Al-Watan – Popular sayings attest to how dearly Egyptians cherish their children. But in Egypt, 100,000 infants are dying each year due to a chronic shortage of neonatal incubators in units caring for prematurely-born or under-grown babies.
Al-Watan has tracked the tragic experiences of several families whose joy at the arrival of a newborn quickly turned to grief because the infant could not be saved due to the unavailability of incubators in government hospitals. This investigative report found that the problem does not stop there. It is compounded by the serial violation of regulations in neonatal units, a severe shortage of qualified nurses to staff them, and a longstanding legacy of administrative neglect.
Muhammad Eid Thabet clearly remembers the day Adam died. When his wife started having contractions, he rushed her to Umm al-Masriyeen Hospital in Giza. She was going into labor and moaning in agony. But doctors told him she could not be admitted because there was no incubator available for the baby. He became alarmed. The baby was starting to descend, and the mother could no longer stand the pain. It was suggested they go to al-Galaa Hospital in central Cairo. They went, but were told the same thing there. His wife clutched his hand and gave him an agonized look of desperation. The child’s head was emerging, but they knew its life would be in danger without an incubator. The father called friends and relatives on his mobile phone to ask them to help find a hospital with an available incubator.
They raced against time scouring different parts of the city for one – the Pyramids… Zaitoun… Nasr City – but to no avail. No free incubator could be found. Private hospitals charged between 400 Egyptian pounds (LE) and LE 1,000 a night for one, unaffordable for a low-paid worker like Muhammad. They ended up in Demerdash Hospital, which agreed to admit his wife on condition that he sign a document absolving the hospital of any liability should it be unable to provide an incubator immediately after the birth. He signed readily. Adam was born with weak lungs that could not provide him with enough oxygen. Muhammad waited for a friend or relative to call to tell him they had found a hospital with an incubator that could take the baby. He remembers the anguish he felt as the time passed. He died a thousand times before he was finally informed of the death of his newborn son.
Adam is not the only victim of the incubator shortage in public hospitals. Ministry of Health statistics, contained in a report on the state of hospitals that was posted on the ministry’s website for only a few hours before it was removed, indicated that there were 2,382,000 births in Egypt in 2010. Around 10% of those babies — i.e. 238,200 – will have needed neonatal incubation, according to Dr Hisham Shihab, former head of the health ministry’s medical treatment division. But the total number of incubators in all public health facilities amounts to only 3,689. One incubator can deal with an average of 30 babies per year, giving a total figure of some 111,000. That means more than 127,000 newborns have no access to incubators, and thus risk death due to the acute shortage.
Dr Alaa Ghannam, who heads the Health and Human Rights Program at the Egyptian Initiative for Personal Rights, explains that the World Health Organization (WHO) classifies countries into three groups regarding the proportion of premature babies who require incubators. In high income countries it amounts to less than 1%; it reaches 25% in very poor countries: and in middle-income countries, including Egypt, it stands at 10% and above.
The Role of Voluntary Organizations
Adam’s parents went through a similar experience when the birth of their second child approached. Muhammad again found himself sitting outside the delivery room at al-Galaa Hospital fearing the worst.
But suddenly, he felt a hand on his shoulder and heard a voice asking: “Are you looking for an incubator?” At first he thought his anguish had made him start to hallucinate. But when he looked up he found a man standing in front of him waiting for a reply. “Yes, yes,” he responded. The man introduced himself as a member of the Alshareyah Society, which provides free incubators for children who cannot obtain them in public hospitals. He said he had learned of Muhammad’s case from a nurse at the hospital, and would wait for him downstairs.
Little baby Fatima was indeed taken to the Alshareyah Society’s center in Nasr City, and remained there for 25 days before her parents took her home.
The Alshareya Society is one of Egypt’s largest charities focusing on the promotion of Islam and the provision of social and medical services — including 750 incubators which it makes available for premature babies in different part of the country. It is the only charity offering such a service for free.
The Society’s medical advisor, Dr. Muhammad Rashad, said it started doing this after conducting a study which found that there were 3,500 fewer incubators in government hospitals than required in light of the national birth-rate — and the shortfall rises to 6,000 if the incubators owned by private hospitals are excluded.
Nurses Without Hearts
We went to al-Galaa Hospital, not because Fatima and Adam’s parents twice failed to find an incubator there, but because it is the biggest maternity hospital serving the Cairo and Qalyubia governorates and also receives thousands of patients from other nearby districts.
The head of the hospital’s Premature Births Unit, Dr Amr al-Khashshab, said it performs between 1,200 and 2,100 deliveries per month. The Ministry of Health’s statistics on the mortality rate for premature babies at al-Galaa are shocking: 31% percent in January 2010, rising to 43% in March, before falling back to 29% in November that year.
