Gazan rocket attacks may not seem to kill many Jews, with notable, tragic exceptions such as 4-year-old Daniel Tragerman, 16-year-old
Daniel Viflic, and most recently, 80-year-old Inga Avramyan. But Gazan terror
rockets may be killing Jews in other, more insidious ways. Since 2012, for
example, researchers have known that rocket attacks are a significant risk
factor for preterm delivery (PTD), the leading cause of infant mortality among
Jewish Israelis. In effect, one might say that rockets are killing Israeli Jews
even before they are born.
Tamar
Wainstock, PhD, School of Public Health; Faculty of Health
Sciences Ben-Gurion University of the Negev, has done groundbreaking work
on the effect of rocket attacks on pregnancy outcomes for women in Southern Israel. I reached out to
Wainstock who sent me the 2012 study, Was the military operation
“cast lead” a risk factor for preterm deliveries?, along with three related studies that she, personally led.
Pregnancy and Delivery Outcomes: Operation Cast Lead
In the 2012 study, pregnancy and delivery outcomes of women
who gave birth during Operation Cast Lead are compared to those of women who
gave birth during the same time period of 1 and 2 years before and after the
war. Women exposed to the stress of the military campaign were found to have
significantly more preterm deliveries at gestational age 32-34 weeks (1.6% vs.
0.8%).
The researchers introduce the subject of the study as follows (emphasis added):
Gestational age is one of the most important predictors of
an infant’s subsequent health and survival. Preterm infants are at an
increased risk of death or short-term and long-term disability than those
born at term. Preterm delivery (PTD) refers to birth that begins after 20 weeks
gestation and before 37 completed weeks of gestation.
The 2012 study authors explain that stress is recognized as
a risk factor for PTD, offering examples of other stress-producing attacks and
conflicts in various parts of the world that have affected pregnancy outcomes.
At that time (2012), the data was sparse, as the researchers note:
Studies on the influence of war related acute stress on
fertility and pregnancy outcomes are limited and very controversial. The
Persian Gulf War at 1990–1991 which presented Israel with a threat of chemical
attacks on civilian localities have been studied and examined for the effect of
environmental stress on health. After the Gulf War a significant rise of
spontaneous abortions has been observed – starting from 1992, reaching a peak
in 1994, which then began to decline in 1996.
The NATO aggression against Yugoslavia in 1999 included
widespread bombing [affecting] civilians for a period of four month. Krstić et
al. examined the influence of stress on duration of pregnancy and prenatal
outcomes during the NATO operation. They found a significant shortening of the
last trimester under the influence of stress but no significant difference in
the incidence of PTD. Spandorfer et al. examined women undergoing in vitro
fertilization (IVF) cycles over 13 weeks that included September 11th, the
terrorist attack on New York. Although conception rates were similar before and
after the terrorist attacks, patients who became pregnant in the weeks after
September 11th had a pregnancy loss rate of 47.9% compared with 28.6% among
women pregnant in the weeks before this period.
[Aside from these] few studies, there is not enough evidence
of the impact of war and terrorism on gestational duration.
The researchers write of the need for national resilience in
times of emergency:
Emergency national resilience is the physical and mental
ability of the country’s civilian economy and government authorities to ensure
the continued functioning of routine life, in light of the ongoing emergency.
This strength is measured by the ability to effectively manage the event, and
to return to a functional community thereafter. Treatment of populations with
special needs at the time of emergency reflects the society’s resilience.
Preliminary mapping of special populations by the local and national
authorities has a great influence on the ability to handle effectively these
populations during an emergency. Historically special attention was given to
special populations at times of war.
During World War II in the “London Blitz” the government
decided on preventive evacuation beginning with children and elders from the
city centers. They also [devised] a special maternity care plan for pregnant
women and sent them to maternity homes established far from [cities under
attack]. At Israel’s independence war (1948) an organized evacuation of
children was carried out. The “Second Lebanon War” between the terrorist
organization Hezbollah and Israel (2006) [lacked any] organized national
evacuation program.
In their conclusion, the Operation Cast Lead-related study researchers
find that the period of the military operation “was adversely associated
with an increase in the rate of early PTD (<34 weeks gestation). From a
public health perspective, pregnant women should be considered a special
population and should be taken into account in a preparedness program for an
emergency crisis and must be an important part of the public agenda and the
state’s infrastructure.”
Preemies are rushed to shelters at Barzilai Hospital
Rockets, Preterm Delivery, and Low Birth Weight
Wainstock’s 2014 study, Exposure to life-threatening
stressful situations and the risk of preterm birth and low birth weight, evaluated
the association between exposure to life-threatening rocket attacks and the
risks of preterm birth (PTB) and low birth weight (LBW). The rates of PTB and
LBW were found to be higher among the exposed women as compared to those in
other parts of the country (PTB: 9.1% versus 6.8%, P=0.004; LBW: 7.6% versus
5.8%, P=0.02). The paper offers the following context for this research:
The unfortunate situation in southern Israel presents an
opportunity to study this association. The southern Israeli town of Sderot
(population of approximately 20 000) has been a constant target of
rocket-firing from the Gaza Strip (4 km away) since 2001. These rocket attacks
are preceded by a warning alarm, informing residents to seek shelter. The alarms
are loud, sudden, and stress-inducing because they are sounded only a few
seconds before rockets hit the town. Between April 2001 and December 2008, over
1000 alarms were sounded around the town. Numerous rockets fell and exploded,
causing damage to property and human lives.
