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FOR HUMAN RIGHTS AND REPORTS OF THE OFFICE OF THE
HIGH COMMISSIONER AND THE SECRETARY-GENERAL
The issue of Palestinian pregnant women giving birth at Israeli checkpoints
Report of the High Commissioner for Human Rights
1. The Human Rights Council, in its decision 2/102, requested the United Nations High Commissioner for Human Rights to “continue with the fulfilment of her activities, in accordance with all previous decisions adopted by the Commission on Human Rights and to update the relevant reports and studies”. In its resolution 2005/7, the Commission on Human Rights requested the High Commissioner to report on the issue of Palestinian pregnant women giving birth at Israeli checkpoints owing to denial of access by Israel to hospitals. The Office of the High Commissioner (“the Office”) understands decision 2/102 as preserving the previous annual reporting cycle in respect of this issue, until otherwise decided by the Council. The present report to the Council accordingly addresses the developments that have occurred since the last report on this issue was submitted to the Council at its fourth session. A/HRC/4/57.
2. On 20 November 2007, the Secretary-General addressed notes verbales to the Permanent Mission of Israel and to the Permanent Observer Mission of Palestine to the United Nations Office at Geneva, in which he indicated that he would appreciate receiving any comments or observations that they might wish to submit following Commission resolution 2005/7 and the most recent report submitted by the High Commissioner on the issue of Palestinian pregnant women giving birth at Israeli checkpoints.1
3. On 11 December 2007, the Office received a reply from the Permanent Observer Mission of Palestine indicating that the Israeli practices described in a report compiled by the Palestinian Ministry of Health in early 2007 persist. It also indicates that the number of cases of Palestinian pregnant women giving birth at Israeli checkpoints recorded in that report (69 cases) remains the same. The above-mentioned Israeli practices and cases of deliveries at checkpoints were described in detail in the previous report of the High Commissioner.1
4. At the time of writing, no reply had been received from the Permanent Mission of Israel.
5. In order to gather information on the issue, the Office also wrote on 6 November 2007 to the following United Nations entities and specialized agencies represented in the Occupied Palestinian Territory: the Office for the Coordination of Humanitarian Affairs (OCHA), the Office of the United Nations Special Coordinator for the Middle East Process (UNSCO), the United Nations Development Fund for Women (UNIFEM), the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), the World Food Programme (WFP) and the World Health Organization (WHO).
6. Replies were received on 23 November 2007 from UNRWA and WHO. Both indicate that since all internal Israeli Defense Force (IDF) checkpoints were dismantled in Gaza in 2005, there were no cases of pregnant women giving birth at checkpoints in Gaza during the reporting period. In addition, WHO reports that since there was no referral for pregnancy-related conditions from Gaza to outside hospitals, no delivery was reported at the Erez checkpoint (currently the only checkpoint where patients can exit Gaza). Neither UNRWA nor WHO replies contain information concerning deliveries at checkpoints in the West Bank. However, on 3 January 2008, OHCHR received information from B’Tselem, the Israeli Information Center for Human Rights in the Occupied Territories, concerning two cases of deliveries of Palestinian women. Both women had been forced to give birth in their respective cars following the refusal of the Israeli soldiers guarding a gate north of the village of ‘Azzun ‘Atmah, which is cut off from the rest of the West Bank by the Wall, to allow them to pass to get to a hospital in nearby Qalqiliya. A first case occurred on 12 December 2007, in which the delivery took place in the car after a delay of over half an hour at the gate. In the other case, which took place on 15 December 2007, a Palestinian woman from the village began to deliver in her car at 4.30 a.m., following a delay of more than one and half hours at the gate.
