank did not meet this standard (12). Another study on the association of ANC quality
and the MCH handbook states that 60% of women
utilised services and were more likely to receive a higher
quality of care among handbook users (13). One possible
explanation is the prioritisation of maternal health by the
Palestinian MOH with the provision of around 475 ANC
clinics in 2020 (12). Furthermore, the integration of ANC
into the primary care system may have contributed to the
higher figures. Despite this, it is important to note that
context of socioeconomic and geographical disparities
continue to affect timely and adequate care – whilst
coverage may be high, quality and consistency of that
care can still reflect the structural inequalities.
In relation to maternal care, poor communication and
inadequate supervision were identified as major factors
affecting the delivery of care (14) – this contributes to the
willingness of mothers accessing care, which is
consistent with data from other LMICs in the literature
review. Another study looking at maternal mortality in
the West Bank found that 25 of 36 maternal deaths can
be classified as avoidable due to either complications or
unjustifiable delays in life-saving interventions (10).
PNC is typically a service utilised the least by women
globally, where 55% of maternal deaths in Palestine
occur within this period. Despite large antenatal coverage
in Palestine, PNC utilisation only reached 30% in 2006,
with roughly two-thirds of women not receiving any
postpartum care(15). Figures doubled in the Gaza Strip
within the year, however the West Bank saw a regression
after 2004 potentially due to the tightening of Israeli
mobility restrictions (16). Looking at the quality of PNC,
it is difficult to quantify the level as perceptions of care
are deeply affected by education and birthing situation
which can be masked in the context of occupation (17).
Infant mortality dropped sharply in the 1980s but
declined much more slowly over the following decades,
with only a 1% annual decrease from 1990 to the early
2000s reported by Giacaman, Khatib (18). Another study
found that in the Gaza strip, the infant mortality
ratebegan to decline slowly due largely to a rise in
neonatal mortality. In 2009, the Palestinian MOH
reported infant mortality rates to be 21.5 per 1,000 live
births (19). Rates have remained stagnant at 16 since
2006 with further insight needed into quality of care
during birth(20). This isn’t a simple matter of medical
capability which is the case in other countries in the
Global South but deeply tied to mobility restrictions and
systemic neglect. It is important to consider how
additional intervention from specialist care and restricted
mobility may have reduced the infant mortality further.
Prevention from timely specialist services exacerbates
preventable deaths and impedes progress.
Differences in ANC/PNC and perceived quality suggests
a reality shaped by prolonged occupation and
overreliance on external aid. Under these conditions,
perception of care is survival-based rather than
measurable, comprehensive health data.
3.2 The politics of childbirth in Palestine
Many childbirth-related health policies, are heavily
influenced by Western ideas of modernisation and
development, ignoring a country’s own specific history
and culture (21). After independencewas gained from
colonial powers, many countries tried to establish a
system where hospital births were the norm, influenced
by international organisations that focussed on high
maternal mortality. Despite vertical solutions in
addressing safe motherhood in the Global North, these
strategies have not significantly reduced maternal
mortality in poorer contexts that are affected by war and
globalisation (22).
From the mid-1990s, childbirth policy under the
Palestinian Ministry of Health (MOH) was driven to
reduce infant mortality rates which they believed was due
to high levels of home births, and so they encouraged
hospital births; by the end of 1999, almost 99% of births
occurred in medical facilities in Palestine(23). Both the
MOH and Israeli Civil administration adopted this notion
that home births, no matter the conditions, was a risk to
both mother and newborn(21). This idea was not
established in research as outcomes were not assessed
and studies from other developing countries highlight the
misleading institutionalisation of childbirth without a
focus on quality (24). This practice also allowed a greater
oversight to document, register and monitor Palestinians
as part of a bigger plan tied to the political dynamics of
the conflict. The proportion of caesarean sections in
Palestine also increased from 6.0% in 1996 to 14.8% in
2006 with this procedure being more common in
governmental sectors (25). This shift reflected a broader
global trend of westernisation of childbirth that did not
align with local realities and imposed models of colonial
control.
