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 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.

“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,” says Intissar. “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.”

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.

Safer births

“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.”

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.

Today, the morning’s first patient is 32-year-old Assia, who is somehow managing to smile through her contractions while 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 well-being.”

While 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.

Women at risk

“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 while 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.”