Iraq
Mosul's expectant mothers just can't wait
It’s 2016 and the battle for Mosul has just begun, with Iraqi forces sweeping through Mosul from the east. Street by street, a city that has been under the control of the Islamic State (IS) group for over two years is retaken by the Iraqi government.
The sun has not yet risen when Intissar, a midwife from Mosul, receives a knock at her door. When she answers, a panicked young man and his mother beg her to go with them to assist the man’s teenage wife to give birth to her first baby. Intissar is afraid but, with many of Mosul’s gynaecologists and other female medical staff having fled IS rule, and most of the city’s maternity facilities damaged, the need for midwives who can assist at home births has never been greater. Intissar swiftly obliges.
A newborn in the arms of his grandmother in Nablus maternity run by MSF in Mosul.
A newborn in the arms of his grandmother in Nablus maternity run by MSF in Mosul.
Intissar Abdulrahman Mostu, 39, midwife.
Intissar Abdulrahman Mostu, 39, midwife.
Midwifery is a beautiful profession, because we live alongside women, hear their stories and share their moments of sorrow and happiness and it is very much needed in times of war.
Intissar, a midwife from Mosul
"During the last conflict, I helped women give birth at home. I had women’s relatives come and beg me to care for their wives, sisters and daughters. I was pregnant myself, but I walked long distances as I knew that I was the only midwife in the entire area. People found out about me by word of mouth: ‘You will find a good midwife, she can help’, they told each other," says Intissar.
Later that day, with Intissar’s gentle but firm assistance, the teenage girl becomes a mother. With some thread and a razor blade sterilised in boiling water, Intissar ties and cuts the newborn boy’s umbilical cord, wraps him tightly in a white cloth and hands him to his grandmother, before helping the young mother deliver the placenta. Intissar goes on to deliver three more babies, all of them home deliveries that afternoon.
“If it were up to me, I would not have performed these deliveries at home – I really feared cases of post-partum haemorrhage,” says Intissar. “Today, I advise women to deliver their babies in a hospital, because everything that is required for a safe delivery is available. A pregnant woman’s condition can deteriorate rapidly, or she can have complications and need a caesarean. Hospital is much safer.”
In their own words: Zeina*
"We come from a village called Ein Naser, close to Hammam al-Alil. Our relatives came to this hospital and they told us about the quality of services in this hospital, so we chose to come here. My sister in law delivered in this hospital and she was the one who informed me about it. We chose to go the distance to get good quality than to go to the closer hospital. This is my first delivery in this hospital. I have four children, three sons and a daughter.
It was on 13 May, I remember this date very well. I was having excruciating pains, and arrived in the hospital at 04:00pm. I had a normal delivery that took less than an hour, but my baby was pre-maturely born. He was only 6.5 months, and weighed 800gms. I was very afraid for his health.
They told me I should remain in the hospital for a month or two until he is healthy enough for us to be discharged. Yesterday, thank God, they stopped the oxygen intake, they saw a big improvement in his health. I am not in a rush to leave, I just want him to be healthy and safe.
My baby stayed an entire month without a name, until the family agreed to one! The doctor and nurses used to come to me and inquire about his name, and I respond ‘I haven’t named him yet’. Finally, three days ago, his uncle picked his name, and his father and I are happy with it. We now have a new member in the family, my family cannot wait to welcome ‘Murtada’ home.”
*Name has been changed
In their own words: 7-year old Sahar*, mother of 2-day old Haider*
“I live in Hay Abar area in west Mosul with my in-laws. We are four people, and three children now, so we are seven in total living in that house,” says Sahar. This is my third child. I gave birth to my eldest son in 2013, and at the time, Nablus hospital was not functional. My second child, my daughter, she was born in 2016 under the rule of IS, also in a different hospital."
Her voice suddenly changes to soft whispers, “there were many life restrictions under IS; if you go out you have to be fully covered, even your eyes should not show. Most of the pregnant women did not leave their houses or deliver in hospitals because of these constraints and strict laws. Yet, I preferred to have an operation and was determined to deliver in a hospital. Once I got discharged, I returned home and did not leave the premises unless there was an emergency.
