CAIRO — When Farida, not her real name, started feeling extreme fatigue and pain in early April, she chalked it up to her increased load of housework. Schools were suspended and daycare centers closed, and so she has had to shoulder the responsibility of caring for her two children under age 6 — full time, all by herself.

Farida is also a freelance journalist, and keeps herself updated on COVID-19 outbreaks in hospitals, and so rather than risk contagion by visiting a doctor, she opted to rest and take herbs to try and feel better. But by mid-April, the young mother's symptoms had only intensified. After she missed her period, it hit there that she was probably pregnant. A trip to the doctor was no longer avoidable, so she called the OB-GYN who had helped deliver her two daughters, only to learn that his office was closed until further notice.

For an entire week, she searched for a trusted and recommended gynecologist. Finally, she found one with the help of a friend. The tests he ordered showed that she was on the verge of losing her fetus. He prescribed some supplements to prevent a miscarriage, but they were not effective. An abortion was inevitable.

Both Farida and the doctor agreed that hospitals, public and private, were out of the question. News of medical workers contracting the novel coronavirus were popping up daily on social media, particularly among doctors' groups. She had to cope with the bleeding for another week, until she managed to find a doctor's office with a simple procedure room that she could rent.

Meanwhile, on the poorer side of the capital, on the ground floor of a building where her husband works as a doorman, 22-year-old Sahar Zakariya was repeatedly rushing to the bathroom: a corner in the small room where she and her husband live with their daughter, partitioned off with a curtain full of holes.

For days, she had been vomiting and coughing. Fearing for her four-month-old fetus because of the rheumatic fever that she has been coping with since childhood, she went to a service center maintained by the nearby church, where her family usually goes for affordable medical care. There, she was informed by security personnel that the OB-GYN clinic, among other services, was closed due to the coronavirus pandemic.

Desperate to stop the recurring vomiting and ease the unrelenting stomach and back pains, Zakariya then tried several pharmacies. But once they saw her pregnant belly, pharmacists would refuse to sell her anything without a prescription. She finally headed to an outpatient surgery hospital as a last resort, but the situation at the gynecology clinic there was no better: Doctors had stopped coming several days earlier, also due to the coronavirus pandemic, she said.

"I haven't seen a doctor in six weeks," says Zakariya. "I don't have my doctor's phone number. The hospital staff refused to give it to me. The pain is too much, I need some medicine. How long is this coronavirus thing going to last? I deliver by c-section. How am I going to give birth?"

Medically unnecessary caesarean deliveries have soared since 2017 to place Egypt among countries with the highest rates of c-sections in the world. In 2018, a record 63% of all deliveries in Egypt were caesarean, according to the WHO. Several investigative reports have been published by journalists on the profit-driven rise in c-sections, but they have had little effect.

Zakariya and other women like her still find themselves in a predicament exacerbated by a fast-spreading novel virus that has, as of now, infected over 8 million people around the globe. With more and more Egyptian hospitals becoming COVID-19 hotspots, those seeking medical care — including pregnant women, women in labor and those who experience miscarriages — face the risk of infection.

"We have a serious problem," says Dr. Khaled Amin, the head of the OB-GYN department at the public Sheikh Zayed Central Hospital. "There is an alarming number of women who deliver by c-section. These women have nowhere else to go to give birth but hospitals. And hospitals are generally high-infection risk settings, especially so these days."

In 2018, a record 63% of all deliveries in Egypt were caesarean.

Farida resigned herself to seeing a doctor she did not know. "I was so scared," she says. "I didn't trust that doctor. I didn't know him. I had never seen him before. But he was reassuring and he helped me sleep the night before [the surgery.] I hadn't been sleeping for a while." But once inside, all the fear came surging back. "Once I laid eyes on the procedure room, I was terrified," she says. "I thought, that's it; I'm going to die. It wasn't an operating room like that you would find in a hospital. It was just a room with a bed, some surgical tools and a [surgical] light. I was disheartened that my doctor wasn't there for me, to be honest. I felt let down."

Dr. Eman Hashim, a sexual and reproductive health specialist, says that patients need to trust the doctor providing them with health care — especially women with conditions that involve sexual organs, pregnancy or birth. "Women need all the support and reassurance that they can get," the specialist explains. "Having a doctor who knows their medical history is comforting in stressful situations, such as pregnancies, births and abortions."

Zakariya points out how money issues complicate the treatment scenario as well. "A consultation at a private practice would cost $9. But my husband only makes $12 per week," says. "I go to the church hospital because a consultation only costs 30 cents there. At the time of the birth of my first child, they made me get up and leave the operating room for falling $9 short on payment."

She was later re-admitted to the delivery room at the same hospital after her husband paid the amount owed.

Shortly after COVID-19 was declared a pandemic on March 11, the WHO warned about the strain on health care systems undermining their capacity to help non-coronavirus cases, such as high-risk patients with chronic diseases, pregnant women and women in labor.

