Regional Inequalities in Maternal and Neonatal Health Services in Iraq and Syria From 2000 to 2011

Abstract

We analyze regional inequalities in access to maternal and neonatal health services in Iraq and Syria during the period 2000–2011, before the rise of the Islamic State in Iraq and Syria, ISIS. Utilizing nationally representative survey data (Iraq 2000, 2006, 2011; Syria 2006, 2009), we examine changes in the rate of babies weighed at birth and women delivering at home. We calculate 4 regional inequality indicators: (1) extremal quotient, (2) interquartile quotient, (3) coefficient of variation, and (4) systematic component of variation. Despite national improvements in both countries over time, indicators show increasing regional inequalities in access to maternal and neonatal health services, particularly in Syria between 2006 and 2009. Spatial regression results indicate that these inequalities associate with inequalities in maternal education, rurality, and wealth. Regions where women experienced deteriorating access over time, reflecting overall inequalities, are those that fell under the control of ISIS. Inequalities in access to basic services (education and health) deserve more attention in understanding social and political change in the Arab region.

Keywords

regional inequalities access to health services Iraq Syria

Background

The Islamic State in Iraq and Syria (ISIS) stormed onto the world stage after its members began carrying out terrorist attacks in European cities. ISIS, however, has been in the making for many years in the peripheral regions of Iraq and Syria, establishing a territorial stronghold and recruiting disenfranchised youth to its ranks. Recent books and articles abound on the political and ideological roots of ISIS, providing competing explanations as to how the group was able to control vast geographic areas in the 2 countries. With the exception of a few journalistic accounts (e.g., see Napoleoni¹ or Tankersley²), however, writings have overlooked an important determinant of the ISIS phenomenon – rising regional inequalities in access to services and resources and the marginalization of large segments of the Iraqi and Syrian populations. Notwithstanding the importance of colonial interests and global political agendas, we propose that regional inequalities was a “threat multiplier,” further fueling sectarian bloodshed in Iraq and civil war in Syria. Inequitable economic policies and disinvestments in the public sector in both countries resulted in increased unemployment among young men in peripheral regions,^3,4 thus facilitating their recruitment as ISIS fighters.

These policies also affected Iraqi and Syrian women for whom disinvestments in the public sector translated into limited access to education and health services and increasing economic dependency on men in their families.⁵ This dependency accentuated patriarchy and paved the way for an anachronistic “return to the Caliphate” ideology. In this study, we trace the status of women in Iraq and Syria in the decade preceding the rise of ISIS, focusing on women’s ability to access basic maternal and neonatal health services. Utilizing nationally representative data, we examine changes in regional inequalities in 2 maternal and neonatal health measures between 2000 and 2011 – rates of women whose babies were not weighed at birth and rates of women who delivered at home. The evidence presented exposes stark and expanding geographic inequalities in these basic health services leading up to 2011. The analysis was driven by a desire to provide a new, explanatory lens to the rise of ISIS through tracing the inextricable link between inequalities and women’s health during times of social and political change.

Political Change and Health Inequalities

Studies on the association between political change and health inequalities have been based on either macro-level comparisons between countries that have different political systems – e.g., neoliberal versus social democratic regimes⁶ – or longitudinal studies focusing on countries undergoing political change – e.g., a formerly socialist country transitioning into a capitalist economy.⁷ To date, 2 systematic reviews have been conducted to describe the empirical evidence on how political traditions or welfare state characteristics determine inequalities in population health.^8,9 Informed by frameworks from social epidemiology and political sociology, Beckfield and Krieger⁸ examined evidence published between 1992 and 2008 on the interconnections between politics, inequality, and health. The body of research was grouped into 4 main themes: “(1) the transition from a command economy to a capitalist economy (command economy is a system where a central government, often communist, controls economic decisions, as opposed to a free market.); (2) neoliberal restructuring of economic regulations; (3) welfare states and welfare regimes; and (4) the political incorporation of subordinated racial/ethnic and indigenous groups and women.” (p. 5) Studies on formerly socialist states have shown that health inequalities generally expand after transitioning from socialism to capitalism. By contrast, the adoption of neoliberal restructuring policies in Northern European countries has had a mixed effect on health inequalities.