In 2014, I was still a student attending classes at the university. I had only to sit in for another three exams, but the conflict erupted, so I had to drop everything and forget my education for some time. When Mosul was retaken from IS, I took the three remaining tests and graduated successfully. I am now a lecturer, giving courses for free to eliminate illiteracy.
After graduation, it was hard to work when IS was in control of the city, so I remained at home, unemployed for a couple of years, and so was my husband. We lived off my uncle/father in law’s pension, which we received every two months. Pension was the only salary that was not cut off during the conflict. Teachers’ salaries and salaries of the health ministry’s staff were all cut off.
What encouraged me to deliver in this hospital were the positive comments of people I know. I wanted to come to this hospital because I knew they would take good care of me. I suffer from chest allergies so it is prohibited that I undergo general anaesthesia, for fear of suffocation. The hospital’s staff followed the right procedure and applied local anaesthesia. Even before this delivery, I visited Nablus hospital whenever I suffered from shortness of breath. The staff would check my blood pressure, sugar level, and put me on a ventilator. That is when I discovered that MSF is running a maternity department in the hospital and that all these services are free-of-charge."
Sahar’s eyes start to surrender as she’s been sleep-deprived for long hours after her surgery, “I will leave home today, I prefer to be resting at home since it is…. Home. It is my property, it is where my husband and children are, it is where my in-laws are. My family would not allow me to leave bed. But also more importantly, I am not suffering from any health problems or complications, thank God, and I think there are other more urgent cases and women in need of this bed and this space more than I do.”
*Name has been changed
In their own words: Najlaa Mohammad
“I live in Mosul in the western part. This is the first time I come to Nablus hospital. My relatives and neighbours gave birth in this hospital. My sisters and my nieces gave birth in this place.
I have been childless for nine years, but God graced me with this baby suddenly. This is my third baby. When I was told I was pregnant I was shocked and I started crying and I did not believe them. It is an indescribable feeling.
As soon as the labor pains restarted, I arrived at the hospital at 1 pm. The doctor told me to wait until the night comes and maybe even until dawn. When the bleeding started, that is when they rushed me into the operation room.
Today is my third day in this hospital since I had a caesarean, but I will be discharged today. This time, my sisters will come to pick me up instead of coming as visitors. I cannot describe my happiness, leaving the hospital and with me my child, little Mahmoud.”
More than two years after the battle for Mosul was officially declared over, normal life has in many ways returned to the city’s streets but the health system has been very slow to recover.
...Many of Mosul’s highly regarded doctors and other medical staff fled the city or the country during the fighting, and mothers and babies still struggle to access care.
Intissar is now working in Al Rafadain, the smaller of the two free-of-charge maternity facilities run by MSF in West Mosul. She is part of a team of midwives and gynaecologists who assist mothers with regular vaginal deliveries and quickly refer those with complications or in need of caesarean sections to MSF’s larger Nablus maternity hospital, just 10 minutes up the road.
They’re often persuaded to pay for expensive ultrasounds in private clinics but, with no real antenatal care – not even vaccinations or vitamins – it seems these ultrasound clinics are taking advantage of these vulnerable women and doing little more that telling them the gender of their unborn baby.
Emily Wambugu, an MSF midwife
Today, the morning’s first patient is 32-year-old Assia, who is somehow managing to smile through her contractions whilst in labour with her eighth child. Like many women in Mosul, her babies born in the past five years were delivered at home – not through choice but through necessity.
“I had three deliveries at home,” says Assia. “At the time, the conflict was going on, IS were still in control and it was very dangerous to leave the house and go outside, so I had to give birth at home. The roads were blocked and nothing was guaranteed. I was afraid for my baby’s safety as well as for my own wellbeing.”
Whilst there are no official figures for home births in recent years, patients in MSF’s maternity units in Mosul often tell similar stories. Even women who have previously undergone caesareans, and are therefore at high risk of complications, often deliver at home, either because they cannot afford the fee charged by local facilities and are unaware of free services like MSF’s, or because their families believe it is better for them to deliver at home attended by a traditional midwife.
Most pregnant women in Mosul receive no care before giving birth, even those who have paid for an ultrasound scan at a private clinic. “Almost none of the women we see have had proper antenatal care, so we have no idea about how the pregnancy is progressing when they arrive at our door,” says Emily Wambugu, an MSF midwife with over 20 years’ experience around the world. “They’re often persuaded to pay for expensive ultrasounds in private clinics but, with no real antenatal care – not even vaccinations or vitamins – it seems these ultrasound clinics are taking advantage of these vulnerable women and doing little more that telling them the gender of their unborn baby.”
