Send to

Choose Destination
Lancet. 2018 Feb 21;391 Suppl 2:S48. doi: 10.1016/S0140-6736(18)30414-8. Epub 2018 Feb 21.

Maternal and child health outcomes and intensity of conflict in the occupied Palestinian territory in 2000-14: a pseudo longitudinal analysis.

Author information

Department of International Development, London School of Economics and Political Science, London, UK. Electronic address:
Department of Social Policy, London School of Economics and Political Science, London, UK.
Institute of Community and Public Health, Birzeit University, Ramallah, occupied Palestinian territory.
Department of International Development, London School of Economics and Political Science, London, UK.



Armed conflicts can undermine a country's health-care capacity and disrupt the delivery of basic health services. Yet the public health consequences of war remain difficult to quantify, mainly because adequate data do not exist. We hypothesised that the ongoing conflict in the occupied Palestinian territory (including the restrictions on free movement and the strain on health-care services) have had detrimental effects on maternal and child health outcomes.


We reconstructed data on delivery by caesarean section and diphtheria, pertussis, and tetanus vaccination with pooled data from Demographic and Health Surveys for 2000-14. We use probit regression for binary outcomes to explain changes in caesarean sections (using data on the last pregnancy of 8700 woman aged 15-45 years) and child vaccination (using 12 600 schedules). All-age mortality of non-combatants was used to measure the intensity of conflict (the explanatory variable). Excess mortality is commonly used as a proxy for conflict intensity in the absence of more detailed data.


There is a general increase in the prevalence of all indicators (less so for caesarean sections, which increased from 10% to 20% between 2002 and 2014). Intensity of conflict is negatively associated with vaccination (β=-0·2; p<0·0001). A visual examination shows that vaccination is more susceptible to peaks in conflict intensity-prevalence increased from 65% to 80% in the years after the Second Intifada. Boys were more likely than girls to be vaccinated (β=0·31; p<0·0001). The negative association between conflict intensity and delivery by caesarean section is weaker but significant (β=-0·04; p=0·007). Education and wealth are not significant predictors for caesarean section.


The conflict spares no one: women are affected irrespective of their socioeconomic status. The closer association between vaccination and intensity of conflict might result from their dependency on specialised resources and infrastructure. The slight negative correlation with caesarean delivery during conflict could be due to the difficulty of accessing health centres that provide caesarean section. It is also possible that the rates of planned caesarean section increases during calm periods. The most acute effects occurred when conflict intensity increased or decreased sharply, which suggests that these periods are crucial for health-care provision.


Emirates Foundation through the London School of Economics Middle East Centre.

Supplemental Content

Full text links

Icon for Elsevier Science
Loading ...
Support Center