On March 23, the UNFPA released a brief about the severe impact on reproductive health services available to women around the globe due to the diversion of medical workers, staff and funding toward combating the pandemic. The brief also outlines ways to protect women's health safety during the crisis, including prioritizing the protection of health care workers. It instructs that areas where pregnant women and women in labor are provided with care should be completely segregated from areas where COVID-19 patients are treated. This requires a dedicated protocol for health care facilities in countries battling the virus.

On May 22, Britain's Royal College of Obstetricians and Gynecologists released updated instructions for medical workers who provide care to pregnant and breastfeeding women with COVID-19. The report makes no reference to any special measures or protocols for pregnant patients, although it also advises that pregnant women and women in labor should receive health care in separate areas away from COVID-19 patients. Additionally, it urges pregnant women with COVID-19 to inform health care workers of their condition ahead of time before visiting a clinic or health center, in order to protect medical workers and other pregnant women.

But Egypt's Health Ministry has not publicly detailed any information on pregnant women in quarantine hospitals. It has yet to issue any work papers monitoring the health conditions of pregnant women who have the virus or have been in contact with confirmed cases. Last week, the Ministry advised women to delay pregnancy during the pandemic.

According to Dr. Amin, who is also the head of the Giza division of the Doctors' Syndicate, the Health Ministry has not put in place a standard protocol on treating pregnant women and women in labor during the pandemic.

"But the entire world is grappling with this new and unusual situation," he says. "Egypt is no different. We're dealing with an unprecedented emergency. To expect that we would have an established protocol in the midst of such disastrous conditions is, at best, wishful thinking."

The doctor also says that under the circumstances, with medical workers falling ill, one after the other, it is actually unrealistic to demand that the Health Ministry set a standard protocol while the race is still on to provide then with adequate protective equipment and testing.

"Separating some outpatient clinics and moving them away from hospitals and into nearby health care centers was a step in the right direction by the Health Ministry, but it's not enough," he adds. "Pregnant women are facing a truly difficult situation, given that c-sections are the most commonly used technique. Unfortunately, they have no choice but to go to hospitals despite the circumstances."

The ongoing crisis in Egypt is exactly what international organizations warned would happen in under-resourced health care systems, according to Dr. Amin.

"There are indications of a recent rise in death rates among cardiac patients. Clinics dedicated to rare and life-threatening conditions have been shut down, leaving their patients at risk. It's not only pregnant women and women in labor," he says. "Anyone who needs ongoing or emergency medical care on an inpatient basis is now at risk, given the increasing number of medical workers contracting the infection as well as the closure of hospitals and some outpatient clinics. This is what really needs to be dealt with."

Dr. Amin also says that some pregnant women worry so much that they wait too long after the onset of fatigue before they go to a hospital. "We have had cases come in with dangerously low levels of amniotic fluid, threatening both the fetus's life and to the mother's health," he explains.

In a COVID-19 quarantine hospital in Cairo — Photo: Xinhua/ZUMA

The lack of a standard protocol did not, however, stop Dr. Amin from trying to protect pregnant women and women in labor who come to Sheikh Zayed Central Hospital for help.

"We can't really call it a protocol; it's more of an initiative by doctors," he explains. "What we did was set up a safe passage for pregnant women to get to the gynecological clinic. It provides them with total isolation from other patients and medical workers. I haven't heard of any similar initiatives at other hospitals. We don't have a protocol. But we do have our observations, and we use them to shape how we engage with pregnant women in this novel climate."

On May 21, the Health Ministry officially announced that 320 more public, central and insurance hospitals operating under its supervision were enlisted to test potential COVID-19 cases as well as quarantine and treat patients in moderate condition. Manshiyet al-Bakry, a hospital recommended to Zakariya by her neighbor, Omm Aya, was one of them.

"My neighbor told me that she gave birth at Manshiyet al-Bakry Hospital. She recommended it as an affordable option," she says. Our interview with Zakariya took place before the announcement. Later, several medical workers at Manshiyet al-Bakry tested COVID-19 positive.

Mada Masr tried to contact Dr. Alaa Eid, the director general of preventative medicine at the Health Ministry, to find out about the training provided to doctors at recently enlisted hospitals and whether any special protocols were put in place to protect health care recipients who are not COVID-19 patients. He did not answer our calls.

Despite the novelty of the situation, as pointed out by Dr. Amin, there have been initiatives in other countries to document doctors' observations treating pregnant women, fetuses and newborn infants during the pandemic, and develop guidelines for gynecologists and obstetricians. These include, for example, a page maintained by the Royal College of Obstetricians and Gynecologists, one set up by the medical non-profit KFF and one edited by the OB-GYN staff at Massachusetts General Hospital.

"Generally, in Egypt, there are no such initiatives that document medical experiences during crises and catalog them to serve as a reference," says Dr. Ahmed Hussein, a former board member with the Doctors' Syndicate. "If doctors were to start such a website or page, it may introduce yet another point of friction between them and the state," he says. "Everyone just waits until the Ministry issues guidelines and protocols, if it ever does. And even then, they're usually nothing more than an instruction sheet that isn't based on doctors' on-the-ground experiences.

Dr. Hussien says that in this current case, the lack of a standard, ministry-issued protocol concerning pregnant women (or any health care recipients with chronic conditions) may actually be a positive thing.