Using a political economy of health framework, Muntaner et al.⁹ reviewed a total of 73 studies to identify the political factors and mechanisms that associate with better population health outcomes. The overarching conclusion of their review confirmed that egalitarian political traditions produce the most salutary conditions. Specifically, advanced social democracies (characteristic of Northern European countries) exhibited the best population health indicators, whereas late democracies (Southern European countries which lived through authoritarian regimes after World War II before transitioning to democracies) exhibited inconsistent health outcomes. The review also included a small number of studies on health inequality in post-socialist countries (Eastern and Central European countries); those showed that inequalities increase during the initial phase of transitioning into a capitalist economic system but later normalize.

Research that monitors trends in health inequalities in response to political change in the Arab region is scarce. Only a handful of studies have examined the effects of macro-level political factors on health, mainly focusing on the rise in mortality in the aftermath of the United States invasion of Iraq¹⁰ and the effects of Israeli military occupation and policies on Palestinian mental health and access to health care services.^11,12 Through investigating changes in regional inequalities in maternal and neonatal health services in Iraq and Syria between 2000 and 2011, we hope to fill a void in the burgeoning literature on political conflict and health in the Arab region, which has rarely addressed how inequalities intertwine with political change and lead to violent conflict. We also hope to provide new insights on the living conditions of Iraqi and Syrian populations during the decade preceding the appearance of ISIS on the world scene.

During the first decade of the 21st century, Iraq experienced bombardment, economic sanctions, an authoritarian political regime, and sectarian conflict.¹³ While Syria seemed to be faring well, the discontent of poor and rural populations was simmering underneath the surface as haphazard neoliberal economic reforms, coupled with authoritarian rule and corruption, increased poverty and regional inequalities.^3,14 Presenting a detailed history of Iraq and Syria is beyond the scope of this paper. However, we provide in the following section an overview of recent political transformations that led to increasing economic and social inequalities, disproportionately affecting the health of women and children.

Health and Social Welfare in Iraq and Syria

Although authoritarian dictatorships ruled over Iraq and Syria for decades, the 2 regimes have historically espoused a social welfare system, which promised large-scale and state-sponsored education and health services.^15,16 The concept of social welfare is embedded in the Ba’th party’s ideology (Ba’th is the Arabic word for renaissance), which was born in Syria in 1947 and expanded into Iraq in the 1950s. Ba’thist ideology is, in theory, secular and calls for establishing a large welfare sector to reduce inequalities. Initially, Hafez al-Assad, who rose to power in Syria in 1970 after leading a “bloodless coup d’état,” and Saddam Hussein, who formally assumed the presidency in Iraq in 1979, expressed strong commitment to rural development and regional equalization in education and health services.

As one of the strategies of Ba’th was to broaden its support base, educational institutions were used as sites to indoctrinate young members; as such, both regimes invested in expanding educational opportunities for both boys and girls in rural areas. United Nations indicators show that educational achievements for girls and women in Iraq and Syria steadily improved during the most prosperous decades of the Ba’th.^17,18 The health system was also the focus of attention during the early years of the 2 regimes.

In Syria, recruiting medical students from rural regions was employed as a strategy to reduce regional inequalities in health services, although evidence from the early 1980s raised doubts about the strategy’s success.¹⁹ Aggregate data on Syria showed consistent improvements in education and health for decades under authoritarianism. Specifically, government statistics show dramatic declines in poor maternal and neonatal health outcomes between 1970 and 2009. For example, the infant mortality rate (per 1,000 live births) dropped from 132 in 1970 to 17.9 in 2009, and the maternal mortality ratio (per 100,000 deliveries) dropped from 482 in 1970 to 52 in 2009.²⁰ Regional inequalities, which reflect the distribution of poverty and the ethno-religious composition of the population, were concealed in official accounts.^4,21 These inequalities translated into inequitable distribution of health services and resources across regions and the expansion of private services.²⁰

