first published in the New York Times https://www.nytimes.com/2024/01/09/opinion/children-mothers-pregnant-gaza.html
By Alice Rothchild
Dr. Rothchild is a retired obstetrician and gynecologist, an author, a filmmaker and a former assistant professor at Harvard Medical School.
After Israel began its invasion of Gaza shortly after Hamas’s attack on Oct. 7, Aya Khrais — a pregnant 26-year-old dentist, wife of a doctor and mother of a 2-year-old girl living in Gaza City — lost contact with the doctors and health services she needed for prenatal care and for managing her diabetes.
She and her family were forced to leave home and move five times to flee the constant bombings, sometimes trekking several miles on foot. When we spoke in early December, she was staying at her sister-in-law’s home in southern Gaza. Dr. Khrais was 32 weeks pregnant and sleeping on a thin mattress directly on the ground, sharing a house with 74 people from 11 families. They lacked water, adequate food, medications, electricity and the tools for basic hygiene.
For the past two months she has had no prenatal care and no vitamins and has not gained any weight. She found a private obstetrician on Dec. 10 who informed her that she had excess amniotic fluid and needed an immediate C-section. She found a private hospital with an opening on Jan. 16. The estimated cost will be $4,000; the family has lost all of its savings as well as its bombed-out home. She has no baby clothes, diapers or formula and no proper place for postpartum recovery. “I am really frightened,” she told me over WhatsApp.
Dr. Khrais’s account is far from uncommon. There are approximately 50,000 pregnant women in Gaza, all struggling with a lack of stable shelter, inadequate nutrition and polluted, salty water. Prenatal, postnatal and pediatric care are difficult to obtain. U.N. agencies have dispatched lifesaving medicines and equipment to Gaza but it’s not enough to meet the needs of the population. Extreme shortages of pain medications, antibiotics, seizure and diabetic medications and blood are common. According to the World Health Organization, of the more than 180 women delivering babies each day, 15 percent are likely to encounter complications and be unable to obtain appropriate obstetric and pediatric emergency services. All the while, the threat of injury or death from bombings and military action looms, as does unimaginable emotional trauma.
If these mothers and their children manage to survive the war, they will grapple with its effects for the rest of their lives. Health research into multiple areas of armed conflict (such as Syria, Afghanistan, Somalia and Kosovo) reveals that these kinds of conditions are linked to an increase in miscarriages, congenital abnormalities, stillbirths, preterm labor and maternal mortality. Other studies of armed conflict from 1945 to 2017 show that children exposed to war are more likely to suffer from poor living conditions and sanitation and multigenerational poverty caused by the loss of educational and economic infrastructure.
“Gaza has simply become uninhabitable,” Martin Griffiths, the under secretary general for humanitarian affairs and the emergency relief coordinator at the United Nations Office for the Coordination of Humanitarian Affairs, has said. Women and children have experienced the brunt of this tragedy. The only chance they have at living healthy lives free from lifelong consequences is for the fighting to stop now and for health services to be restored and rebuilt immediately — a prospect that becomes more challenging and elusive the longer the war is waged.
Pregnancy and childbirth occur in a sociopolitical context; repeated military assaults, the collapse of the health care system and food supply, the absence of adequate shelter and general safety, have lasting impacts on mothers and babies — well after the fighting is quelled.
Before the war, life for pregnant women in Gaza was very challenging. Women there are expected to have large families and are cared for by overworked doctors and midwives with an unreliable supply of electricity and oxygen. There was already little time for each patient. Despite efforts by the Gaza Health Ministry and the United Nations Relief and Works Agency, obstetric practices tend to be a blend of the developed and the developing world. Doctors are rarely allowed permits to leave Gaza to update their skills, and Israeli authorities restrict the kinds of medications and equipment that are allowed in. Infant mortality rates are about seven times Israel’s. For mothers, hemorrhage, infection, thromboembolic disease, pregnancy-induced hypertension, obstructed labor and unsafe pregnancy terminations have been the leading causes of maternal mortality. Those complications are largely preventable or manageable in the developed world.
Those dangers have worsened during the war as hospitals and health services deteriorate. Some women are giving birth in cars, on the street and in overcrowded shelters at a time when there are increasing infectious diseases such as respiratory illness, hepatitis A and meningitis. Some hospitals, including Al-Nasr Medical Center in Gaza City and Kamal Adwan in northern Gaza, have reported direct hits on neonatal and maternity departments, resulting in deaths and injuries. There are reports of women having C-sections without anesthesia and mothers being discharged as quickly as three hours after birth. The trauma of war can also directly affect newborns: During the 2014 conflict in Gaza, mothers with high exposure to war trauma gave birth to infants who suffered negative sensorimotor, cognitive and emotional development.
Rising food scarcity and malnutrition in Gaza resulting from the current assault will likely lead to its own complications. According to UNICEF, pregnant women suffering from poor diet and nutrition see an increased risk of pre-eclampsia, hemorrhage, anemia and death. Stillbirths can occur, and children may be affected by low birth weight, wasting and developmental delays.
Though Israel says it is scaling back some of its fighting in Gaza, there is unfortunately still no end in sight. Medical resources and food are trickling in, but aid groups in southern Gaza report that they can meet only 25 percent of the needs for two months for malnourished children and their vulnerable mothers.
Dr. Khrais and the estimated 50,000 pregnant women in Gaza are desperate for an end to the fighting so they can safely give birth. But they are just as desperate for an end to the devastation affecting every generation born and raised there.
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