On June 8, the second day of the Muslim holy month of Ramadan, Fatma* took her newborn baby to Aleppo's Children's Hospital. Days after she gave birth, her baby boy began to experience problems breathing.
"He was turning blue," said the 29-year-old mother of five. The doctors placed the baby in one of Aleppo's 20 remaining incubators and Fatma exited the facilities. Moments later, inside her parked vehicle, she watched as a missile hit the hospital.
Government air strikes across rebel-held Aleppo and the deliberate targeting of medical facilities present yet another deadly challenge for pregnant women and newborn infants in the besieged city.
|The aerial attacks across rebel-held Aleppo have decimated the obstetric care infrastructure that was once available to pregnant women [Ismael Abdulrahman/IDA/Al Jazeera]
There were seven nurses and two doctors in the children's hospital at 10:05 am that Wednesday, at the time of the air strike. After the attack, amid clouds of dust and broken glass, the doctors rushed nine newborn infants to the basement and carried roughly 30 children and infants to a section of the hospital that had been spared.
All nine babies survived and stayed in incubators underground for two days. While the children's hospital closed partially, its medical staff never evacuated. Volunteers joined the hospital's staff to help with repairs. After only two days, the hospital reopened and was back on its regular work schedule of receiving between 15 and 20 newborns every day for paediatric check-ups.
The aerial attacks across rebel-held Aleppo have decimated the obstetric care infrastructure that was once available to pregnant women in Syria. Al-Zahra Hospital, the last remaining obstetric clinic in Aleppo, and the Children's Hospital are both supported by the Independent Doctors Association, a Syrian medical NGO based in Gaziantep that runs medical facilities in Aleppo province.
Of the two remaining general hospitals, Omar Bin Abdulaziz Hospital and Al-Quds Hospital, the former has a small obstetric department but has come under attack in the month of June, and the latter closed down after the air strike on April 28 which killed approximately 30 people.
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Today, Al-Zahra Hospital specialises in obstetric care, assisting in the majority of births in eastern Aleppo. It is the last of its kind. The small clinic has only one operating room, nine medical beds, and one delivery room with three beds. About 100 pregnant women visit the clinic every day and 30 births take place.
"The hospital is very small and we have to reduce recovery time," explained Dr Malek, one of the last three gynecologists in eastern Aleppo, in a phone interview. "Normally, women who undergo C-sections need between 12 and 24 hours of recovery time," he continued, "but here we discharge them in three hours."
The lack of healthcare facilities and medical staff in eastern Aleppo has created a void in prenatal and postnatal care. The small supply of doctors makes it impossible for the three gynecologists working in Al-Zahra to take appointments.
"Before the war, pregnant women would see their doctors nine to 10 times," said Dr Malek.
The gynecologists all work 24-hour shifts for 10 consecutive days and rotate, but it is not enough. Furthermore, patients must still wait on average around four hours before they see a doctor. "It is exhausting work and there is a serious need for another hospital in Aleppo for pregnant women and deliveries."
The hospital is very small and we have to reduce recovery time. Normally, women who undergo C-sections need between 12 and 24 hours of recovery time but here we discharge them in three hours.
In the meantime, most women visit the clinic only to give birth to their children.
Access to the seven hospitals operating in eastern Aleppo is also a great impediment when women seek obstetric care. A visit to Al-Zahra can prove to be a life-threatening endeavour.
Public transportation and taxis stop running at night for fear of attacks and pregnant women in need of urgent care must wait until the next morning to reach the clinic. "Sometimes women give birth at the hospital's door,” said Dr Malek.
According to Dr Malek, the lack of medical facilities, doctors and unsafe access to hospitals has led to an upsurge of clandestine clinics run by "inexperienced and uncertified midwives".
"These are very dangerous and have negative effects on the newborn babies," explained Dr Hatem, the director of the Children's Hospital. "Sometimes they bring the newborns to our hospital after two to three hours from birth and we find them in terrible health. Many of them are dead before they reach our hospital."
The five years of Syria's civil war have killed more than 400,000 people, according to a report by the Syrian Center for Policy Research and pushed thousands to the brink of starvation.
| Nine newborns stayed in incubators underground for two days after the attack [Ismael Abdulrahman/IDA/Al Jazeera]
Stress, poverty, poor health and malnutrition in pregnant women are all leading causes for prematurity and miscarriages. Any given month, Al-Zahra Hospital assists on the birth of 20 premature infants, according to Dr Malek.
Dr Malek treats one or two cases of anaemia in pregnant women who, depending on the severity of the case, may require blood transfusions. Malnutrition in pregnant women is harder to treat. "They need a dietary programme and this depends on the financial state of the family," Dr Malek told Al Jazeera. "They are not supported by any NGO."
The price of baby milk in eastern Aleppo, for instance, is around 3,200 Syrian pounds ($6.6 USD).
"Mothers prefer to breastfeed, but a lot of them can't access their babies," explained Dr Mustafa, a paediatrician working at the Children's Hospital, 300 metres away from Al-Zahra. "They send their husbands to check up on their children."
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Indeed, for women who have children at home, paying a visit to their children in the hospital is not always a sensible choice. Ruaa, also a mother of one of the nine babies inside the hospital on the day of the air strike, chose to return home to her three children after witnessing the attack on the children's hospital. For a whole hour, Ruaa remained uncertain about the fate of her baby.
In eastern Aleppo, a kilo of diapers stands at 1,200 Syrian pounds ($2.5), a hefty sum for most families. According to Dr Malek, some women ask to be sterilised after they give birth. There are still others who ask for contraception, which al-Zahraa offers despite its shortage of birth control.
"There are some cases of women that ask for an abortion," said Dr Malek. But the hospital does not perform an abortion unless there is a medical reason that makes it necessary. In these cases, continued Dr Malek, women opt for dangerous and alternative methods with the aid of clandestine midwives.
Pregnancy in Aleppo is plagued with precariousness and uncertainty. Women lack the necessary access to prenatal and postnatal care, and even when scarce medical care is available, patients are made into targets. "This is where we live," said one of the doctors working in Al-Zahra. "We don't have a choice but to keep fighting."
*All the names in this article have been changed at the subjects' requests, except for Dr. Malek, who agreed to use his name for the purposes of this article.