Stress and Fetal Sex
Wainstock led a further study on maternal
stress and pregnancy outcomes that same year, Fetal sex modifies effects of
prenatal stress exposure and adverse birth outcomes, with the aim of discovering
whether the sex of the fetus makes a difference in “the association between
continuous exposure to life-threatening rocket attack alarms and adverse
pregnancy outcomes.” Wainstock and her team found that male fetuses may handle
stress better than their female counterparts. “Regarding all adverse outcomes,
the male-to-female ratio was higher in the exposed group than in the unexposed
group. The findings support the hypothesis that male and female fetuses respond
differentially to chronic maternal stress.”
The introduction explains:
Male-to-female ratio at birth, defined as secondary sex ratio (SSR), is usually
greater than 1.0, and has been shown to vary with exposure to stressful
conditions experienced by pregnant women either pre-conception or during
pregnancy. Under circumstances including terror
attacks, earthquakes, periods of economic insecurity and unemployment, a decreased
SSR has been observed (Catalano et al., 2005, 2006; Hansen et al., 1999;
Navara, 2010; Obel et al., 2007).
It is suggested that female fetuses adapt to poor
intrauterine environment by decreasing growth rate, while fetal male response
may be less adaptive, and may be expressed as IUGR stillbirth or early pregnancy
loss, often referred to as the ‘‘male culling effect’’ (Clifton, 2010; Torche
& Kleinhaus, 2012).
Here the focus is on stress produced in relation to the
sirens that warn of impending rocket-fire:
Since 2001, the Israeli southern city of Sderot (population 20,000)
has been constantly exposed to rocket attacks from the Gaza Strip (distance 4
km), creating extremely stressful conditions. These rocket attacks are preceded
by warning alarms, informing residents to seek shelter. The alarms are loud,
sudden and stress-inducing, as they are sounded only a few seconds before the
rocket hit the town and residents have 15 [seconds] to run for cover.
This study looked at the data on deliveries from years 2002
to 2008. While we are now somewhat better prepared, for
example with Iron Dome, things have not much changed since that time. The pregnant
women of Sderot are still hearing alarms, and running for cover. Quite possibly
to the detriment of the female population.
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| Premature babies being moved to safety at Barzilai Hospital |
Objective and Perceived Stress
The final study shared with me by Dr. Wainstock, The association between prenatal
maternal objective stress, perceived stress, preterm birth and low birthweight,
involved a smaller sample and self-reporting, but was, in some way, even more striking: “Women exposed to rocket
attacks during the second trimester of pregnancy were more likely to deliver
LBW infants than were unexposed women (14.9% versus 3.3%, p = 0.03).”
Note that according to the World
Health Organization (emphasis added), “Low birth weight infants are about 20 times more
likely to die than heavier infants."
Two groups of women were studied this time around:
[The] women residing in Sderot were considered the Exposed Group. Women
residing in Kiryat Gat, located 20 km from Gaza strip, which at the time was
not a target for rocket attacks, were considered as the ‘‘unexposed group’’.
Kiryat Gat was chosen for comparison since it has the same socioeconomic
ranking as does Sderot and is located at the same distance from Barzilai
Medical Center.
The study population composed of 267 women who resided in
Sderot at the time of delivery and 403 women who resided in Kiryat Gat, all of
whom delivered singletons at Barzilai Medical Center during 2008. During that
year the rate of rocket-attacks and alarms intensified, with 500 alarms sounded
in and around Sderot (versus 239 during 2007 and 125 during 2006).
The paper concludes:
Although sample size was limited, the present findings suggest
that the use of objective measure of stress might adequately identify women at
risk for adverse birth outcomes, whether or not the extent of the stress is
perceived.
Most of us realize that stress and trauma lead to anxiety,
depression, and PTSD. All of these ill effects have been found to be more
extensive in residents of the Gaza envelope who suffer from hundreds of rocket
attacks each year. But how many of us realize the impact of rocket attacks on
infant mortality and consequently on the overall population of Israel?
Media consumers look for a body count. When they don’t see
reports of large numbers of Jewish dead, they tell us that it’s the people of
Gaza who are suffering—that for Jews, the rockets have only nuisance value. What
they don’t see (and aren’t looking for) is the number of babies who just don’t make
it due to maternal stress—the kind of stress that is due to alarms,
rocket-fire, and living under constant threat of death.
That’s a body count that has yet to be tallied and you’ll likely
never see it in the news.
A special thank you to Dr. Tamar Wainstock, who gave so generously of her time to share the research cited here. Any and all errors here are my sole responsibility.
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Friday, May 19, 2023