During the 1970s and 1980s, the Iraqi health care system was lauded as one of the best in the Arab region, providing free health care in hospitals and primary health care clinics.²² Decades of conflict (starting with the war with Iran 1980–1988), sanctions (1991–2003), and occupation by the United States and coalition forces (2003–2011) severely weakened the Iraqi health system. The sanctions in particular exposed the fragility of this system and had a devastating impact on child mortality rates.²³ With an infant mortality rate of 31 per 1,000 live births in 2013, Iraq did not achieve the 2015 Millennium Development Goal 4 on reducing child mortality.²²

Recent comprehensive scholarly writings advance that stark inequalities existed in Iraq throughout and hid behind propagandistic accounts. Al-Ali and Pratt’s¹⁷ historical tracing of the status of Iraqi women revealed that only urban middle-class women were able to draw on the benefits of the modernization policies of the Iraqi regime in the 1970s and 1980s, while poor and rural women were left behind. In particular, Shi’a women in the South and Kurdish women in the North suffered from the brutality of the regime and from increasing conservatism regarding gender roles in their own communities. Women’s status in Iraqi society took a particularly negative turn during economic sanctions (1991–2003). Al-Ali and Pratt¹⁷ describe the disastrous impact of the sanctions on women in particular:

Aside from the most obvious and devastating effects, related to dramatically increased child mortality rates, widespread malnutrition, deteriorating health care and general infrastructure, unprecedented poverty, and an economic crisis, women were particularly hit by a changing social climate. The breakdown of the welfare state had a disproportionate effect on women, who had been its main beneficiaries.^17(p46)

In response to the sanctions, Saddam Hussein, in an effort to remain in control, launched a rallying cry against the West that fanned the flames of religious identities.¹³ Political Islam became a major shift away from the previously purported secular, socialist identity of the state and contributed to changing the discourse about women’s rights.

As in Iraq, the political history of Syria has been dominated by the Ba’th rhetoric of secularism and socialism. In 2000, Bashar al-Assad inherited Syria, after the death of his father, and set on a project of “authoritarian upgrading” giving a new, neoliberal face to the regime.²¹ To consolidate his power, he engaged in a “balancing game” in which he sought to maintain the privileges of a powerful urban elite, while at the same time seeking out the loyalty of the rural masses in peripheral regions.¹⁴ The little economic growth achieved in the early 2000s was offset by an increase in poverty rates in rural areas and rising unemployment, particularly among the young.^3,4 A 2009 estimate put 32% of rural residents at or below the poverty line, which is markedly higher than that in urban areas.²⁴ The out-migration of low-skilled workers to Lebanon and the Arab Gulf countries served as a safety valve for some time. However, a series of unexpected events that hit the agricultural sector, coupled with the institution of new liberal economic policies that favored the service sector, contributed to economic and regional inequalities.

These inequalities disproportionately affected Syrian women in less-developed and agricultural regions. Alsaba and Kapilashrami⁵ trace how haphazard policies in the 2000s led to a cascade of events that lowered Syrian women’s agency and increased their vulnerability to violence. Lack of social protections for informal workers and neoliberal policies that favored the service sector led to a drop in women’s employment in the agriculture sector. This contributed to higher social and economic dependency of women on men, particularly in the less developed regions. The authors go further in stating that the Syrian regime, despite its secular rhetoric, strengthened religious parties by giving them more power to govern the lives of women in local communities, reinforcing patriarchy, and decreasing women’s mobility and access to services and rights.⁵

Methods

Data

We used nationally representative, cross-sectional data on ever-married women aged 15–49 from UNICEF’s Multiple Indicator Cluster Surveys (MICS) and from the Pan-Arab Project for Family Health Surveys (PAPFAM). We selected all available surveys for Iraq and Syria, namely MICS Iraq 2000,²⁵ MICS Iraq 2006,²⁶ MICS Iraq 2011,²⁷ MICS Syria 2006²⁸ and PAPFAM Syria 2009.²⁹ Iraq and Syria are constituted of 18 and 14 governorates (regions), respectively. Women’s sociodemographic characteristics by region and survey-year are presented in Supplemental Appendix A. The 2 variables considered are (1) the rate of women whose babies were not weighed at birth and (2) the rate of women who delivered at home. Both variables were calculated per 1,000 women who gave birth in the 2 years preceding each survey.

