On the Frontline with Lebanese Midwives

On a rainy and cold November night, Rayane sat outside her neighbor’s classroom in Tariq-El-Jdideh, a predominantly Sunni district in Beirut. She had moved to the neighborhood, already pregnant, two months before, when she was displaced from Dahiyeh, a suburb on the southern edge of the city during the heavy Israeli bombardment that began mid-September in Beirut, and that has been ravaging the country’s south for over a year.

Sixteen years old and nine months pregnant, Rayane had wrapped herself in a pink bathrobe with black hearts and welcomed her midwife, Darine Ayoub, who had been accompanying her for over a month now. Like Rayane and an estimated 1.2 million Lebanese, Ayoub had also been displaced by the conflict. Originally from the southern suburbs of Beirut, she found shelter with her extended family in a flat closer to the center, in what is considered a safer neighborhood. She finds meaning and purpose in her work and says that helping other displaced women is essential for her to avoid “sinking into depression.”

Ayoub is part of the Order of Midwives, which was created by the Lebanese government in 2014. With 300 midwives offering emergency care and home visits to pregnant women, the initiative aims to address the country’s maternal mortality rate, which almost tripled in the space of a few years from 13.7 in 2019 to 37 deaths per 100,000 births in 2022. The country’s severe economic crisis that began in 2019, combined with the coronavirus epidemic, proved a lethal cocktail for access to healthcare in a country with an already failing health system. According to the Ministry of Health statistics in 2023, a drop was recorded in 2022, with a ratio of 15.4 deaths per 100,000 births. But the ratio has risen again in the last year to 25.4 deaths per 100,000 births.

Ayoub placed her hands on her patient’s rounded belly. “Can you feel the baby’s movements?” The veteran midwife asked. “You must tell him: ‘I love you very much, and you’re going to be called Jad; Dad loves you too.’ Do you know he can hear you?”

The classroom where Ayoub carried out her consultation doubled as a kitchen, living room, and bedroom for several families. Rayane’s social context was equally precarious, with little support system: her mother and husband were out of the picture, her father is impoverished and her brother lives with a disability. 

“She’s like an orphan,” the midwife said.

For the first months of her pregnancy, Rayane had had almost no pre-natal care. 

Serving Women Displaced by Israeli Bombs 

In response to the war, 57 satellite units in primary health centers and five mobile units have been launched in addition to the home visit program. Since October, UNICEF, which is a partner in the program, along with the Lebanese Ministry of Health, claims that over 2,500 displaced women have had access to care under the program.

“We have also asked our midwives to look for pregnant women in their networks…This way, they can inform their colleagues or the coordinator that a pregnant woman is around,” explains Dr Rima Cheaito, President of the Lebanese Order of Midwives.

Midwives receive incentives for visiting women affected by the war — $8 per patient or  $15 for visits lasting around one hour. However, the economic crisis has led to an almost total devaluation of the local currency, so midwives now only receive a few hundred dollars a month at best. Ayoub works in several medical settings, struggling to earn a salary of $500 a month.

Cramped Conditions 

In another school shelter, Ayoub climbed the six flights of stairs to reach a tiny classroom where two of her patients live with their families. More than sixty people were living in this tangle of corridors and small rooms. There is only one toilet and no shower. Rouqaya, aged 32, was expecting her second child, 12 years after her first. “I’m afraid of having a cesarean section. And I’m afraid of cleanliness because there’s not enough water here. The toilets are small…There are a lot of infections, like urinary tract infections…” she explained. 

Since the Israeli ceasefire on Nov. 27, the bombs and the explosions have stopped, at least up north of the Litani River. But pregnant women still need care.

Next to her, Malak, 23, expecting her second child, nodded in agreement. The two expectant mothers were delighted by the midwife’s visit, to whom they listened with rapt attention. “Darine helps us by asking about the baby, taking my blood pressure, and bringing me medication, even though I’m still short of it,” said Malak, as her young daughter played on a mattress next to her.

“We learned during the 2006 war that displaced people needed prenatal care. This is extremely important because it enables us to detect pregnant women at risk and provide them with the care they need to reduce maternal morbidity,” explained Dr Ghina Ghazeeri Professor of Obstetrics and Gynaecology at the American University of Beirut. 

The university hospital has set up a reception area dedicated to displaced mothers-to-be. Around thirty patients are seen each week. “In the last six weeks, I have seen three patients with placental abruption. Two of them had been through explosions…It’s linked to war, bombs, and explosions. Two of them had to give birth in an emergency, and one of the babies was sick,” Ghazeeri described, who added that she has also seen many miscarriages. 

She and her team are continuing their research to find out and understand exactly what impact the war has had on the health of pregnant women and their babies. Now, since the Israeli ceasefire on Nov. 27, the bombs and the explosions have stopped, at least up north of the Litani River. But pregnant women still need care.

Putting the Midwife Back at the Heart of the Maternity Care 

Following the ceasefire, nearly 800,000 displaced people have begun to return home, according to the International Organization for Migration. The Order and its 300 midwives continue to give care to women. “They still need follow-up. Besides, many medical infrastructures are still closed when not destroyed. As we can see, there is a lot of instability,” says Cheaito. According to the Lebanese government, there were 67 attacks on hospitals by Israel during this war.

Rayane gave birth to her baby boy Jad on Nov. 22 via cesarean. The little one weighed less than four pounds at birth, and he’s still in the incubator at the ICU unit of one of the leading Beirut hospitals. Rayane left the hospital at the beginning of December and returned home to the southern suburbs. Ayoub also returned home, grateful to find her house still standing. But, for the patient and her midwife, the fragile truce is the first step on a long road toward normalcy.