Barriers and challenges facing Iraq’s sexual and reproductive health sector

In the Middle East and North Africa (MENA) region, the youth’s sexual and reproductive behaviour is influenced by the economic, social, and cultural environments in which they are brought up in, including the dominant forces of religion and tradition, which establish gender roles and identify taboos.

Without a doubt, parents and families strongly influence children’s behaviour by administering these social norms.

At the same time, however, globalisation has created a new dimension into people’s lives, especially the youth, who have a huge ability to discover and accept new trends and technologies.

"It appears that the improvement of Iraq’s sexual and reproductive health sector still has a long way to go, especially in terms of disclosing information, receiving appropriate treatment, and education related to both of the sectors"

In recent years, a number of publications have shed light on the challenges the youth face in the MENA region, their adjustment to childhood, particularly their sexual and reproductive health – a socially delicate topic for communities in the region.

Realising the importance of addressing the needs of young people in terms of accessibility to sexual and reproductive health materials and services, a number of countries in the region are rising to the challenge.

With a key focus on Iraq’s sexual and reproductive health sector, this article brings to light some of the barriers and challenges facing the country, as well as the health risks stemming from the lack of sufficient services.

In an exclusive interview with Hayder Ali, Head of Programs at the Iraq Health Access Organization, it appears that the improvement of Iraq’s sexual and reproductive health sector still has a long way to go, especially in terms of disclosing information, receiving appropriate treatment, and education related to both of the sectors.

Sexual health sector

At present, STI testing in Iraq is a common practice among couples seeking to get tested before marriage.

STI testing requested by couples mainly takes place in Iraq’s primary healthcare centres. For individuals who do not fall under this category of society, STI testing mainly takes place in private health clinics instead.

According to Ali, the latter fragment of society fears the stigma, judgement, and culture of shame surrounding premarital sexual intercourse.

Commenting further on this issue, Ali added that travel to private health clinics away from an individual’s hometown is a preferred option amongst those who are concerned that members of staff working in primary health care centres may know the individual and possibly disclose confidential information to the individual’s family members.

The reality of Iraq’s STD testing services reinforces the notion that cultural taboos are still in place and are acting as major barriers to informed conversations about sexual health concerns, particularly with regard to those who are engaging in sexual intercourse outside of marriage.

In the MENA region, the common belief is that premarital sexual relationships are prohibited and discussing such matters about sexuality more broadly is often deemed taboo.

As is known, the silence originates in part from the high value that society places on a girl’s virginity before marriage and the idea that speaking openly about sexual and reproductive health might urge unmarried individuals to have sex before marriage.

Due to the cultural taboos, Ali explained that individuals who fear judgement and possible exposure within society are paying extortionate prices to get tested in private health clinics, whilst those who cannot afford such services, are exposing themselves to the long-term health risks that certain STIs can pose if left untreated.

Chlamydia, for example, can lead to damage to a woman’s womb and cause a serious condition called pelvic inflammatory disease (PID) if not given treatment. This is a key cause of ectopic pregnancy and infertility in women.

"One of Iraq’s biggest challenges and barriers to reproductive healthcare is the absence of a cervical cancer screening programme"

Reproductive health sector

Moving on to Iraq’s reproductive health sector, there are a number of important issues which need to be addressed, especially within the Gynecologic Oncology department.

According to Ali, one of Iraq’s biggest challenges and barriers to reproductive healthcare is the absence of a cervical cancer screening programme.

Unfortunately, cervical cancer is the second most cancer amongst women in the world and ranks as the 12th most common cancer amongst women in Iraq.

As one can imagine, cervical cancer screening is important because it is the most effective method available to prevent cancer from progressing to more advanced stages.

During the cervical cancer screening process, pap smear tests detect the human papillomavirus (HPV), including high-risk HPV which allows cervical cells to become abnormal.

Key to the triumph of global cervical cancer screening programmes is the functioning of a programme in its entirety. Such requirements include the capability to ensure high levels of reporting of the target population, to offer exceptional quality and caring services, to advance and observe virtuous referral systems that guarantee excellent patient follow-up and to guarantee that the patients obtain suitable, adequate and considerate treatment in the framework of informed consent.

Like most cancers, early detection of cervical cancer is more likely to be treated successfully.

For women in Iraq, however, the lack of screening programmes is contributing to more deaths, as a result of late detection. Regrettably, there are specific barriers which are delaying cervical screening programmes across the country.

Cultural factors are pertinent, including lack of awareness about the virus, stigma, and fear of the diagnosis.

In an investigative report conducted in 2021, doctors interviewed disclosed a range of obstacles to cervical screening uptake mostly related to poorly organised healthcare services, lack of specialised knowledge and staff, and poor awareness of the disease among women.

"Nationally, since the majority of youth attend school in Iraq, working against cultural taboos begins with education. As most would agree, it would be a missed opportunity to not offer knowledge about sexual health in Iraqi schools. Currently, sex education courses in Iraqi schools is rare"

When asked why Iraq has a more active role in breast cancer screening and not cervical cancer screening, Ali explained that, unlike cervical cancer screening, the equipment required for breast cancer screening is easier to use.

In other words, Iraq’s healthcare facilities do not have a formal system set up to provide training on how to use cervical screening and colposcopy equipment.

Besides the absence of much-needed cervical cancer screening programmes across Iraq, other issues facing women regarding the reproductive health sector include limited reproductive health services in Iraqi villages.

As noted by Ali, the current situation in terms of reproductive care is that women leave gynaecological problems until their symptoms become unbearable. With nowhere to go, women living in villages visit midwives nearby.

Of course, midwife visits are problematic because midwives are not trained to deal with gynaecological issues. As a result, women are exposing themselves to serious health risks and complications.

Looking towards the future, especially in the midst of Iraq’s new government formation, it is clear that the sexual and reproductive health issues complicating the lives of women must be tackled on both an international and national level.

Internationally, the following factors should be considered: heightened support in terms of capacity building for Ministry of Health staff; sharing the experiences of countries with similar contexts and challenges; financial support to the Ministry of Health and Non-Governmental Organisations working on reproductive health. 

Thus far, the UK has intervened to boost cervical cancer services in Iraq. Fairly recently, Whittington Hospital in London sent cervical screening and colposcopy equipment to Iraq.

However, there is still no screening programme in place. Given these circumstances, the MoH should engage in collaborative work with other countries to help with the organisation of training courses. Indeed, training will be key when detecting the HPV virus and providing the most appropriate advice to women being monitored.

Nationally, since the majority of youth attend school in Iraq, working against cultural taboos begins with education. As most would agree, it would be a missed opportunity to not offer knowledge about sexual health in Iraqi schools. Currently, sex education courses in Iraqi schools are rare.

Only Algeria, Iran, Morocco, Tunisia, and more recently, Bahrain, have incorporated a human reproduction and health education module in their national school curricula.

The following national strategies should be implemented: the distribution of professional staff between central and referral areas by the Ministry of Health; the provision of incentives to encourage health service providers working in distant areas; following correct training services, a cervical screening programme should be set; education surrounding gynaecological issues in village areas.

Education should also be accompanied by the provision of services in such areas. 

Zainab Mehdi is a Researcher and Freelance Journalist specialising in governance, development, and conflict in the Middle East and North Africa region.

Follow her on Twitter: @zaiamehdi