Iraq's Woes Are Adding Major Risks To Childbirth
Violence, Curfews Curtailing Services

By Nancy Trejos
Washington Post Staff Writer
Thursday, January 4, 2007; A01

BAGHDAD -- Noor Ibrahim lay shivering underneath two blankets on a bed at al-Jarrah Hospital. Steps away was a red plastic bassinet. It was empty.

A few doors down, her recently born son lay wrapped in a pink blanket. He was a chubby boy of nearly nine pounds with a big patch of black hair. His eyes were closed, his head cocked to the left, his mouth slightly open, his skin soft and pale.

The boy was not in a bassinet. He was in a cardboard box. He was not heading to his mother's room. He was heading to the morgue.

"Fresh death," Ibrahim's obstetrician said as she reached into the box and lifted the boy's limp right arm, still covered in blood and amniotic fluid.

Giving birth is painful enough as it is. In war-torn Iraq, it's also becoming more dangerous.

Spontaneous road closures, curfews and gun battles make even getting to the hospital a challenge for expectant mothers. Once they arrive, the women have no guarantee that they will receive adequate health care from a qualified physician.

"It's spiraling downward. It's getting worse each day," said Annees Sadik, an anesthesiologist at al-Jarrah.

Iraq once had a premier health-care system. But the trade embargo of the 1990s and now the exodus of medical professionals have made it no better than a third-world system, doctors say. Hospitals lack the equipment, drugs and medical expertise to make labor easier or to handle complications.

Women are forgoing prenatal visits to doctors as a result. Fearful of going into labor during the nighttime curfew, they are having elective Caesarean sections. Others are relying on midwives in their neighborhoods.

Doctors, especially women, have been targeted by unknown groups for kidnapping and murder. The kidnappers often appear to be motivated by money, seizing professionals because they are among the wealthiest people in Iraq. But many Iraqis also say that insurgents are waging a campaign to eliminate the people with the skills most needed to rebuild Iraq.

As is often the case in Iraq, where bombs usually kill civilians rather than their intended targets, the death of Ibrahim's son was a matter of bad timing. Her mother-in-law, Amira Saeed, told their story as Ibrahim recovered at al-Jarrah. Ibrahim would later confirm the details.

Ibrahim felt labor pains at 9 p.m. Dec. 23 at her home in Madain, a town 15 miles south of Baghdad that has become a flash point for tension between Sunni and Shiite Muslims. Few ambulance crews are willing to pick up patients at night for fear of encountering death squads, militias or rogue police officers. Few doctors are willing to work at hospitals at that time for fear of kidnapping.

Ibrahim decided to bear the pain until morning rather than drive in the dark. At 3 a.m., her water broke. It was still too dark to go out. Once the sun rose, she, her husband and her mother-in-law drove to the public hospital in Madain.

When they arrived, there was no obstetrician and no anesthesiologist, Saeed recalled. A surgeon had just been kidnapped and the doctors refused to go to work. That left the nurses to deliver Ibrahim's baby.

For several hours, Ibrahim pushed. But her baby was big and she got tired. The nurses used forceps to try to pull him out. When that didn't work, they told her to go to another hospital, Saeed said.

The family decided to go to al-Jarrah, a private hospital in the Karrada district of Baghdad. The ambulance driver refused to take them into the capital, even after they offered to pay him, Saeed said.

Ibrahim, her husband and Saeed got back into their own car. They drove for 30 minutes, past several checkpoints, as Ibrahim's baby struggled to break free from her pelvis.

An Exodus of Doctors

One of al-Jarrah's most experienced obstetricians carries a pistol to work.

She has received three death threats. Her ultrasound machine has been stolen. She agreed to speak to a reporter only if her name were not used because, she said, she feared for her life.

"I came here to serve my people," said the Iraqi-born and London-educated doctor, who wears a purple hijab, or head covering, and green scrubs when delivering babies.

According to a December 2006 report by the Washington-based Brookings Institution, 34,000 physicians were registered in Iraq before the 2003 U.S.-led invasion. Since then, about 12,000 have fled and 2,000 have been killed, it said.

At al-Jarrah, two doctors have been kidnapped and killed. Two were kidnapped and released. Three have left Baghdad. Thirteen remain on staff.

"It's a campaign to drain the country," said Aviad Najeed, a surgeon at al-Jarrah. "A very, very well-organized one. We don't know who's behind it."

Sitting in their lounge, a windowless room with lockers and leather chairs, four doctors at al-Jarrah talked about the hope they had after the invasion. They recalled buying oranges and flowers to greet U.S. troops. They thought the Americans would bring the best technology and medicines.

The Iraqi health-care system was once considered one of the best in the Middle East, with the most up-to-date equipment and well-educated doctors. Iraqis could get basic health care free, and each town had at least one hospital. That changed when the U.N. Security Council imposed an embargo after Iraq invaded Kuwait, leading to the 1991 Persian Gulf War.