With the implementation of the separation wall and Gaza
blockade in the early 2000s as seen in figure 1, access to
maternity facilities had been severely disrupted, changing
birth location patterns- births at home had increased by
roughly 20% in the span of 3 years (21). The isolation of
regions created conditions that required local responses, as the efforts of the Palestine MOH to centralise birth
was proven redundant. Many hospitals were placed under
long periods of curfew and closures with private
hospitals having to shut down with the decline in
deliveries. However, through this we have witnessed the
creation of a new network of childbirth with the focus on
birthing centres, dayats (TBAs) and birthing homes to
accommodate the new reality (21, 26). This comes at a
risk as policies that are implemented without planning or
integration into the wider system, reinforces existing
power imbalances that have historically shaped maternal
care in conflict. Although decentralisation of health
systems is useful in emergency settings, it lacks the
foresight and sustainability to form stronger health
systems in the future.
3.5 Undermining health systems under settler colonialism: Beyond fragmentation
To critically examine the health of Palestinians, we must
understand that settler colonialism is a fundamental
determinant of health, where the health system does not
only need strengthening but an anti-colonial approach is
essential to deconstruct structural discrimination. Farmer
expands on the concept of structural violence by applying
it through a global heath lens, stating how structural
factors such as colonial histories, economic exploitation
and political marginalization often determines health
outcomes far more than biology alone (27). This is
foundational in the State of Israel as defining a state
around a single religious identity coupled with settler
colonial practises creates unequal health outcomes (28).
A wider understanding of health is needed in the
humanitarian field for medics as it exposes how
marginalisation becomes a form of long-term harm
towards an individual’s health which cannot be solved
with the practise of medicine alone.
As part of the International Covenant on Civil and
Political Rights, it states that “Everyone lawfully within
the territory of a State shall, within that territory have the
right to liberty of movement and freedom to choose his
residence” (29).This right has systematically been denied
within the context of settler colonialism in Palestine. The
Israeli state imposes restrictions that will be discussed
further to fragment and control indigenous populations.
Access to health in the oPt is shaped by two major
structural barriers- the division of the West Bank into
areas and the development of the Israeli permit system.
Both impose strict movement restrictions on those
seeking medical care. The attempt at developing a health
system in Palestine can be dated back to the Oslo
Accords where the West Bank was divided into Areas A,
B, and C; only areas A was administered full control to
the Palestinian Authority, while area C, which covered
60% of the land, remains under full Israeli control(30).
Figure 2illustrates the fragmentation caused by the permit
system and restricted zones (1).
Even without active conflict, movement within the West
Bank remains severely limited. This form of governance
that restricts movement and creates classes of citizens is a
key example of structural violence. Healthcare and
movement are allocated based on citizenship rather than
need causing long-term harm that is largely invisible and
institutionalised.
Since the early 2000s, there have been extreme
restrictions on movement with closures, sieges and
curfews that extend beyond reasons for security. With the
erection of the separation wall in 2002 along the entire
West Bank, this was followed by a new permit system
that restricted access to tertiary care facilities (31). To
this day, Palestinians living in the West Bank cannot
access Jerusalem or Israel without obtaining a permit,
which contains roughly six Palestinian hospitals for the
entire West Bank population- this creates a hierarchy of
mobility and entitlement in accessing care. In order to
access the hospital, you must have a referral from a
Palestinian hospital and coordination documents -a
process that can take several weeks (32). A study
quantitively looking at health barriers in the occupied
territories found that in 2011, nearly 35,000 patients were
referred by the MOH requiring Israeli permits for access
to hospitals. 19% has their application denied with the
death of 6 patients whilst waiting for permits(33). These
systematic delays illustrate how a permit regime
functions not only as a bureaucratic hurdle but as a
structural determinant of health outcomes.
The Palestinian health system remains heavily focused on
responding to ongoing emergencies due to recurrent
attacks and prolonged blockades. This state of constant
crisis disrupts daily operations and long-term
development initiatives. While some level of
coordination exists along international organisations,
efforts are limited as the root causes of the crisis are
political in nature and cannot be resolved through
humanitarian support alone (34). Settler colonialism
functions not only through territorial control but through
the gradual erosion of institutional capacity and
sovereignty. The intentional design of bureaucratic
barriers continues to disrupt efforts to build a cohesive,
resilient health system. Understanding health access in
this context demands a lens that centres it within the broader settler colonial framework that perpetuates
dependency and de-development.