Many women delivering at MSF’s maternity facilities in Mosul come from families who struggle financially. With unemployment running high across the city, many families cannot afford even daily essentials like food and housing, and some of the expectant mothers are clearly suffering from malnutrition.
In MSF’s maternity units in Mosul, the youngest mothers are in their early teens whilst the oldest are in their mid to late 40s, sometimes pregnant with their fourteenth or fifteenth baby. The very young women whose bodies are not ready for childbirth, as well as those older women who have had upwards of 10 babies, are at very high risk of complications during pregnancy, labour, delivery and post-partum.
“Women need close monitoring during pregnancy so that complications like gestational diabetes, anaemia and pre-eclampsia are picked up and treated before they become life-threatening,” says Wambugu. “They also need special attention after delivery to watch closely for post-partum haemorrhage. As well as receiving medical care, women young and old need proper information about how to space out their births and give their bodies and families time to recover after welcoming each new baby.”
Sanaa, 41, married very young. “I was only 14 or 15 years old and I didn’t know what being pregnant meant,” she says. Sanaa has a history of difficult pregnancies, including six miscarriages, two in the late stages of pregnancy, which left her feeling traumatised. “Afterwards I developed a complex,” says Sanaa. “I didn’t want to have children anymore – I didn’t want to relive that pain ever again.”
Twenty-five years after her first child was born, she has just given birth again by caesarean – but she has decided that this baby will be her last and had a small surgery to tie her fallopian tubes and ensure she will not conceive again after her latest delivery.. “Now I have five girls and three boys, thanks be to God. I can’t wait to go back home with my new baby.”
The Midwife's team of Al Rafadain maternity run by MSF in Mosul, Iraq.
The Midwife's team of Al Rafadain maternity run by MSF in Mosul, Iraq.
MSF’s maternity centres in West Mosul
More than two year since the battle between the Islamic State (IS) group and the Iraqi forces officially ended in Mosul, Iraq, the healthcare system remains fragile with thousands of families struggling to access quality affordable health care and even the community’s primary health care needs remaining unmet. Amongst the most vulnerable are pregnant women, many of whom have been pushed to deliver at home with untrained traditional midwives, either because they cannot afford the fee for delivery or because maternity services are overcrowded or completely absent in their area, as well as their newborn babies who cannot wait for care because the health system is not ready for them.
In order to respond to this high unmet need, in 2017 MSF opened a specialised maternity unit in Nablus Hospital, West Mosul, to provide safe, high quality and free maternal and neonatal care to women and their babies in an area of the city where the community and the health system continue to struggle. In July this year, a second MSF team opened a smaller facility at Al Rafadain Primary Health Care Centre, also in West Mosul, providing routine obstetric and newborn care and offering local women another safe place to deliver even closer to home.
Combined, these two facilities are staffed with almost all female teams of skilled Iraqi staff and international mentors that welcome almost 170 babies each week. The teams also offer high quality care to sick and premature newborns, family planning services and gynaecological consultations. Whilst these services are well received by the community, they, along with the other government run maternities, are not sufficient to provide high quality care for Mosul’s population estimated to be around 1.8 million people.
As of August 31st, MSF midwives and gynaecologists in Mosul have assisted 5,176 women to safely deliver their babies so far this year.
An MSF Nablus midwife poses with a new born baby.
An MSF Nablus midwife poses with a new born baby.
Emily Wambugu, a midwife from Kenya with more than 20 years experience all over the world, poses with a newborn baby.
Emily Wambugu, a midwife from Kenya with more than 20 years experience all over the world, poses with a newborn baby.
Asma Mohammad Saleh, Midwife in Al Rafadain maternity run by MSF in Mosul, Iraq.
Asma Mohammad Saleh, Midwife in Al Rafadain maternity run by MSF in Mosul, Iraq.
Leila Mohammad Hasan, 24, 1 year and two months working as midwife in Mosul.
Leila Mohammad Hasan, 24, 1 year and two months working as midwife in Mosul.
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