We encountered – and documented on video – many surprises during our tour of al-Galaa Hospital. At the main entrance to the Premature Births Unit, people were sitting on the stairs waiting for news from here or there about the availability of an empty incubator. Voices rose: “Have mercy… the kids will die.” One family was keeping calm: they’d been lucky enough to secure one from the Alshareya Society. They waited by the door until a nurse emerged holding their baby wrapped in a sheet. One of the relatives shouted, “hurry up, hurry up, the child is sick.” The nurse smiled at him, and asked where the “celebration gift” for the newborn were. We noticed that most of the nurses bargain with the parents for “gifts” before handing over the babies.
The man put his hand in his pocket and took out a few pounds. But they clearly did not match the nurse’s expectations. “Is that his worth, a child, God protect him?” retorted the middle-aged nurse. But the father was already shouting at her: “The boy is sick because of you! Nobody would hold a piece of meat out in the sun like that!” That seemed to startle her into hurrying to pass the child to the Alshareya Society nurse waiting by the door of an ambulance equipped with a mobile incubator, where the baby was placed until it was transferred to one of the Society’s incubators.
Accusations and Rule-Breaking
Dr Khashshab questioned the account of the baby wrapped in the sheet when confronted with it. “I cannot imagine such a thing happening here,” he said. He added that the responsibility for transferring babies out of the hospital lay with the party transferring them, i.e. the Alshareya Society. The Society’s Dr Rashad, however, said that the hospital had responsibility for the child until it was in the custody of the Society, i.e. at the ambulance door.
Dr Khashshab explained there were a number of reasons for the shortage of incubators, including space shortages inside hospitals: “The distance between incubators should be no less than one or two meters, in order to avoid infections occurring between the babies. Of course, in advanced countries they apply international standards providing for six meters between them, but because we lack the resources we have to ignore that. We have 22 incubators in the free sections, and nine in the commercial section. An incubator isn’t just a glass box you put a baby in. It requires a lot of support, including a nursing team. Theoretically you need to have one nurse for every two babies at most, but in reality we have one nurse for every eight babies.”
Dr Khashshab did not deny that regulations are routinely breached regarding the maximum number of babies who can be placed on the “servo” – a device for keeping babies warm for a few hours until an incubator becomes available. But he said insufficient funding for public hospitals made that unavoidable. “We know that the maximum number of babies to put be put on the servo is two, but sometimes we have to put five at the same time.”
He conceded that this was potentially dangerous. “Babies of this age easily catch infections from each other. But what can we do when we receive between 40 and 70 cases every day? We do tell the doctors that the maximum time a baby can be kept on the servo is 24 hours, but some of them stay there for days.”
The Hardest Choice Ever
The situation in Alexandra differs little from that in Cairo. The city hosts the country’s biggest university maternity hospital, al-Shatebi Hospital, which also serves the governorates of Kafr al-Sheikh, Buhaira, and Mersa Matrouh. Figures made available to al-Watan show that it performed between 45 and 79 deliveries per day, even though – according to a former head of its premature babies unit – only 40 of its 55 incubators are functioning.
Samia Ali Ibrahim went to al-Shatebi from Buhaira to have her pregnancy monitored on the advice of her doctor after it transpired she was bearing triplets, and they would need incubators immediately after birth. While on her way to the hospital for a check-up, she started having contractions and, after a long ordeal in the delivery room, gave birth to three babies, all requiring incubation. Samia was still unconscious when the doctors informed the father that there were no incubators available, that the babies’ lives were in danger, and that he would have to find another hospital which had incubators equipped with respirators.
The father listened without replying and felt in his pocket for the few pounds he had there. The cost of incubators in private hospitals in Alexandria starts from LE 500 per night. Tripling the sum was unthinkable. Suddenly, a doctor rushed in to say that an incubator had been vacated. The mother heard him, but did not know what was going on. She asked about her babies and requested to see them. A heavy silence fell on all present, finally broken by one of the doctors: “There is only an incubator for one of them. Which one should we put in it?”
The question struck like a thunderbolt. Samia could not imagine that she or anyone else could ever be made to make such a choice. She lost consciousness again.
After she awoke, she was taken aback by a medical report – al-Watan retains a copy — signed by a doctor from the premature babies unit. It stated that three under-grown babies were delivered by natural birth in poor condition, that there was only one incubator with an artificial respirator in the unit, so one baby named Samia Ali Abu-Ali was placed in it, but no places were available for the other two at the unit or other health ministry facilities, and their death occurred between seven and ten hours after birth.
Dr Magdi Badreddin, a consultant at the hospital and former head of its premature unit, said the reason it has so many more patients than it can handle is that that there is no other specialist maternity teaching hospital in the governorates of Alexandria, Buhaira, Kafr al-Sheikh or Mersa Matrouh. There are units run by the health ministry, but their facilities and expertise are meager and the medical care they provide does not compare with that at the university hospital. He has complained about this situation repeatedly to the authorities.
When the hospital has too many babies needing incubators, he explained, it is forced to do one of two things — both of which put infants’ health at risk. They can either be transferred to other hospitals if found, which is dangerous for premature babies; or else – and this happens a lot – they are placed alongside others on the servo heater in the premature babies waiting room.
