In Syria, most babies are born by Caesarean section. There is no time for natural deliveries under the shelling. There are not enough doctors. Mothers give birth in underground shelter-like hospitals, with health facilities having become targets of war.
Mothers-to-be call the doctor and request an appointment for a C section. This is what Islam Mohammad did, twice, for her first delivery in Damascus, in a regime area, and her second in Idlib, one of the last opposition bastions.
“My husband couldn’t be with me for my first delivery, we were afraid he would be arrested,” explains Islam, from Idlib, where she now lives with her two daughters and husband, Yasser Abu Ammar, an Arabic teacher and former prisoner, blacklisted by the regime since he took part in protests against Bashar al-Assad.
Islam couldn’t afford many medical check-ups during her pregnancy. The couple, from Darayya, was living in Zakia at the time, a small town in Western Ghouta. It was 2016 and the area was being bombarded with barrel bombs. There are no hospitals in Zakia, “only a midwife and a urologist,” recalls the young mother.
Delivering in opposition areas such as western Ghouta is possible, but in underground hospitals such as those assisted by Doctors Without Borders (MSF) since 2013. According to MSF figures, about a hundred airstrikes hit the medical facilities they are supporting in opposition areas in Syria, killing 81 medical staff, in 2015 alone.
According to the World Health Organization(WHO), Syria has the worst record in terms of attacks on medical staff and facilities in conflict areas, with 121 during the first quarter of this year alone, as compared with the eight attacks in Pakistan, which comes second in the ranking.
Infant and maternal mortality rates have risen as a result. In 2010, before the conflict erupted, Syria had reached a record low of 16.3 infant deaths for every 1,000 live births, but the figure steadily grew and stood at 17.5 in 2016. Similarly, maternal deaths, which had reached a historic low of 49 deaths per 100,000 live births in 2010, rose to 68 in 2015 (the most recent figures published by international bodies).
Increasingly rare family planning and pregnancy care
Given the lack of medical staff, Islam and Yasser decided to pay for a C section with health guarantees in a regime-controlled area. Each appointment with a private gynaecologist costs about US$50, in a country where the per capita income is less than US$150 a month. Fortunately, a charitable organisation was financing half of the procedure and treatment at the Damascus hospital. But Islam had to go alone to avoid her husband being arrested.
Before the war, a drive from Zakia to Damascus would take an hour. It took Islam ten hours to reach the hospital, due to the many checkpoints where she was questioned by pro-Assad militias, who finally discovered photos of Yasser on her smartphone. She lied, saying she had no news of him, and gave them cash to buy their silence.
On reaching the hospital, the doctors stopped Islam’s mother from accompanying her. She felt alone and was afraid she would talk too much under anaesthesia. One hundred kilometres away, Yasser feared she would be detained. “I was scared and sad because I couldn’t be with my wife, the love of my life. I was praying to God, asking for my wife and daughter to be well, and for Islam not to talk whilst under anaesthesia. I messaged my mother-in-law and sister-in-law, asking them to stay with her and to stop her from talking.”
Jouri, Arabic for Damascene Rose, was born on 15 July 2016, on the same day as the failed coup in neighbouring Turkey, one of the main backers of the Syrian opposition. “The militias of the Syrian regime were celebrating by shooting the [supposed] fall of [Turkish Prime Minister Recep Tayyip] Erdogan. It was a terrifying night for the people of Damascus. The shooting did not stop and many people were killed during the celebrations,” recalls 31-year-old Yasser. Finally, “Islam called me, she was crying. I told her that they were celebrating, but I couldn’t calm her fears. I felt useless and sad”.
The trials and tribulations faced by the couple went on for weeks. Islam had to stay in hospital for a fortnight after the birth. On her return home, the couple were woken by shelling at dawn. Despite the pain from the C section, Islam jumped out of bed, took Jouri in her arms and ran to the shelter. The shelling intensified over the following month and Islam admits that she was becoming hysterical. There was no baby milk or bread left. The couple decided to flee to Damascus, travelling across the dust-filled, devastated roads. Jouri could barely breathe during the trip. “It was a real journey towards death,” says Islam.