Analysis

This subsection outlines the methodology employed to measure regional inequalities in maternal and neonatal health services in Iraq and Syria, at different time points between 2000 and 2011. We first calculated age-adjusted rates for the 2 health care services considered (namely, the rates of women whose babies were not weighed at birth and the rates of women who delivered at home) at the regional level. We then calculated a series of regional disparity indicators based on the age-adjusted regional-level rates previously computed. Finally, we implemented a spatial regression framework to determine the factors that influence the regional disparity, if any, in the 2 health care services considered. This methodology has been commonly used in the health economics and public health literatures (see, for instance, Weeks and colleagues³⁰). Although initially designed to investigate geographic variation in health care services utilization,^31,32 this methodology can also be used to analyze geographic variation in health outcomes.³³

Population-adjusted regional-level rates

We first calculated the population-adjusted rates of women whose babies were not weighed at birth and of women who delivered at home. These rates were computed for the 18 Iraqi governorates and the 14 Syrian governorates, respectively. In further analysis, we also computed population-adjusted rates for the 102 districts of Iraq (when data are available). We used an indirect method to compute population-adjusted rates.³⁴ The indirect adjustment was meant to correct for demographic differences between populations of different governorates or districts. In our case, the age-structure of the population of women was taken into consideration. We calculated population-adjusted rates per 1,000 women at the regional level (and at the district level, when available), as well as national rates, for each survey year.

Indicators of geographic variation

We then calculated several indicators of geographic disparities based on the population-adjusted regional-level rates previously computed. Following the methodology outlined by the Dartmouth Atlas Project,³⁴ we measured geographic variation using (1) the extremal quotient, measured as the ratio of the highest regional rate to the lowest; (2) the interquartile ratio, which is the ratio of the 75th to the 25th percentile; (3) the coefficient of variation, computed as the standard deviation divided by the mean; and (4) the systematic component of variation (SCV), calculated by subtracting the random component of variation from the estimate of total variance. As is common, we multiply the SCV by 10 to ease the interpretation of the results. Hence, an SCV greater than 5 would indicate high geographic variation, and an SCV greater than 10 would indicate very high variation.

For the abovementioned measures of geographic variation, the higher the value, the greater the variation. However, contrary to the first 3 measures, the SCV is not affected either by extreme values or by the random variability within each region.³² These measures of geographic variation are suitable for comparison between different countries, or in the same country at different points in time.

Spatial regression framework

Finally, we carried out a spatial regression analysis to determine the factors that influence the geographic variation in maternal and neonatal health services, if any. This technique addresses the issues associated with the presence of spatial autocorrelation in the data, that is, the influence of neighboring geographic regions. Spatial regression models allow taking into account the spatial dependence of the data, which is likely to arise when data is collected in regions located in space.^35–39 More specifically, we implemented a spatial lag model, that is, a model containing a spatially lagged dependent variable. As spatial regression models require a sufficiently large number of geographical units to yield accurate estimates, we could not take the governorates (18 for Iraq and 14 for Syria) as geographical units. Hence, we were able to perform this analysis on the 2011 wave of Iraq MICS only, because it is the only survey for which the information about the district of residence was collected (Iraq has 102 districts). In turn, the dependent and explanatory variables were calculated at the district level. The district-level rate of women whose babies were not weighed at birth was taken to be the dependent variable in a first set of spatial regressions, and the district-level rate of women who delivered at home in a second set.

To determine whether the spatial regression technique is needed, we performed a likelihood ratio test for spatial dependence to test the presence of spatial autocorrelation. If the null hypothesis of spatial independence is rejected, a spatial regression model has to be employed, while if the null hypothesis is not rejected, a standard ordinary least squares regression can be used. In the case where the spatial regression technique was employed, we used a queen-based contiguity spatial weights matrix, for which a neighboring district is defined as a district with a shared border or vertex (see Anselin⁴⁰ and Anselin and colleagues³⁸ for further methodological details).

