In Syria, the extra weak link of women’s health Image Credit: Niño Jose Heredia/©Gulf News

Fatima, 25, was at her home in eastern Aleppo with her three children when the first barrel bomb struck. Her husband, who was at work at the time, heard the explosion from his office. He knew instantly the sound had come from the direction of his house. He waited for the “double-tap” — the second round of barrel bombs that would drop from the Syrian and Russian warplanes — before sprinting off towards home. He arrived in time to watch a third round of bombing decimate his family.

The While Helmets rushed Fatima and nine-year-old Mammoud to hospital, but Mammoud’s twin brother, Abdo, and their three-year-old sister, Eilaf, were found dead beneath the rubble. Fatima, who was three months’ pregnant at the time of the bombing, suffered a miscarriage and internal bleeding, leaving her in critical condition and on life support.

Dr Zaher Sahloul, Fatima’s critical-care doctor, uses his patient’s story to illustrate how the conflict in Syria is crippling maternal health care, with thousands of women suffering as warplanes systematically wipe out medical facilities, and blockades leave hospitals with almost no equipment or resources.

Sahloul, a Syrian-American trauma specialist, and Chicago-based paediatrician John Kahler arrived in war-torn eastern Aleppo last year as members of the medical charity Syrian American Medical Society (Sams). They flew to Syria in June 2016 to spend five days working in hospitals that were bombed daily.

Doctors in besieged areas of Syria have been struggling throughout the conflict to provide proper medical care to those in need. Syrian-Russian government forces have specifically targeted health care workers and hospitals, killing more than 750 health care providers and bombing 265 medical facilities throughout the country. When Sahloul and Kahler arrived last June, only 30 doctors were left to treat eastern Aleppo’s 300,000 civilians.

Farida, who, for safety reasons would only allow her first name to be published, was the last obstetrician-gynaecologist in eastern Aleppo until she was evacuated to Idlib at the end of last year. While in Aleppo, she worked at Omar Ibn Abdul Aziz hospital, code-named M2 by doctors in a futile attempt to protect its coordinates from bombings by the Syrian regime.

Farida’s voice is high and urgent as she describes what she witnessed in Aleppo, describing widespread malnutrition among women in besieged areas. She says basic food such as meat, vegetables and dairy products are unavailable. “Most of the women are anaemic with decalcification in their bones ... there are no vegetables,” she says.

The vice-president of Sams, Dr Basel Termanini, travels to northern Syria every six months to provide medical care. “I have seen mothers who really don’t even know how to describe an orange to their children, because their children have never seen one before. People are really deprived,” he says.

‘The baby eats nothing’

Malnutrition has a devastating impact on prenatal and neonatal health, leading to a host of problems, including low birth weight — “Most of the babies being born are under six pounds,” says Farida — and an inability to produce breast milk. In northern Syria, aid organisations prioritise the delivery of baby formula, as many mothers can’t breast-feed their babies, says Termanini. In places where fighting and blockades make it impossible for aid deliveries to get through, even formula feed isn’t available. Asked what mothers in eastern Aleppo feed their babies when they are unable to breast-feed or buy formula, Farida says: “Nothing. The baby eats nothing.”

Doctors across besieged areas of Syria have reported an increase in the number of deliveries by caesarean section, which they also attribute to the constant bombings. Knowing that hospitals are targets for air strikes, women are often too frightened to visit doctors for prenatal screenings, says Termanini. Many don’t find out about serious conditions during their pregnancy, such as pre-eclampsia, until it comes time to deliver their babies, which can result in the need for emergency C-sections.

Many pregnant women also choose to have C-sections so they can plan to deliver their babies at night, when bombings are less likely. It’s a decision doctors say is understandable but risky. “It is an unnecessary surgery that is not appropriate as it increases the risks of complications and future complications related to pregnancy,” says Sahloul. With hospitals in parts of Syria being targeted by air strikes on an almost daily basis, Kahler confirmed that there are no longer any working medical facilities in Aleppo. Sahloul says that during his last mission to Syria, every few minutes the government would detonate bunker-buster bombs and barrel bombs in the direction of hospitals. “These things happen all the time in Syria,” he says.

And that means health providers have had to adapt in ways they never imagined. Farida recalls one incident when M2 hospital was bombarded as she was performing a C-section. The explosion caused parts of the ceiling above her to cave in, and crumbling debris dropped into her patient’s open abdomen. As the bombings continued, Farida asked nurses to remove the rubble from inside her patient and clean her abdomen with saline. “We finished the operation, and in the end, the patient [survived] and was very good,” Farida says.

No preventive measures

The daily destruction also means that trauma care takes precedence over preventive or primary care. During times of bombardment, civilians only seek medical care if they are seriously injured, says Sahloul. Preventive care for women, such as mammograms and cervical screen tests, are nonexistent in Syria’s war-torn areas. “The last thing a person under siege will be thinking about is preventive measures of medicine,” he says. According to doctors in the country, if a woman is aware that she has a serious condition, such as a lump in her breast, she will not seek medical attention because she knows there are no oncologists or surgeons who can perform the surgery.

As Syria and Russia continue to bombard Syrian citizens, women don’t have the luxury of thinking about their future health — they are focusing only on how to keep themselves and their children alive right now. Hana Dawood and her husband, Humam, are former residents of Moadamiya. With Humam acting as her interpreter, Dawood tells of how she had a baby boy in October 2016, at home and without the care of an obstetrician. Less than a day after she gave birth, Dawood and her family were loaded onto an evacuation bus bound for Istanbul. For 24 hours, she sat on a bus with no bathroom facilities, cradling her newborn son.

Humam, a dentist who had to train himself to be an orthopaedic surgeon and anaesthesiologist because there was none in Moadamiya, says he was upset that his wife had to make the journey so soon after giving birth. “It was really difficult for her,” he says. “I can’t believe she was able to do that.”

— Worldcrunch 2017, in partnership with Syria Deeply/New York Times News Service

Alexandra Bradford has an MA in Terrorism, Security, and Society from Kings College London. Her main area of study focuses on homegrown extremism and female radicalisation. Sheh is a co-author of Becoming Mulan? Female Western Migrants to Isis, Threat and Response, a report by the London-based Institute for Strategic Dialogue.