Beyond the Battlefield: The Hidden Impacts of War on Maternal Health and The Cost of Academic Indifference

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By: Elnaz Guivatchian MPH MD(c), Elnaz earned her MPH in Health Promotion from the University of Southern California and is currently a second-year medical student at Wayne State University.; Lara Rostomian MS MD(c), Associate Director of the Maternal Health Taskforce. Lara earned her MS in Epidemiology from the Harvard T.H. Chan School of Public Health and is currently a second-year medical student at Wayne State University.

An Armenian mother in Nagorno-Karabakh holds her baby
A mother in Nagorno-Karabakh, who is one of thousands at risk in the war-torn region in Armenia | Emile Ghessen | @emileghessen

Disease outbreaks, healthcare system disruptions, and the displacement of populations: these are just a few of the acute symptoms of armed conflict. But the consequences of war extend and reverberate across generations, amplifying the impact of violence and destruction far beyond the battlefield. It is increasingly clear that armed conflict represents not only a humanitarian crisis, but also a public health emergency. In fact, the burdens of conflict are disproportionately borne by maternal and child populations, whose health is dependent on regular access to functioning healthcare systems, leaving them deeply vulnerable in times of war.

Barriers to Studying Armed Conflict as a Public Health Crisis

Despite mounting evidence of the devastating impact of armed conflict on public health, the academic community has been slow to fully engage with this issue. Why is that? In part, this gap is due to logistical factors; the destruction of health infrastructure and health information systems during times of conflict compromise a healthcare system’s capacity to respond to the direct and indirect health consequences of conflict and lead to the fundamental challenge of quantifying health impacts of conflict on the population.

However, let’s be honest: the academic community’s reluctance to engage with armed conflict as a public health crisis often boils down to a fear of politicization. Given armed conflict’s staggering contribution to the global burden of disease throughout human history, ignoring or downplaying the political dimensions of this issue may come at a steep cost. Indeed, failing to engage with the political drivers of armed conflict may result in critical gaps in our knowledge and limit our ability to develop effective strategies to mitigate the health consequences of war. 

The Combined Impact of War and COVID-19 on Maternal Health in Armenia

Research conducted in the first half of 2020 revealed that besides the major impact it had on population health, the pandemic also had significant economic and political implications that altered the opportunity structures pertaining to armed conflicts and presented new obstacles to health diplomacy. One notable example is the 2020 war between Armenia and Azerbaijan over the territory of Nagorno-Karabakh, which erupted during the pandemic and resulted in significant casualties and displacement of the Armenian civilians who historically occupied the lands. Already burdened as one of the countries with the highest prevalence of COVID-19, cases in Armenia increased 8-fold during the war.

The war-related surge of COVID-19 in Armenia as well as the influx of wounded soldiers put the Armenian and Nagorno-Karabakh healthcare systems under severe strain and created barriers to care for new and expectant mothers. Physicians and humanitarian aid workers on the ground in Armenia reported noticing a shift in Armenian mothers’ priorities during the war, including a decrease in health-seeking behaviors as they prioritized the allocation of healthcare resources to wounded soldiers, and adopting a perspective that healthcare services should be conserved for those directly affected by the conflict. Additionally, key informants noted a unanimous concern regarding the effects of stress and grief on maternal health and pregnancy outcomes, noting anecdotally an increase in miscarriages, premature births, and adverse pregnancy outcomes.1

Since December 12, 2022, Azerbaijan has maintained a blockade of the Lachin corridor, Nagorno-Karabakh’s only humanitarian lifeline to Armenia and the rest of the world, leaving 120,000 indigenous ethnic Armenians without food, fuel, medicine, or other humanitarian supplies and aid. The public health impacts of this conflict continue to persist and pose a great threat to maternal health. Pregnant women’s health and maternal health are at risk due to shortages of essential medical supplies in conflict-affected areas. These essential items include medicines, hygiene products, baby essentials, and incubators, causing hospitals to struggle to provide adequate care. The shortage of resources and poor conditions of the maternity ward are causing significant fear and uncertainty for pregnant women giving birth under difficult conditions.

The Burden of Conflict and Sanctions on Maternal Health in Iran 

The Nagorno-Karabakh conflict, unfortunately, is not the only unrest in the Middle East affecting maternal and child health today. In 1978, tensions in Iran led to an Islamic Revolution in an attempt to overthrow what many felt was an authoritarian government. Since then, the political landscape of Iran has changed, including the establishment of new laws at great detriment to women, such as the compulsory hijab law for women above the age of 9 years old. This has been enforced in an inconsistent and often devastating manner

On September 16, 2022, 22 year-old Jina “Mahsa” Amini was killed by the morality police while in custody for not following the compulsory hijab, despite covering her hair at the time. This was the catalyst for several months of conflict between the people of Iran, mostly young women, and the theocratic, authoritarian government. The slogan of these protests became “women, life, freedom”, capturing the world as one of the largest women-led protests in history. The Iranian government, however, swiftly reacted to these protests, and most recently started attacking young women not only protesting in the streets, but also protesting in schools. 

Despite the persecution and violence they face, the Iranian Women’s Liberation Movement has been a driving force behind improvements in maternal health. The movement advocates for gender equality and reproductive rights, and has successfully campaigned for increased access to family planning services and improved maternal healthcare services. As a result of these efforts, maternal mortality rates in Iran have decreased by 67% between 2000 and 2017. While these improvements in maternal mortality are worth celebrating, there remains much to be done.

External factors also put Iranian maternal and child health at risk. There are several severe sanctions that restrict the Iranian people’s access to medications and healthcare supplies. Since the 1980s, Iran has been economically sanctioned in several waves, with the most recent sanctions being re-enacted in 2018 by former United States President Donald Trump. These sanctions directly affect many groups, but specifically women and young children. It was reported that as a result of these sanctions, the price of infant formula increased 14-fold, and access to other medications were severely restricted. The Iranian government’s inability to reach international agreements with several countries has forced it to fall victim to these sanctions, with women and young children bearing the brunt of the negative outcomes. 

Ultimately, these conflicts disproportionately affect women, and pose a threat to female and maternal health. Lack of resources as a result of conflict leads to worse health for women, especially those in rural areas of Iran. One post-revolution study found that even though the number of hospitals has increased since the revolution, women are still less likely to have access to adequate healthcare. This inability to access medical care led to deficient prenatal and postnatal care in these women, with a disproportionate effect on women living in rural Iran. In short, conflicts and international sanctions ultimately lead to worse health outcomes for women.   

A Call to Action

As academics and public health practitioners, we cannot let fear of politicization drive us away from addressing the devastating impact of conflict on maternal health. Research is a powerful tool for advocacy. By conducting and disseminating research on the health impacts of conflict, we can generate evidence-based policies to help enact change, garner support, and raise awareness. We have the power and responsibility to advocate for these crisis-affected populations who are otherwise neglected when setting the global health agenda.

1 Data collected by Lara Rostomian MS, MD(c) for her Masters thesis submitted to the Harvard T.H. Chan School of Public Health Department of Epidemiology. Publication Forthcoming