Results

Geographic Variation

Table 1 presents national age-adjusted rates, the lowest and the highest regional rates, and the 4 indicators of geographic variation in the 2 health care services considered. This is shown for each survey. National rates indicate that the overall access to maternal and neonatal health services have improved in both countries. On average, the rate of women whose babies were not weighed at birth decreased by 35.9% between 2000 and 2011 in Iraq and by 17.2% between 2006 and 2009 in Syria. During the same time periods, the rate of women who delivered at home decreased by 52.9% in Iraq and by 25.4% in Syria. However, although results show an overall improvement in access to maternal and neonatal health services, observed at the national level, they also show a dramatic increase in regional disparities during the same time periods. Indeed, each of the 4 measures of geographic variation across Iraqi and Syrian governorates increased over the survey years considered (2000, 2006, and 2011 for Iraq and 2006 and 2009 for Syria). In Iraq, the SCV, which was relatively low in 2000 (<5 for the 2 health services considered), had increased substantially by 2011 (>10 for the rate of women whose babies were not weighed at birth and >20 for the rate of women who delivered at home). The box plots in Figure 1(A) also illustrate the pattern for Iraq. In Syria, in 2006, the 4 measures of geographic variation reveal dramatic regional disparities in access to maternal and neonatal health services. The geographic variation in the 2 health services considered then increased dramatically between 2006 and 2009, as can be seen in Figure 2(A).

Table 1.

Indicators of Geographic Variation (at the Regional Level) in Maternal and Neonatal Health Services in Iraq and Syria.

	Babies Not Weighed at Birth			Delivered at Home
Iraq	2000	2006	2011	2000	2006	2011
National age-adjusted rate per 1,000	590.46	483.97	378.74	553.55	356.20	260.52
Lowest regional rate per 1,000	404.09	301.07	155.28	366.06	240.93	107.41
Highest regional rate per 1,000	787.59	669.61	547.05	750.55	582.57	399.20
Extremal quotient	1.95	2.22	3.52	2.05	2.42	3.72
Interquartile ratio	1.19	1.62	1.65	1.33	1.42	2.18
Coefficient of variation	0.17	0.26	0.31	0.21	0.24	0.40
Systematic component of variation (×10)	2.35	7.35	14.26	3.98	4.84	22.13
Syria		2006	2009		2006	2009
National age-adjusted rate per 1,000		431.92	357.83		293.43	218.91
Lowest regional rate per 1,000		67.05	18.34		59.06	8.49
Highest regional rate per 1,000		751.05	756.67		463.35	470.96
Extremal quotient		11.20	41.25		7.85	55.48
Interquartile ratio		2.82	5.49		1.37	6.66
Coefficient of variation		0.58	0.79		0.40	0.84
Systematic component of variation (×10)		70.71	206.00		31.40	198.35

Figure 1.

Geographic variation (at the regional level) in maternal and neonatal health services in Iraq. A, Change over time. B, 2000. C, 2006. D, 2011. E, 2011 (district level). Note: Regional rates are computed per 1,000 women who gave birth in the 2 years preceding each survey. Regions in darker shades are worse-off with respect to access to maternal and neonatal health services.

Figure 2.

Geographic variation (at the regional level) in maternal and neonatal health services in Syria. A, Change over time. B, 2006. C, 2009. Note: Regional rates are computed per 1,000 women who gave birth in the 2 years preceding each survey. Regions in darker shades are worse-off with respect to access to maternal and neonatal health services.

Maps of the population-adjusted regional-level rates calculated for each survey are shown in Figure 1 (Iraq) and Figure 2 (Syria). Based on their rate of access to maternal and neonatal health services, regions are divided into quintiles. Regions in darker shades are worse-off with respect to access to maternal and neonatal health services. For instance, for the rate of babies not weighed at birth in 2011 Iraq, Al-Anbar region is shown in the darkest shade (the poorest quintile), corresponding to a rate of babies not weighed at birth between 491 and 547 per 1,000 women who gave birth in the 2 years preceding the survey.

In Iraq, the 2 western governorates of Al-Anbar, which came under the control of ISIS in 2013, and Nineveh, the governorate whose capital Mosul was overtaken by ISIS in 2014, experienced a decline in access to services over time. The maps show an increase in the rate of babies not weighed at birth between 2006 and 2011 and a gradual increase in the rate of home deliveries from 2000 to 2006 and from 2006 to 2011. The maps also show a gradual decline in access to services in Nineveh, with the rate of babies not weighed at birth increasing gradually from 2000 to 2011 and the rate of home deliveries increasing between 2000 and 2006 and plateauing afterwards. On the other hand, access to maternal and neonatal health services in northeastern regions (e.g., Dohuk and Sulaymaniyeh) and central Iraqi regions (e.g., Karbala and Babel) either remained the same or improved over time.

