ALEPPO — Fatimah, 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 which 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 Fatimah and 9-year-old Mammoud to the hospital, but Mammoud’s twin brother, Abdo, and their 3-year-old sister, Eilaf, were found dead beneath the rubble. Fatimah, 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, Fatimah’s critical care doctor, uses his patient’s story to illustrate how the conflict in Syria is crippling maternal healthcare, 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 pediatrician John Kahler, arrived in war-torn east 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 healthcare workers and hospitals, killing over 750 healthcare 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.

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

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.

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 foods such as meat, vegetables and dairy products are unavailable. "Most of the women are anemic with decalcification in their bones … there are no vegetables," she says.

SAMS vice president 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 organizations prioritize the delivery of baby formula, as many mothers can’t breastfeed their babies, says Termanini. In places where fighting and blockades make it impossible for aid deliveries to get through, even formula isn’t available. Asked what mothers in eastern Aleppo feed their babies when they are unable to breastfeed 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 cesarean section, which they also attribute to the constant bombings. Knowing that hospitals are targets for airstrikes, 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 preeclampsia, until it comes time to deliver their babies, which can result in the need for emergency C-sections.

Destroyed hospital in Aleppo — Photo: Miguel Juarez Lugo/ZUMA

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 airstrikes 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.

The daily destruction also means that trauma care takes precedence over preventative or primary care. During times of bombardment, civilians only seek medical care if they are seriously injured, says Sahloul. Preventative care for women, like 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 mass in her breast, she will not seek medical attention because she knows there are no oncologists or surgeons who can perform the surgery.

These things happen all the time in Syria.

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 orthopedic surgeon and anesthesiologist because there were 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."

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