Deborah Harrington is a British doctor who recently spent two weeks at Gaza’s Al-Aqsa Hospital. Since 2016, Harrington, a consultant obstetrician and a subspecialist in maternal and fetal medicine, has been going to Gaza almost every year to teach obstetrics to medical students and doctors-in-training at several of the territory’s hospitals. In December, 2023, she went back to Gaza as part of a partnership between Medical Aid for Palestinians (MAP) and the International Rescue Committee (I.R.C.). According to Gaza’s health officials, more than twenty-eight thousand Palestinians—many of them women and children—have been killed in the course of Israel’s war, and I wanted to speak to Harrington about the challenges of maternal care and childbirth in a war zone, and what she saw on the ground. Our conversation, edited for length and clarity, is below.
What are your biggest concerns about maternal care in Gaza right now?
By far the most worrying thing is that women are not getting maternal care. There is almost no—or very limited—access to prenatal care. All the women I saw, and I asked them, haven’t had any prenatal care since October. And that is the experience pretty much across the board when I talk to my obstetric colleagues in Gaza. There may be the odd opportunity where somebody has got prenatal care, but the vast majority of women are not getting any prenatal or postnatal care for themselves or their babies.
For people who might not know, what does prenatal care consist of?
The World Health Organization recommends that pregnant women go to at least eight prenatal medical appointments, where there should be an opportunity to give women iron and micronutrient supplements so that they’re not anemic when they go into childbirth. This sounds like such a simple thing, but it can lead to really potentially severe complications. And pregnant women in Gaza, prewar, had high rates of anemia. About forty-five per cent of women were anemic. So the lack of access to something as simple as iron means that those women are entering labor severely anemic. All the women I saw when I took a full blood count were severely anemic. And that means that they’re more likely to give birth prematurely, they’re more likely to have small-for-gestational-age babies, and they’re more likely to die in childbirth because, if they hemorrhage, they’ll not have the reserves. So even that sort of simple prenatal care is really important.
Women are also not being screened for the other major killers of pregnant women, such as hypertensive disorders and thrombosis. The other obstetricians at the hospital told me that, the day before I arrived there, a woman who had come in from one of the surrounding neighborhoods, and who had no prenatal care, was having seizures. She had developed a complication called eclampsia, which is due to untreated high blood pressure.
So she was having continuous seizures. They tried to give her medication to stop that. They ended up giving her a general anesthetic and delivered her baby by Cesarean section. The baby was in the neonatal unit. The mother was in the intensive-care unit because she’d had a very big cerebral hemorrhage, and she hadn’t regained consciousness at the time that I was there. I don’t know what’s happened to her since. The whole time I was there, she remained in the intensive-care unit.
Were you seeing people at every stage of pregnancy or later in pregnancy?
It was ad hoc. One of the problems is that there is no primary care, so that’s why women are not getting any sort of prenatal care. There are no outpatient clinics, so anyone seeking medical care just turns up at the hospital. There are hundreds and hundreds of people each day trying to access some kind of medical care for all sorts of complications, such as diabetes, or hypertension, or strokes, or their normal heart failure, not to mention all sorts of common infectious diseases, as well as trauma. One of the concerns for women is that hospitals have become overwhelmed with trauma cases. So the provision for women, the infrastructure, the obstetric units, the delivery wards, the operating theatres for obstetrics are all moved out because the hospital is overwhelmed with trauma, and it needs those theatres, and that ward space, for patients with injuries.
Maternity services have moved out to much smaller, often private providers, but they’re really tiny, and they just don’t have the capacity to look after those women. In many instances, women are trying to access those providers, which may be in areas that have active fighting.
So, actually, I didn’t see that many pregnant women. I obviously saw anyone that I could that was pregnant, and, as soon as anyone arrived, they were, like, “Oh, we’ve got a pregnant woman for you,” because I am an obstetrician. But actually, although I thought I was going to go and do lots of obstetrics, in the end I didn’t, because it was moved out of the hospital where I was placed.
So women are not accessing prenatal care. The simple things of diabetes screening and treatment, hypertensive screening and treatment, checking them to see if their baby has grown normally, checking them for anemia and giving them appropriate treatment for that, any other complications—none of those are being picked up. What is being reported is that there’s been a three-hundred-per-cent increase in miscarriages.
Where are you getting that number from?
There is very good information from other conflicts, such as Syria. The Lancet last year published a fantastic series about vulnerable women and the implications of that in pregnancy, with increased miscarriage, increased stillbirth, delivering early, delivering too small, and then those children growing up stunted, particularly if they haven’t had access to early nutrition, which then leads to developmental issues, chronic illnesses, and not living as long. Those vulnerable children grow up to be vulnerable mothers, and the cycle starts again.
You mentioned specific things like iron deficiency, but, broadly speaking, there’s not enough food in Gaza. What does that mean for people who are pregnant?