Figure 2 shows change in population-adjusted rates in Syria between 2006 and 2009. At both points in time, the northern and eastern governorates of Deir Ezzor, Al-Hasaka, Al-Raqqa, and Aleppo (which came under ISIS control shortly after 2011) are displayed in noticeably darker shade than western and central governorates (which remained under the control of the regime). With the exception of Al-Hasaka, which experienced a decrease in home deliveries (an improvement), the maps display either lack of improvement (Aleppo) or a sharp deterioration (Al-Raqqa) in access to maternal and neonatal health services during the 3-year interval between 2006 and 2009. Al-Raqqa was the site of fierce battles between Islamist groups and the regime and has become known as the “capital of the Caliphate.” Conversely, the governorates of Damascus, Latakia, and particularly Tartous, which remained under the tight control of the regime since the war erupted, are displayed on the map in lighter shade, indicating better access to health services compared to peripheral regions.

We also present maps of Iraq at the district level – a more refined scale – for the year 2011, which is the only survey for which the information about the district of residence was collected. Here, the population-adjusted rates are calculated using a smaller geographical unit, that is, the 102 Iraqi districts. The maps of Figure 1(E) reveal that the most disadvantaged districts are concentrated in the west and south of Iraq.

Spatial Regression Results

As spatial regression models require a sufficiently large number of geographical units to yield accurate estimates, we were able to perform this analysis on the 2011 wave of Iraq MICS only, in which the information about the district of residence was collected. Model 1 includes as explanatory variables the proportion of women with no formal education in each district and that of women living in rural areas. Model 2 adds to these explanatory variables the proportion of women in the lowest wealth quintile. The district-level rate of women whose babies were not weighed at birth is used as the dependent variable in the first set of spatial regressions. The dependent variable in the second set of spatial regressions is the district-level rate of women who delivered at home.

The results displayed in Table 2 reveal that the results remain qualitatively the same using either of these 2 dependent variables. For all models, the spatial lag term is significant and the likelihood ratio test for spatial dependence indicates the presence of spatial autocorrelation, confirming the need to use spatial regression models. Hence, the dependent variables are partially explained by the outcomes in neighboring districts. The estimated coefficients in Table 2 are consistent with theoretical considerations and other related empirical studies on the factors associated with the access to maternal and neonatal health services (see, for instance, Bulatao and Ross⁴¹ and Ahmed and colleagues⁴²). Model 1 indicates that the lack of access to these services is positively and significantly associated with the proportion of women with no formal education and with that of women living in rural areas. However, model 2 indicates that this geographic variation is mostly driven by economic considerations. Wealth disparities across districts seem to be the main factor associated with the substantial geographic variation in access to maternal and neonatal health services observed in Iraq.

Table 2.

Results of Spatial Regression Analysis for the 102 Districts of Iraq in 2011.

Dependent Variable	Population-Adjusted Rate of Women Whose Babies Were Not Weighed at Birth		Population-Adjusted Rate of Women Who Delivered at Home
	Model 1	Model 2	Model 1	Model 2
Explanatory variables
Proportion of women with no formal education	292.625**	83.043	293.905***	55.266
Proportion of women with no formal education	(129.455)	(163.202)	(104.460)	(128.193)
Proportion of women living in rural areas	216.193***	114.447	170.061**	54.421
Proportion of women living in rural areas	(83.670)	(96.483)	(67.082)	(75.997)
Proportion of women in the lowest wealth quintile		274.423**		312.485***
Proportion of women in the lowest wealth quintile		(136.891)		(108.296)
Constant	58.839	73.989	22.826	38.341
	(58.113)	(58.327)	(44.175)	(43.655)
Spatial lag term	0.383***	0.375***	0.353***	0.346***
	(0.122)	(0.122)	(0.124)	(0.122)
Statistics
Likelihood ratio statistic of spatial dependence	10.261	10.035	7.839	7.892
P value	.001	.002	.005	.005
Adjusted r²	.228	.257	.237	.295
Number of observations	102	102	102	102

The symbols ** and *** indicate statistical significance at the p < .05 and p < .01 levels, respectively. Reference categories for the explanatory variables: proportion of women with at least primary school education; proportion of women living in urban areas; proportion of women in higher wealth quintiles. Standard errors in parentheses. Maximum likelihood estimation. Spatial weights matrix: first-order queen-based contiguity matrix.