Premature Babies Waiting Room “is a scientific term we invented in Egypt in order to solve the problem,” Dr Badreddin quipped. “But medically and internationally, there is no such thing as a room in which a premature baby must wait for a chance to live while a vacant incubator is found. It entails risks. When there are five babies on a single heater, or ‘servo,’ they are vulnerable to infections, or even falling off because of the overcrowding.“ That actually happened once, and the baby suffered a brain haemorrhage. Dr Badreddin filed another formal complaint after that incident, to no avail.
Dr Badreddin sees little justification for the critical shortage of incubators at al-Shatebin Hospital. Two additional rooms were equipped at the hospital, at a cost of LE 6 million, to take another 16 incubators, which would have gone a long way to alleviating the crisis, he said. But they were not brought into service, because the engineering department served notice that the hospital’s electricity circuits would not be able to cope with the extra load.
Dr Nuha Muhammad, a physician in the premature babies section who wrote a detailed report on the case of Samia’s triplets, said part of the problem was administrative. “We have 26 incubators equipped with respirators out of a total of 50… But there is no coordination between the incubators unit and the gynaecology and maternity departments. They need to know when artificial respirators are unavailable so they stop admitting new cases,” she explained. “But what makes things more complicated is that the cost of an incubator with a respirator can reach 1,000 pounds per day in some private hospitals, and many people cannot afford that. The heater the babies are put on, the ‘servo,’ is only meant to take two at most, but it has got to the point where in some cases, 12 babies are put there side-by-side at the same time. “
Pediatrician Dr Gamal Batran said poor administration was the key underlying cause of the thousands of infant deaths caused annually in Egypt by the lack of incubators and the moving of premature babies between hospitals in search of them. As a result, babies were being kept on temporary heaters for far longer than permitted by local or international regulations. One baby, he said, had died of burns after being left too long on such a device in a government hospital.
Dr Ashraf Galal, the dean of Alexandria University’s medical school and the man in charge of its hospitals, including al-Shatebi, conceded that the inadequate provision of incubators was a critical problem. But he said it was compounded by an equally acute shortage of qualified nurses. He said that while there are supposed to be 18 nurses staffing each shift, usually no more than around eight show up.
Meawhile, “we have huge numbers of maternity cases coming to us every day,” he said. “We cannot turn people away. They refuse to go, and quarrels break out between them and hospital security. They see us as their only hope, especially as the cost of a caesarian delivery in other government hospitals ranges between LE 250 and 900, whereas here they only pay the LE 40 admission fee.”
As for the piling up of a dozen babies at a time on a servo, the dean replied: “I did not see the case myself, but I’ve seen pictures of over eight babies together on a single servo. But in any case we should look at the half full cup and not just the empty half. I admit we have a problem and our services are deficient. But there have been meetings between the health ministry and medical institutions, university hospitals and health insurance to resolve the crisis of lack of coordination between all these parties – although it won’t be resolved overnight.”
Absent Planning, Fleeing Nurses
Dr Hassan al-Burnus, former MP and chairman of parliament’s health committee, said he had inspected the relevant health ministry documents, and found that it had no plans to address the need for additional incubators to match the rising annual number of births in the country. According to Burnus, a leading member of the Freedom and Justice Party (FJP), five parties share responsibility for the crisis: the university hospitals, the health ministry, health insurance, the armed forces and the police. The complete absence of coordination between them compounds it and makes it harder to resolve.
So does the nursing factor. Burnus said that while the international norm is for there to be around three nurses per one doctor, Egypt has some 200,000 doctors but only 170,000 nurses — and needs at least double that number. In premature birth units, while there should be a nurse in charge of every one or two incubators, in reality there is one nurse for every eight or ten. They are deterred from working in premature units by the low pay they receive for such hard work in comparison with what they can earn at private hospitals. But instead of acting to tackle this problem, the former health minister, Hatem al-Gabali, switched the nursing school training program from a three- to a five-year course system, meaning no new nursing graduates for two years.
The head of palliative care at the health ministry, Dr Adel Abu-Zeid, conceded there is a major shortfall in the provision of incubators, and that it puts the lives of premature and under-grown babies at risk. But he said the ministry was trying to find solutions to the problem. As a first step, it had conducted a major survey to find out how many incubators there are in the country. “There were no statistics about this problem before,” he said. “But we have done a study about it, and as a result requested the purchase of 500 new incubators just as a preliminary solution. The issue is still under study to find a way of ending the long-standing headache in the health sector caused by the incubators and those responsible for them. But it will need some time.”
Several months have been taken up by the production of this report. Mothers’ screams meanwhile continue to fill the air, while long lines of fathers, their poverty compounding the pain, stand waiting for a vacant government incubator, in the hope of returning home with a birth certificate for their cherished one, and not a death certificate giving the shortage of incubators as the cause of death.
This report was produced with help from ARIJ, Arab Reporters for Investigative Journalism, under the supervision of Ali Zalat.