August 29, 2008
Birth of Septuplets Raises Ethics Concerns
By HADEEL AL-SHALCHI
By Hadeel Al-Shalchi
The 27-year-old woman and her husband already had three children - all girls. They badly wanted a boy, and she had not conceived in five years, so doctors gave her hormones.
The startling result was healthy septuplets - four boys and three girls - heralded by Egyptian doctors as a miracle. But debate persists about the ethics of fertility treatment in a nation where medical oversight is lax, incubators and neonatal respirators are rare, and many families face pressure to have a son.
In addition, Egypt faces concerns about overpopulation and cheap fertility drugs could lead to a wave of multiple births. President Hosni Mubarak warned in June that growth is hindering Egypt's economy, saying Egypt's population of 79 million - mostly crammed into the 3 percent of the country's area around the Nile River - will double by 2050.
For the mother, Ghazala Khamis, the most pressing question now is how her impoverished family is going to get by.
"I'm really scared," she said, lying in her hospital bed in this Mediterranean coastal city. "We live in a mud hut with only two rooms. I don't know how we're going to afford 10 children now."
Khamis' husband Farag Mohammed Ali, a 31-year-old farm laborer, can find work only a few days a week, she said. "I'm really worried about what the future looks like."
Much about the Aug. 16 birth, by Caesarean section, was stunning. The babies are large for a multiple birth, weighing between 3 pounds 3 ounces and 4 pounds 10 ounces each. The duration of the pregnancy was also the longest ever for septuplets - 34 weeks.
By contrast, the world's first surviving septuplets, born to the McCaughey family in Iowa in 1997, came at 31 weeks, and the biggest baby weighed about the same as Khamis' smallest. There are two other sets of surviving septuplets, both born to Saudi women.
Khamis' doctors waited so long to deliver the babies because Egypt has only a few respirators for newborns, and none were available. So for weeks, doctors kept Khamis in Alexandria's Shatby Maternity University Hospital, letting the fetuses develop enough that their lungs could function on their own after birth. But the wait also increased the risk to the mother.
"We were simply blessed by God that no complication happened. ... If there had been a complication, Ghazala would have died," Dr. Mahmoud Meleis, who performed the Caesarean section, told The Associated Press.
After their birth, images on television showed the boys - Mohammad, Kareem, Bilal and Yassin - and girls - Israa, Habiba and Do'a - lying side-by-side in two makeshift incubators, oxygen hoods covering their heads. Four were then whisked by ambulance to two other hospitals because there were not enough incubators at Shatby.
Except for the television images, Khamis has not yet seen all her babies; she has been able to hold and breast-feed only the three at Shatby. Though she was ready to leave days after the birth, she remains hospitalized because she has nowhere to stay in Alexandria, a four-hour drive from her farming village of Ezbat Emara.
Last week, baby girl Habiba and boys Yassin and Mohammed were resting in incubators at Shatby, tiny caps on their heads - red for the boys and lime green for the girl. All were breathing on their own, though Habiba and Yassin wore protective eye patches.
Some Western medical ethicists have questioned the use of fertility drugs by a young woman who already has three children, considering the risk of multiple births.
"This is a medical failure," said Guido Pennings, a professor of fertility ethics at the University of Ghent in Belgium. "You cannot take this risk because of the complications to the mother and the babies."
Pennings, who was not involved in the case, said Khamis' doctors should have been more careful in prescribing fertility drugs to a woman who had already demonstrated she was capable of conceiving.
"Twenty-seven with three children: That woman is fertile," he said. "Even if she had a period of infertility, that's an indication that you should be careful when you stimulate" ovulation.
Some Egyptian doctors are worried that the mix of cheap fertility treatments and Egyptians' eagerness to have many children could lead to more risky multiple pregnancies - which the country's health system cannot handle. Locally made versions of the drugs are government-subsidized and only cost about $7.50 a shot.
There is also pressure on women to produce a son as a point of pride and for financial reasons. Boys help families by working and earning incomes - often at a young age - and they ensure inheritance, since daughters and wives can only inherit a portion of their father's money, and if there are no male children, the bulk goes to the fathers' brothers.
"The important question to ask is why did she want to become pregnant after already having three children," said Hassan Sallam, head of Obstetrics and Gynecology at the University of Alexandria.
"It's because she had three daughters and didn't have a boy. In many parts of Egypt, if she doesn't have a boy, it's as if she didn't have children at all."
Khamis sought fertility treatment five years after her youngest daughter, 5-year-old Rahma, was born because she was having trouble conceiving and wanted a boy, said her doctor, Abdel-Rahim Moussa.
He said he prescribed fertility drugs to stimulate egg production. After five injections, he recommended Khamis and her husband have intercourse.
The doctor said he was stunned when he later found nine heartbeats; he said he couldn't remember whether he did a sonogram to see how many eggs had developed before recommending the couple try to conceive.
"It's just so rare that all the eggs would get fertilized with regular intercourse," he said.
The doctor said he strongly advised Khamis to undergo fetal reduction, in which some fetuses are terminated to ensure the safety of the others and the mother. But he also told her there was the possibility of losing all the fetuses, and Khamis refused. Later, two of the fetuses were lost during the course of the pregnancy.
Although Islam forbids abortion, a recent religious decree by Islamic authorities at the country's main Sunni religious institution, Al Azhar mosque, allows fetal reductions due to the high risk to the mother and babies in a multiple pregnancy.
The real problem, doctors say, is a lack of guidelines in Egypt for fertility treatment and not enough facilities to deal with high- risk pregnancies. There are no restrictions on what fertility treatments or drugs can be given, and Egypt does little enforcement of pharmaceutical purity or standards.
Facilities for the septuplets' birth were poor. The Health Ministry sent incubators that were not sterile, there were not enough for all seven babies and there was no air conditioning in the operating room.
"There are just no rules or protocols for doctors to follow in this country," said Meleis. "Laws will be passed and they are not followed or implemented. No one had any idea what to do when it came to Ghazala's births - it sort of all just happened."
Khamis, meanwhile, is pleading for help for her family. The Health Ministry has pledged milk and diapers for two years, but Khamis says what she really needs is an apartment in Alexandria to be closer to doctors.
In line with some Egyptian traditions, each of the septuplets was given a name on their birth certificates, then a second "nickname."
The children were nicknamed after Mubarak and his family - in hopes of winning government help for the children, the mother's brother, Khamis Khamis said.
Surrounded by family in her sweltering room, a cockroach crawling on the ceiling above her head, Khamis raised her head from a pillow when news came that her husband had named the babies.
"They should have asked me first," she said after hearing the names. "I wanted one to be called Abdel-Rahim," after her doctor.
Originally published by BY HADEEL AL-SHALCHI.
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