Discussion and Conclusions

In this study, we examined regional inequalities in access to health services in Iraq and Syria during the first decade of the 21st century. Our aim was to explore, through a social inequalities lens, changes in access to basic services in peripheral regions in the 2 countries prior to the rise of ISIS. The results of our study reveal remarkable regional inequalities in access to maternal and neonatal health services at baseline (2000 in Iraq and 2006 in Syria) and in subsequent years. Furthermore, despite national improvements in access to these services over time, the analysis reveals a dramatic rise in regional inequalities. This trend was consistently observed in both Iraq and Syria irrespective of the geographic variation method used. The results of the spatial regression analysis (which was limited to Iraq) also show an association between access to maternal and neonatal health services and education, rurality, and wealth. Worse-off regions with respect to access to maternal and neonatal health services have lower maternal education, higher rurality, and lower living standards compared to better-off regions. Hence, geographic variation in maternal and neonatal health services reflects underlying inequalities by socioeconomic factors.

The findings revealed by our analysis should not be surprising to anyone who has kept up with recent historical events in Iraq and Syria, particularly the dramatic political and social changes taking place between 2000 and 2010. Although the 2 countries experienced different political trajectories up until 2011, both constitute prime examples of how haphazard and neoliberal economic policies in much of the developing world have increased social and health inequalities. The trend of rising health inequalities revealed in our study does not differ much from trends observed decades earlier in formerly socialist European countries that transitioned into capitalist economies,^8,9 albeit with the exception of the resultant descent into bloodshed and political chaos in the cases of Iraq and Syria.

In Iraq, after the economic embargo was lifted in 2003, the United States deliberately sought to reform the country’s political and economic systems along neoliberal lines through sidelining state institutions and opening the door to private investments.⁴³ Coming out of the devastation of the economic embargo, Iraqis faced a new reality put in place during the short-lived United States occupation, where political power became distributed along ethnic and religious lines, and sectarian violence became a common-day occurrence. Although Iraqis experienced enormous political violence under Saddam’s rule, a new atmosphere of open sectarian violence resulted in population displacement and the increasing threat of violence against women in public spaces.¹⁷ While this affected all Iraqi women, it had a particularly negative impact on the mobility of rural and disadvantaged women in certain governorates. Moreover, neoliberal policies further weakened a dilapidated social welfare system, whose main beneficiaries were women and children, which reduced women’s ability to access maternal and neonatal health services. Thus, it should not come as a surprise that women in peripheral regions such as Al-Anbar, which was the site of an insurgency against the United States occupation and sectarian violence afterwards, experienced worsening access to maternal and neonatal health services while women in central regions had generally better access.

In Syria, on the other hand, with the coming of Al-Assad (the son) into power in 2000, the country transitioned from a populist authoritarian social welfare regime to a system built on balancing traditional regime powers with new “social market” policies that, over time, became indistinguishable from neoliberal economic policies. This sudden shift, as Hinnebusch²¹ described in an article published shortly after the onset of the 2011 Syrian uprising, weakened the legitimacy of the regime while at the same time created a cascade of economic factors that contributed to public sector decline. Disinvestments in the public sector led to reduced spending on health, education, and social security, and a shift of responsibility for social protection to charities and tribal or religious leaders.^5,14 Against this backdrop, it is not surprising to observe the trends revealed by our study, whereby women in peripheral regions experienced diminished access to basic maternal and neonatal health services between 2006 and 2009. This time period, despite its short span, reflects a critical moment in the maturation of neoliberal economic policies and coincides with the unfortunate drought that began in 2007 and affected the livelihood of the vast majority of Syrian agricultural workers.³ Thus, women’s decreasing access to maternal and neonatal health services during these 3 critical years is an outcome of a combination of factors – shrinking public health services in rural and peripheral areas and women’s reduced agency due to their increasing economic dependency on men and the rising power of religious leaders and institutions in local communities.