7. WHO further reports that, while the number of Palestinian women giving birth at checkpoints is an important indicator, it is not sufficient to assess the accessibility of adequate medical services for pregnant women, the changing patterns of behaviour in response to mobility restrictions and their implications for the right to health. According to studies referred to by WHO,2 restricted mobility and increasing poverty have resulted in difficult situations for Palestinian pregnant women and limited access to health care. Closures (roadblocks and checkpoints) continue to have economic, medical and psychosocial implications for Palestinian pregnant women as follows:
(a) Unpredictable access to maternity services due to restrictions on movement is a determinant in medical decisions on induced labour and caesarean sections and it also discourages women from seeking quality post-natal care;
(b) Obstetricians at West Bank hospitals run by the Palestinian Authority (PA) report that complications have increased due to late arrivals after delays at checkpoints and late referrals from private hospitals for caesarean operations free of charge;
(c) Mobility restrictions impede continuity of medical care throughout the cycle of pregnancy (prenatal care, a hospital for delivery and post-natal care may not be accessible in the same location) and thus the development of a relationship of trust between medical staff and patients;
(d) Palestinian pregnant women and their families live with anxiety and stress, especially during the last period of pregnancy, of not being assured that they will be able to reach a maternity facility and to return home. Transport between the home and the hospital is a constant concern;
(e) Studies indicate that physical accessibility to services, in addition to their availability and affordability, is a factor in Palestinian women’s choice of place of birth. According to a Palestinian Central Bureau of Statistics (PCBS) survey carried out in 2004, 20 per cent of women interviewed reported that their childbirth location was not the preferred place of delivery; of those, 13.7 per cent stated that access was impeded by IDF measures;
(f) A drastic change in birth location patterns is reported even if this means a lower standard of health care, e.g. an increase in births attended at home or in doctors’ clinics. While eliminating the need for displacement, home births involve high risks if not supported by emergency obstetric care and the ability to access a hospital when needed. In the Occupied Palestinian Territory, emergency obstetric care is limited and access constitutes a vital problem with many roads blocked;
(g) Changes in utilization patterns have also had an impact on the quality of services: the higher caseloads in some maternity hospitals were generally not accompanied by an increase in the number of health providers putting further strain on PA hospitals already suffering from understaffing and overcrowding;
(h) In order to avoid having access to a maternity facility delayed or denied, pregnant women are reported to move to relatives living in towns (most of the childbirth infrastructure in the Occupied Palestinian Territory is located in urban-based hospitals) a few weeks before the expected delivery;
(i) Mobility restrictions also disrupt social relations depriving pregnant women of psychosocial support by the wider family, which in Palestinian culture and society is especially important. Close family members are not able to accompany pregnant women to hospital or often arrive late.
8. WHO further reports that according to data published in April 2007 by PCBS, the infant mortality rate has slightly increased from 24.2/1,000 live births in 2004 to 25.3/1,000 live births in 2006. The under-five mortality rate has not changed from 2004 to 2006, which is 28.2/1,000 live births.
9. UNRWA reports scarce medical facilities in Gaza, where 7 out of 17 incubators for newborn babies have not been duly maintained due to the lack of spare parts in the local market, which appears to have resulted in a decline in health standards among newborns during the reporting period. According to UNRWA, the number of infant deaths at Gaza’s main hospitals - Shifa hospital, Gaza paediatric hospital and the Gaza European hospital - was on average 20 per cent higher during the period of January-October 2007 than during the corresponding period in 2006. UNRWA also expresses concern over the significant delays of the process applicable for Gazans who require permits from the Israeli authorities to exit Gaza through the Erez crossing to receive necessary medical treatment in hospitals outside Gaza. Referring to WHO statistics indicating that it has become more difficult for Gazan patients to receive an exit permit, UNRWA reports that while 89.4 per cent of patients who applied were granted a permit between January and May 2007, during October 2007, only 77.1 per cent of applicants received permits. Long delays are particularly detrimental for patients whose conditions are critical and necessitate immediate treatment outside Gaza.
10. With regard to pregnant women in Gaza, UNRWA reports that health facilities in Gaza can provide treatment to most high-risk pregnancy women. Therefore, the number of high-risk pregnancy cases referred to hospitals in Israel or east Jerusalem from either health centres of the Ministry of Health or health centres operated by UNRWA is not high. Since February 2007, UNRWA reports that it has referred five pregnant women in need of tertiary care to Israeli hospitals. Among these, four cases resulted in maternal mortality.
2 Laura Wick, Birth at the Checkpoint, the Home or the Hospital? Adapting to the Changing Reality in Palestine, Institute of Community and Public Health, Birzeit University, 15 June 2002; Rita Giacaman et al., “The Politics of Childbirth in the Context of Conflict: Policies or de facto Practices?”, Health Policy, vol. 72, issue 2, May 2005, pp. 129-139; Laura Wick, “Childbirth in Palestine”, International Journal of Gynecology and Obstetrics, vol. 89, issue 2, May 2005, pp. 174-178; Rita Giacaman et al., “The Limitations on Choice: Palestinian Women’s Childbirth Location, Dissatisfaction with the Place of Birth and Determinants”, European Journal of Public Health, vol. 17, No. 1, February 2007, first published online 23 June 2006.