3.6 Mobile restrictions on maternal and neonatal access to care
Another unique issue affecting delay in accessing care is
the implementation of checkpoints. Scholars have
understood checkpoints as spaces marked by systematic
monitoring which is characterised by fear and
humiliation, specifically in the oPt (35). During labour, a
process that is considered a medical emergency, some
women are forced to wait for lengthy periods at the
checkpoints, whilst others are told to leave the ambulance
and walk to the opposite side. This points towards the
broader purpose of the checkpoints, to institutionalise the
occupation under the guise of order or legality in line
with the biopolitical objectives of Israel (36). A news
article by the UN found that 69 babies were born at
checkpoints, leading 35 neonatal deaths and 5 maternal
deaths from 2000 to 2007 (37). These avoidable deaths
reflect more than just delays but is the product of a wider
system that normalises the denial of healthcare through
bureaucratic barriers.
One study researched the rise in women crossing military
checkpoints to give birth in Jerusalem hospitals so their
children will be eligible for ‘permanent residency’
allowing them to live and work in East Jerusalem(38).
Despite this, some women restrict their movement to
avoid checkpoints and other forms of political violence.
This exposure to risky conditions coupled with a lack of
social support during birth was perceived as affirming the
Palestinian presence in the City and a show of resistance.
Palestinian residents of Jerusalem must constantly prove
they live within the city’s boarders to prevent their
residency from being revoked. However, these
restrictions do not apply to Jewish residents who retain
their right to live regardless of their place of birth(38)
This form of resistance works to reverse power dynamics
within a larger system of control, maintaining space and
identity through personal sacrifice. While this paper
primarily focuses on how policy shapes maternal care,
this serves as a powerful reminder that individuals can
challenge the system of oppression through choice and
childbirth.
The research highlights how MNH outcomes are not
merely the result of poor health behaviours but the
consequences of entrenched political structures and past
policies, further emphasising Farmer’s ideas. As such,
this framing is crucial to any analysis of health under
occupation and sets the stage for exploring how settler colonial practices continue to undermine the right to
health in the oPt.
Conclusion – The path to resilience and resistance
This research paper emphasises how generic maternal
health interventions often fail to address the specific
socio-political dynamics of conflict zones like the oPt.
Research moving forward, needs to prioritise frameworks
grounded in local political and cultural realities. Viewing
maternal care through a solely biomedical lens is harmful
and exacerbates disparities, failing to address the
intersectionality of politics, human rights and public
health.
To address the political and structural constraints shaping
childbirth in the oPt, policies must support the re
establishment of midwife-led birthing centres as
alternatives to hospital births. The imposed shift towards
hospital births may not align with the socio-political
realities. This restores autonomy within a context of
disempowerment where research has consistently proven
that care which is informed and by choice leads to better
outcomes(39). The Westernisation of childbirth
reinforces the idea that their bodies are governed by
systems outside of their control, where re-establishing
decision-making is a form of both health interventions
and socio-political justice.
The heavy reliance on international aid interventions
hinders the development of a self-sustaining and resilient
health infrastructure by reinforcing dependency and
colonial structures. Rather than positioning Palestine
solely as a recipient of external aid, the experience of
systemic violence has created a unique form of resilience
and adaptability. Thus, there is a need to switch the
traditional humanitarian learning hierarchies to position
Palestine and other conflict affected countries as a site of
knowledge production from which others can learn where
maternal care can advance despite conflict. Moving
forward, international actors must rethink the role of aid
in fragile health systems. Despite the well intentions of
assistance, it reinforces dependency and undermines local
capacity by flooding the Palestinian system with short
term emergency solutions. True solidarity lies in
supporting Palestinian-led health initiatives and financing
community-based infrastructure to disrupt power
dynamics.
Settler colonialism isn’t just a historic event but a
reshaping of land and services to serve the settler population. This manifests through the criminalisation of
motherhood where women are subjected to violence and
neglect during pregnancy resulting in preventable and
unjust health outcomes. These are not health system
failures but direct outcomes of settler colonialism which
cannot be improved without sovereignty and liberation.
Policies dictating this medical apartheid do not simply
create gaps in care but decides the value of lives. Until
Palestinians can determine the conditions of their own
care, free from occupation and control, health outcomes
will always remain a reflection of broader systems of
domination.
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