Our study was influenced by a number of data limitations. The first is the unavailability of data for Syria before 2006. In contrast to Iraq, where we analyzed 3 national data sets (2000, 2006, and 2011), we were only able to examine change in regional inequalities in Syria over the span of 3 years, between 2006 and 2009. We were not able to include in our study the Syria 2001 PAPFAM survey because information on the place of delivery and babies not weighed at birth were available for only 15% and 10% of the sample, respectively. This unfortunately impeded our ability to show change in Syria since 2000, the year when the regime began to introduce neoliberal economic policies that expanded regional inequalities. The data sets we used also did not have measures related to migration or displacement in the 2 countries before 2011 – rural to urban economic migration in Syria due to the demise of the agricultural sector and population displacement within Iraq following bouts of sectarian violence. As such, we cannot ascertain whether regional inequalities may have been a result of changes in the composition of the population in certain regions. In a similar manner, regional health accounts, which are not available, would have allowed us to explore the relationship between health spending and health outcomes at the regional level. In the Middle East and North Africa region, this relationship has only been investigated at the country level.⁴⁴ Finally, because data at the district level were only available for Iraq 2011, we were only able to perform spatial regression using this survey.

Despite data limitations, our study contributes to the literature on the linkages between political change, social inequalities, and health, and provides evidence from a region in the global south that is plagued by political conflict and war. While public health research in the Arab region has rarely monitored the association between social inequalities and health, our study provides evidence on expanding regional inequalities in women’s access to health services in Iraq and Syria between 2000 and 2011. The methodology employed in the present study is relevant for investigating inequalities in access to health services in other contexts. We present a nuanced analysis that links regional inequalities in maternal and neonatal health services to political and economic changes that took place during the first decade of the 21st century and to the rise of ISIS as an alternative to authoritarian regimes and failed neoliberal economic policies that weakened the social welfare systems in both countries. That the peripheral regions in Iraq and Syria that were most impacted by ISIS in 2011 and later were also the ones that experienced diminishing access to basic health services (Al-Anbar in Iraq and Al-Raqqa in Syria) highlights the importance of adopting a political economy of health framework in a conflict-ridden region.

Supplemental Material

Supplemental material for Regional Inequalities in Maternal and Neonatal Health Services in Iraq and Syria From 2000 to 2011

Supplemental Material for Regional Inequalities in Maternal and Neonatal Health Services in Iraq and Syria From 2000 to 2011 by Sawsan Abdulrahim and Marwân-al-Qays Bousmah in International Journal of Health Services

Footnotes

Acknowledgments

The authors would like to thank Mohammad Abu-Zaineh, Sameera Musapih and Bill Weeks for helpful comments and suggestions. The authors also thank participants at the conference “No one left behind: A feasible goal for the health-related SDGs in the Arab region,” organized by the Center for Research on Population and Health in the Faculty of Health Sciences at the American University of Beirut, for their valuable feedback. The authors are solely responsible for the content of the manuscript.

Availability of Data and Material

The data that support the findings of this study are available at .

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics Approval and Consent to Participate

Our study is based on secondary data from the MICS () surveys, which are approved by national ethical committees.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was completed, thanks to the support of the A*MIDEX project (no. ANR-11-IDEX-0001-02) funded by the “Investissements d’Avenir” French Government program, managed by the French National Research Agency (ANR).

Supplemental Material

Supplemental material for this article is available online at .

Author Biographies

Sawsan Abdulrahim, MPH, PhD, is associate professor in the Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Lebanon. Her research interests include health inequities and the political economy of health.

Marwân-al-Qays Bousmah is a research associate at SESSTIM (UMR 1252), Marseille, France. He obtained his PhD in economics from Aix Marseille University and an MSc in development economics from the University of Paris 1 Panthéon-Sorbonne, France. His research interests include health economics, demography, and development economic.

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