Medical instruments and drugs used to be shipped from Germany, France, Japan and Switzerland. Now, hospitals buy cheaper supplies from Egypt, Jordan and India, the doctors said.

At al-Jarrah, staff members do not have fetal monitors, so they use a trumpetlike device held over the womb, the doctors said. The delivery room has a chair with rusted metal footrests and an examining table with a hole in the leather cushion.

The hospital has three ultrasound machines, but no one to operate them at night because administrators cannot find a qualified person to stay at the hospital during the curfew.

And when the hospital runs out of blood, which it often does, staff members have to go to Baghdad's central blood bank, located in a neighborhood with frequent shootings, too dangerous for even an ambulance to reach. What do they do when they need blood at night? "We hope for sunrise," said Sadik, the anesthesiologist.

Many private hospitals have closed, and the public hospitals are overwhelmed by victims of the many car bombings and mortar attacks that happen across the city each day, the doctors said.

"I don't know why this is happening," said Najeed, a former military doctor who wore a gray suit and speaks perfect English. "Is this a punishment?"

'They Killed Her Baby'

Ibrahim arrived at al-Jarrah on the afternoon of Dec. 24. She was in shock with a ruptured uterus and tears in her vagina.

The obstetrician performed an emergency Caesarean section. It was too late to save the baby. Now, the doctor had to concentrate on the mother.

The baby, the obstetrician said, died because the forceps had crushed his head. Ibrahim lived but might never be able to have another child.

"Look at this disaster," the obstetrician said as she lifted the baby's head, the top of which was slightly caved in. On the right side of his forehead was a spot of blood and a dark purple bruise.

"They killed her baby," the obstetrician said. Then she wrapped him in the pink blanket and sealed the box.

Women are increasingly asking doctors to schedule elective Caesarean sections to avoid experiences such as Ibrahim's, obstetricians said.

At al-Hayat Hospital in Baghdad, doctors used to perform 160 vaginal deliveries a week, said Maysoon Abbas, an obstetrician. As of Dec. 29, they had done 59 during the entire month.

Patients increasingly plead with her to let them have Caesareans before 5 p.m. because they don't want to drive to the hospital at night.

During curfew, ambulance drivers and even police officers sometimes charge women for rides to the hospital, or refuse to take their husbands out of fear that they are suicide bombers, doctors said.

"It's a tragedy," Abbas said. "It is a tragedy."

Unable or unwilling to go to hospitals, many women are receiving inadequate prenatal care, which is contributing to birth defects, doctors said. Al-Jarrah's obstetrician said she used to see one baby a week with congenital abnormalities. Now she sees five or six.

Many women are opting to go to neighborhood midwives when it is time to deliver.

Samira Najeeb, who delivers babies in a small room with pink walls next to her kitchen in her first-floor apartment in Karrada, insists that midwives are just as capable of delivering babies as doctors, despite having less formal training. Each year, she takes a one-month refresher course, she said.

Her mother was a midwife. Her sister is a midwife. Najeeb delivered her first baby when she was 12. Now 40, she keeps a handwritten record of the 350 or so babies she has delivered.

"When there's difficulty getting to the hospital, they come to me," she said. "Now work for me is better than before."

A Mother's Painful Plea

In Ibrahim's room at al-Jarrah, 19 hours after their ordeal began, Saeed tended to her daughter-in-law. She had been wheeled out of surgery a few minutes earlier.

Ibrahim is 20 years old. She lost her father in the Iran-Iraq war when she was 2.

She lost her brother-in-law to a kidnapper four months ago.

Saeed did not want to tell her yet that she had lost her newborn son as well.

After her father died, Ibrahim went to live with her aunt because her mother had too many children to care for. She did not go to high school or college and has never worked at a job, Saeed said. All Ibrahim ever wanted was to be a wife and a mother.

At age 16, she had her first son.

Saeed recalled that her own son, 26, Ibrahim's husband and the owner of an auto parts store, was reluctant to have a second child. Shootouts happen in broad daylight in their neighborhood. Mortar shells destroy homes. But Ibrahim was insistent. She was going to name her new son after her murdered brother-in-law.

Ibrahim moved in and out of consciousness as she recovered. Her lips quivered. She coughed. She told Saeed she was cold.

Saeed, a short, plump woman, took off her abaya and placed it on top of Ibrahim's blankets. "By the name of God, save her," she said, patting Ibrahim's curly, dark brown hair.

"Why am I here? Why am I feeling cold?" Ibrahim asked.

Saeed found a purple bathrobe and placed it on top of Ibrahim.

"My stomach hurts me," Ibrahim said.

She grew more agitated.

"What's wrong with my son?" she asked Saeed.

"Nothing is wrong with him," Saeed answered.

"Did he die?" Ibrahim asked.

"No, he didn't die. He's in the baby's room. He's very tired," Saeed said.

"I want to warm him up," Ibrahim said. "Please keep him warm."



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