After their first child was born in 2014, Mohammed Salameh, 22, and his wife Khoulod Ahmad Suleiman, 21, planned to throw a small party for family and friends with walnuts and cups of hot cinnamon, as is customary in their hometown of Dara'a in southwestern Syria.
But when they learned that a cousin in Syria had been killed in fighting the same day, they cancelled the festivities.
Two years later, the fighting continues. But so, too, does life in the Zaatari refugee camp in Jordan, where the young couple gave birth to their second child last month. The healthy baby girl, named Rima, was the 5,000th newborn registered in the camp.
Swaddled in blankets, Rima was the centerpiece of a happy family portrait at Zaatari's Women and Girls Comprehensive Center, where U.N. and camp officials gathered early last month to celebrate the milestone and a successful record on maternal health. As perilous a journey as pregnancy can be — worldwide, some 800 women die of pregnancy-related causes every day — no women in Zaatari have died in childbirth.
Yet Rima's arrival also points up an enduring challenge — and a failure of efforts to address it. At roughly 42 live births per 1,000 people, the crude birth rate in the camp far exceeds that of both Jordan (24.5) and pre-war Syria (23). And, reports show, many of those births are the product of very young marriages. According to a 2014 report by Save the Children, the rate of child marriage among Syrian refugees in Jordan has doubled since the start of the war.
"Once married, women in Middle Eastern societies are generally under social pressure to have children as soon as possible," says Dr. Valeria Cetorelli, a demographer with the Middle East Center at the London School of Economics and Political Science. And in a place like Zaatari, that pressure may be especially pronounced. "Conflict-induced violence and insecurity can reinforce individuals' perception of group identity, particularly with respect to reproduction," she says. "Some women may feel compelled to compensate for the lives of relatives lost in the war.
"This is very common here," says Lina Hamidi, a nurse with the International Medical Corps (IMC) and manager of the reproductive health clinic at Jordan's Azraq camp. "The wife wants to take a rest from pregnancy, and the husband says, 'No. We've lost so many friends and family. We have to replace this number.'"
Opened in April 2014, Azraq houses roughly 32,000 refugees in austere rows of corrugated metal shelters — a sharp contrast to the hurly-burly of Zaatari, with its bustling shops and houses built of assorted materials.
"Many women want to use family planning tools," Hamidi says. "But their husbands won't allow it. Sometimes they think if they have more children, they'll be able to get another shelter — even if they can't take care of the ones they have."
Hamidi recalls one afternoon when a man burst into the clinic furious that his wife had been given a contraceptive injection: "He was shouting at the nurses, 'What have you done to my wife?'"
The man calmed down when he learned that the effect of the injection is only temporary. But more often, she said, men will simply instruct their wives to undo whatever they've done.
"One day she will come in for an IUD," says Hamidi, using the abbreviation for an intrauterine device, a long-acting reversible contraceptive inserted into the uterus. "And the next day she will come in to have it removed."
The power imbalance between men and women puts the latter at risk not only for pregnancy-related health problems but also a host of sexually transmitted infections.
"Vaginitis has been very common," Hamidi says. "We told women, you have to wash yourself. But then we realized it was the men who weren't bathing." Several months ago, the situation was so bad that Hamidi and colleagues went to speak with the imam at Azraq's main mosque. "We told him, 'Look, you really have to talk to them about this, it's a problem.'"
Although Syrian refugees are mostly banned from working in Jordan, many in the camps have found informal employment. Mohammed Salameh, the father of baby Rima, has a falafel shop on the so-called "Champs-Élysées," the camp's buzzing main thoroughfare. Others work as butchers or barbers, in shoe stores or vegetable stands. In Azraq, the jobs are fewer still and residents there say what work there is — as guards or cleaners or teachers — goes to men.
"There are many more opportunities for men," says Esra'a Matrod, 30, who was a paramedic in Dara'a before fleeing the city for Jordan just over a year ago. Though her skill set was in high demand in a place like Azraq, Matrod was unable to work. As the weeks went by, she says, the boredom began to weigh on her. Then she heard that IMC was looking for refugee women to serve as volunteer health workers. In teams of four, the volunteers fan out into the camp six days a week, going shelter-to-shelter to find those in need of care.
"We might refer a pregnant woman to the reproductive health clinic, or send children to get their vaccinations," Matrod says. "Everyday there's something to do; there are a lot of problems in the camp."
One of the most pervasive, she says, is gender-based violence. Often, when making their daily rounds, Matrod and team hear accounts of abuse from the victims themselves. "Women tell us directly," she says.
Often, too, they say, those victims are wives too young to wed. "You see a 16-year-old standing there holding a baby, and she's pregnant with another baby," Matrod says. "She isn't ready for this."
Patrick Adams reported this story while participating in a United Nations Foundation media fellowship.