At the end of 2016, they moved to the northern province of Idlib, and a few months later Islam fell pregnant again. There wasn’t a single gynaecologist in the city where they had settled. Again, they had two options: to find a public hospital and give birth in an underground shelter together with half a dozen other women, attended to by medical students, or to pay for another private hospital. The only one with incubators was at the Bab al-Hawa border crossing.
The couple decided, once again, to invest all their savings in the birth of their second daughter, called Leen, Arabic for tender or delicate. She was born on 11 November 2017. Yasser, who is currently studying political science, remembers with joy how he kissed his wife on the forehead following the delivery and hugged the baby.
Their doctor, Mahmud al-Mutlaq, now earns so much money that during Ramadan, in May 2018, he was kidnapped and tortured by members of the Salafist jihadist group Hayat Tahrir al-Sham, linked to al-Qaeda, before being released in exchange for a hefty ransom.
Hanadi Hasan is one of the nurses working in the preterm unit at the Bab Al-Hawa hospital. The 27-year-old anaesthetist confirms that this is the only hospital in the area with incubators:
“We have many cases of newborns with congenital malformations, due to some of the weapons being used, such as encephalitis, cerebral infarction, paralysis and intestinal obstruction.”
Half of Syria’s 18.5 million people have been internally and externally displaced since the conflict began. Half a million have died. About five million are living in neighbouring countries such as Turkey, Lebanon, Jordan, Egypt and Iraq, where pregnant women do not have regular access to medical services, according to the UN High Commissioner for Refugees (UNHCR). Inside Syria, according to figures of the United Nations Population Fund (UNFPA), around 540,000 out of the 3.3 women of reproductive age were pregnant at the beginning of 2016.
Islam and Yasser’s story is a tale of the risks of giving birth in both regime and opposition areas. A decisive difference is the airstrikes conducted by the Syrian regime, with Russian support, in opposition areas, whereas the opposition factions, with varying levels of radicalisation, have very limited airpower and anti-aircraft artillery.
Om Kamel confirms the risks. “I was so scared, I lost so much blood, and got into a panic because I had nobody, I was worried for my children.” This 32-year-old mother gave birth to her fourth child in April in Douma, Eastern Ghouta, at the same time as the area was being targeted by the most recent chemical attack. She also gave birth alone, as her husband has disappeared. “Before the war we had doctors and hospitals, and the costs were much lower. This time, I couldn’t even afford to have a blood test. And there was no food.” Om Kamel had to go to one of the eight shelters the UNFPA runs in the area for reproductive health care.
According to Rajia Sharhan, UNICEF nutrition expert for Syria, “The priority needs are micronutrient interventions to address anaemia and micronutrient deficiency among pregnant and lactating mothers.” The rate of anaemia among women of reproductive age in Eastern Ghouta is 25 percent, “not including the besieged areas”, underlines Sharhan.
Doctor Izdihar works in Damascus for an NGO supported by the UNFPA. “In the conflict areas, 90% of births are Caesarean surgeries. We don’t have qualified midwives, the working conditions are difficult and there is no proper follow up,” explains the surgeon. According to medical sources in Syria, the reason for so many Caesareans is the shortage of doctors, given that 50 to 60 per cent of them have left the country since the beginning of the war in 2011.
“There is no follow up in conflict areas. The services are too expensive, there are no medicines, no food. Women visit the clinic once or twice during their pregnancy and then go to a risky delivery,” says the doctor.
The lack of anaesthesia and specialised staff mean many C sections lead to infections. “But we have to keep working, due to the high number of pregnancies, which has reached 85 per cent in periods of conflict,” says Dr Izdihar, as compared with an average of 16 per cent of women of reproductive age in 2016, according to the UNFPA. The high pregnancy rate during conflicts is due to poor access to contraceptives, religious repression, in conservative areas, against the use of contraception, and the use of sex as a psychological coping mechanism against the besiegement, the rage and the loss of relatives.
“We decided to have babies because life must go on,” says Islam. “My country needs a new generation to rebuild itself from the ruins. I hope our children are able to live in peace and safety and grow up to have a happy life.”
“I didn’t have a choice!” protests Om Kamel. “My husband didn’t use contraceptive methods. They were too expensive, we couldn’t afford them. Besides, they were forbidden by the religious people, as was the IUD. I didn’t want more children, we already had three.”