"It allows doctors the freedom to utilize their skills, medical experience and scientific knowledge to save their patients," he explains. "If the ministry establishes a standard protocol in its typical manner, doctors would be forced to follow it; they would not be able to act outside of the confines of the protocol to save their patients. The health care system is in a state of disrepair. Everyone operating within it is fully aware that it has, so far, been unable to absorb the shock of COVID-19. A doctor may only act based on the skills and experience they have. And Egyptian doctors have proven, time and again, that they go above and beyond to save their patients. The Ministry, on the other hand, has no vision or planning."

Dr. Shadia Mohamed, a consultant-level OB-GYN, initially continued to provide medical care to women at a mosque clinic in Manshiyet Nasser, one of Cairo's poorest and most overcrowded districts. But on June 12, she finally decided not to go back.

"It breaks my heart to stop going to the center, where I served women for 16 years," she says. "The district is truly impoverished. [The women there] are in need of devoted, quality health care. But I have no choice, because of the persistent bad practices which put me and my family at risk."

The day Dr. Mohamed made her decision, she examined three patients whom she suspects may have been suffering from COVID-19. "A woman came into the clinic with almost all the symptoms. She wasn't wearing a face mask. She came in accompanied by other women, like people in this district usually do. As it turned out, she was looking for the internal medicine clinic. But when I asked her why she wasn't wearing a mask, she was offended."

The doctor says that the same thing happened twice more that same day. "Women coming in with their children, neighbors and relatives. None of them taking any protective measures," she explains. "Large crowds cramming together in that small office. Each patient with an entire host of attendants insisting on accompanying her into the examination room, some of them exhibiting COVID-19-like symptoms."

This was a regular occurrence for a month, so Dr. Mohamed eventually decided to quit the clinic. "I'm 65 years old; I live with my daughters," she says. "Even if I don't fear for my own life, I have a responsibility to protect the life and health of my family members."

Dr. Hussein says that neither the syndicate nor the Ministry has any kind of authority over privately owned clinics, hospitals and medical centers with regards to whether or not they continue to operate.

"The Ministry is merely a medical oversight body," he explains. "These institutions are like any other private enterprise, in that it is up to the owner to decide if they work or not and at what times, within the framework of the pertinent regulatory laws. Thus, neither the state nor the syndicate can hold a doctor accountable for shutting down their practice during a pandemic. This choice is understandable, too, given how little we know about this virus and the contradictions in information coming out of trusted bodies regarding methods of transmission. Even if I don't personally condone [this choice], I certainly understand it."

Dr. Amin concurs. "Doctors should not be penalized for ceasing to operate their own private practice. But they do, of course, have a moral obligation to ensure that their patients continue to receive medical care, by referring them to other hospitals or clinics," he says. "OB-GYN clinics at public hospitals have indeed been receiving new patients every day. They tell us that they started coming to us because the private practices they used to follow up with shut down. However, I believe these shutdowns were due to the curfew and Ramdan — rather than doctors being afraid of the risk of infection, as is widely said."

Dr. Amin says that that doctors aren't really held to account for shutting down their private practice or even for failing to refer their patients. "But refusing to provide health care to patients at public hospitals, under any circumstances, especially in emergency and life-threatening cases, is criminal — both morally and legally," he says.

Contrary to Dr. Mohamed's experience, Dr. Amin has noticed a change of habits practiced by patients. "To tell you the truth, the virus has helped curb a lot of bad habits. [Pregnant] women used to come in every month for a sonogram, even though that's unnecessary," he says. "They no longer do that. They also stopped bringing their children to the hospital. We no longer see a large number of attendants, including mothers and husbands, accompanying pregnant women and women in labor. This can help relieve the pressure from hospitals and medical workers, as well as lower the possibility of the virus spreading."

All four experts interviewed by Mada Masr agree that it is dangerous for people to continue to go into hospitals and clinics for no medical reason. They believe pregnant women should be discouraged from having regular sonograms, and only have them when recommended by a doctor for a medical reason. Family members accompanying the expecting mother during labor should also be discouraged, the four experts say.

"Thank God, I made it out without an infection."

Raghda Hashim did exactly that when she gave birth at a hospital on April 14. "For the birth of my first child, my family and my husband's family came with me," she says. "This time, I only took my husband. Doctors refused to let him into the delivery room, unlike the first time when he came in with me and filmed the delivery."

Hashim was still fearful, despite the preventive measures taken by the hospital staff. "The nurses sterilized the operating room, but I took it upon myself to go over everything with rubbing alcohol anyway. Thank God, I made it out without an infection."

Azza Mostafa, another new mother, also took additional precautions. Her husband booked a delivery room at a private hospital for a day when it was closed, hoping to limit exposure as much as possible. For Mostafa, who has been "obsessive about cleanliness" since she was a kid, it was the only way her anxiety could be eased.

"I was panic-stricken when my doctor shut down his practice," she recalls. "I felt like I had the worst luck. I was barreling toward my due date, and my doctor wasn't there with me. I even started thinking of ways to postpone the delivery, despite the risks to myself and to the baby. All I could think of was that the hospital, where it's supposed to be safest, had become the most dangerous place on earth."


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