So we know that the whole population is at risk, and the three hundred thousand people in the north are at the highest-ranking risk, which is catastrophic. If you have poor nutrition or inadequate intake, then you may deliver early, and you may deliver a small baby. And certainly what is happening is that those women are unable to breast-feed, and there are numerous examples of that. I went to the pediatric and neonatal unit, at Al-Aqsa, and that was definitely something that they were seeing. So women were unable to breast-feed because they weren’t getting sufficient nutrition or access to clean water.
Does that mean that your body does not produce breast milk?
It means that you just can’t produce. You need a certain amount of energy. Actually, breast-feeding is much more energy-consuming than being pregnant. So, particularly as time goes on, it’s exhausting. Women need quite a lot of calorific intake in order to produce breast milk. I know an obstetric consultant who was working in Gaza City, and she had twins right at the beginning of the conflict. She had to flee her home in Gaza City, and she was staying in a tent with her newborn twins literally a few hundred yards from the hospital, and she couldn’t breast-feed those children. It was partly the trauma of being moved, and, also, she just couldn’t get sufficient food. She then could not source infant-formula milk for her babies. And then there was the risk of making up milk with dirty water. So, in every way, newborns are put at risk.
The other major worry that I have, which my colleagues have repeatedly said, is that women can’t access hospitals for birth. They may not have transport. They can’t summon an ambulance most of the time because there are problems with mobile phones. Many women are not getting to a hospital or not getting to a hospital in time, and that means that they themselves, and their babies, have their lives potentially at risk.
Before the current war, about fifteen per cent of pregnant women in Gaza developed complications in labor, some life-threatening. But it is now estimated that forty per cent of them have high-risk pregnancies, because you’ve got an unhealthy population entering birth. They’re already psychologically traumatized, and they may be nutritionally depleted. The normal complications that could have happened have ticked up. For all of those reasons, they’re entering labor in a very precarious medical condition. And then, if you give birth in a plastic-covered temporary shelter, there’s no privacy. If you bleed—which you’re more likely to do if you give birth to a preterm child, which you’re more likely to do in these circumstances, and it’s dirty and there’s no sanitation and there’s no pain relief—you are much more likely to have major complications or more likely to die.
Can you talk more about the psychological impact of giving birth in conditions like these? What can that mean for pregnancy, either in terms of the health of the mother or the health of the child?
I think it doesn’t take much imagination to think that the whole population is probably psychologically traumatized at this time. But, for women, what does that mean? Certainly there will be a huge increase in depression, anxiety, psychological trauma, P.T.S.D., and that will affect your ability to be a mother. It will affect your ability to bond with your child, to look after the rest of your children. If you’ve got a mother that is psychologically traumatized, that’s going to impact the whole family for years and years.
I am regularly in touch with an obstetrician at what has become the major maternity provider in Gaza. Before the war, it used to be a small maternity hospital with ten births per day, and it’s now doing eighty, or sometimes even a hundred. It does not have the capacity to do that. They’ve got women delivering in the corridors. They’ve got women who can only stay for two hours after a vaginal birth, and maybe six hours after a Cesarean section, before they have to get out and go back to their tent or wherever they’re staying.
One day, the obstetrician contacted me and said, “We’ve just done seventeen Cesarean sections.” They have one theatre, and they had fourteen women waiting to go into the theatre. If you’re doing a Cesarean section for fetal distress, or you’re doing it because there’s a major problem, then the mother and baby are both at risk because you just can’t deliver in a timely way. Sometimes things go wrong and you’ve got to deliver that baby there and then. Fetal distress equals getting into the theatre, doing a Cesarean section, delivering that baby so that it doesn’t asphyxiate. Can you imagine if you’re fourteenth in line, waiting to go into the theatre, when there’s one theatre and one team operating? It is just not going to happen in time.
Is there anything else that you would like to share about your experience?
Women are also being impacted because they can’t access normal maternity services or women’s health-care or hygiene products. There are hundreds of thousands of women menstruating. I think we all got used to excess deaths during COVID. So there will be many, many excess maternal deaths. But the implications of that go on and on and on. It goes on for decades—actually, even for generations. And we know that outcomes for children left behind, or children that may have survived—their outcomes, their education . . . the capital cost, economic and human, is massive and ripples on for decades. Can you imagine the scale of that at the moment in Gaza?
Were there any conversations you had with mothers in Gaza that stuck with you?
I’ve had friends and colleagues there over the years, many of whom are mothers, and many of them had moved their families multiple times. They had the immediate thoughts of, How do I keep my family safe? How do I feed them? How do I come to work? And there are many working mothers who now bring their children to the hospital because they know that they’re not going to be bombed at home. And there was one mother I met who said, “I’d rather we all die together than the thought of I die and then they’d be left alone.”
You’re talking about Palestinian medical professionals that you were working with?
Yeah. They are bringing their children to work just so that they could have some modicum of knowing that their children are a bit safer than leaving them at home and at the mercy of whatever might happen to them. ♦
