Post-Earthquake, Women’s Health Programs in Turkey Offer a Model for Long-Term Response

When a massive 7.8-magnitude earthquake centered in Kahramanmaraş, Turkey, struck in February of 2023, Bülent Kılıç worried about women's health.

Kılıç, a professor of public health at Turkey's Dokuz Eylul University and president of its Association of Public Health Specialists, known as HASUDER, explained that maternal and reproductive health are often overlooked in the aftermath of disaster - as are the increased risks of sexual violence, women's hygiene issues, and sexually transmitted infections.

The 2023 earthquake killed more than 59,000 people in Turkey and Syria, displaced as many as 3 million, many of them already refugees from Syria. The quake caused damage and displacement across 11 Turkish provinces, which was most challenging for women and children. In the hard-hit province of Hatay alone, more than 200 camps, container cities, and other temporary settlements were created to house hundreds of thousands of displaced people.

The lack of women's healthcare "was a very big and serious problem in the camps," he said.

More than two years after the earthquake, HASUDER has found that women's health needs continue to be unmet. Women and girls in temporary settlements report increased exposure to violence, both from family members and strangers. Unsanitary conditions and a lack of clean toilets and showers have led to increased urinary tract and vaginal infections. These displaced women and girls are more likely to be forced into marriage, to experience unintended pregnancies in unsafe conditions, and to contract sexually transmitted infections.

Closed-down primary care centers and maternal health facilities have made it harder to receive prenatal care and safely give birth, significantly increasing the risk of maternal and child mortality. (While HASUDER estimates that the earthquake-affected areas can expect to see about 20,000 births per month, the current healthcare capacity is far lower.)

The organization puts it bluntly: "Disaster has a gender."

To meet women's health needs in the aftermath of the 2023 earthquake, Direct Relief awarded grant funding to HASUDER and the Turkish Family Health and Planning Foundation, or TAPV: above $655,000 to HASUDER and $375,000 to TAPV. For more than two years, these organizations continued to offer mobile women's health services, referrals, community outreach, and education in displacement camps, container settlements, and other affected communities. Today, they are focused on increasing their capacity and training for future emergency response work.

HASUDER and TAPV provided a wide range of services, from education about vaccines, birth control, and hygiene to cancer screenings and hospital referrals for high-risk pregnancies. Both organizations offered services in Turkish and Arabic, making access easier for refugee patients.

By working with local partners and authorities, surveying affected communities to determine needs and approach, and employing flexible strategies to help women access care effectively, they offer essential models for a longer-term approach to meeting health needs after a disaster.

HASUDER provided sexual and reproductive healthcare services to more than 7,200 women affected by the earthquake in Hatay Province over an 18-month period. TAPV provided healthcare services, referrals, and education to more than 8,400 women - through household visits, cancer screenings, family planning, and more - over the course of ten months.

For healthcare workers at TAPV, mobile health services and referrals to hospitals for women who were unwell or experiencing high-risk pregnancies were high priorities. Also top of mind were focus groups and in-depth conversations with women in affected communities about the services available to them.

One patient who noticed a lump in her breast during self-examination was referred to a cancer treatment center, where a high-risk mass was detected, and she was able to undergo treatment. Many women experiencing high-risk pregnancies had never sought maternal healthcare, but were willing to receive healthcare services after receiving counseling from TAPV team members.

A number of women living in container cities, interviewed about their experiences with TAPV, described learning about critical health services. Those included cancer screenings, being informed about family planning and preventing sexually transmitted infections, and understanding the importance of prenatal care and vaccines for their newborns. Women whose husbands were abusive and prevented access to contraception were able to access it by working with a reproductive health counselor.

"After the earthquake, we had actually forgotten about this information," one woman said during an interview. "More precisely, we had forgotten ourselves as women-we had forgotten how challenging gynecological health issues can be. Through this project, we became aware of these again."

Nurcan Müftüoğlu, TAPV's executive director, explained that many of the issues healthcare teams worked to resolve are rooted in culture, which doesn't prioritize women's sexual and reproductive health. Women's health needs, already likely to be overlooked in disaster situations, are even more likely to go unmet in situations where they were not already a high priority.

Many of the women whom TAPV reached are Syrian refugees, who Müftüoğlu explained are already underserved and hesitant to access health services. Transportation to health facilities, even for women eager to reach them, was often nonexistent, so TAPV worked to arrange transportation services for women needing cancer screening or other facility-based care. Many primary care facilities are heavily damaged or simply closed.

"These are more reasons for a crisis situation," Müftüoğlu said.

HASUDER nurses noted that forced marriage of girls as young as 16 - and even younger among refugee populations - is a growing problem in earthquake-affected regions because the schools are closed. "The girl child is seen as a surplus in the family," a report from nursing staff explained. Many men do not allow their wives to use contraception, or deny their wives medical treatments that they worry may damage their kidneys or cause weight gain. Misinformation is rife, and violence against women a widespread problem.

Kılıç said that the women's health needs his mobile teams encountered were huge, ranging from a lack of underwear, sanitary pads, and clean facilities to more complex issues like maternal health and gender-based violence.

Building trust was a high priority, he said. About two years ago, when HASUDER teams began providing traveling clinics in mobile medical units, it was hard to convince many women to access health services or discuss intimate issues like contraception and hygiene.

Then, things changed.

"A few months later, we noticed that at every camp there is a leader woman," Kılıç recalled. (Informal community leaders are a common presence in refugee settings, where people designate trusted community members to advocate for their interests, build vital relationships, and let them know who's safe to trust.) HASUDER's team began cultivating relationships with these community leaders, calling them before driving to a camp site to let them know what services would be available, answer questions, and cultivate a relationship.

Very quickly, Kılıç said, they began seeing hundreds of women each month.

"Every woman [leader] in every camp started to call our team," he said. They were asking, "'When will you come again?'"