Photo Credit: Edi Israel / Flash 90
Premature baby in NICU

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.”

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.

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 birth weight, 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 was 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 in 2008. During that year the rate of rocket-attacks and alarms intensified, with 500 alarms sounded in and around Sderot (versus 239 in 2007 and 125 in 2006).

The paper concludes:

Although the sample size was limited, the present findings suggest that the use of objective measures 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.


{Reposted from EoZ}


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Blogger and mother of 12, Varda Meyers Epstein is a third-generation Pittsburgher who made aliyah at age 18 and never looked back. A proud settler who lives in the biblical Judean heartland, Varda serves as the communications writer for the nonprofit car donation program Kars4Kids, a Guidestar Gold medal charity. The author's political opinions are her own and not endorsed by her employer.