When Mariia Malakhovetska went into labour at 2am, like many mothers-to-be, she picked up her birthing bag. But she and her husband weren’t heading to the hospital. Hiding her pregnancy from the Russian soldiers occupying their village north of Ukraine’s second city of Kharkiv, the couple were improvising – going under cover of darkness to the home of a local doctor, who had never delivered a baby before, armed with a stethoscope and a medical textbook from 1979.
A month earlier, Mariia woke to the sounds of explosions as Russia launched its full-scale invasion of Ukraine on February 24, 2022. She was eight months pregnant. The couple went to collect Mariia’s in-laws to flee to the city, but soldiers arrived before the family could leave. Watching vast columns of armoured vehicles pour in from the border 40km away, and with the nearest clinic incapable of supporting deliveries without electricity, Mariia realised she would be on her own.
Around 265,000 women were pregnant in Ukraine when the war broke out, according to the UN Population Fund (UNFPA). There have since been over 1,220 verified attacks on Ukrainian healthcare facilities, the World Health Organization reports. Mariia was one of 80,000 women due to give birth in the chaotic first three months of fighting, with babies born in basements and bomb shelters.
Pregnant women are some of the most vulnerable in conflict, facing catastrophic disruptions to healthcare, from dwindling drug supplies and missing medics to power blackouts, water shortages and direct attacks on maternity hospitals, as seen in Kabul, Afghanistan, in 2020, and Mariupol, Ukraine in 2022. Women also fall pregnant in wartime as a result of rape.
The UNFPA, the UN’s sexual and reproductive health agency, said it was “critically concerned” for women and girls in Gaza, 50,000 of whom were pregnant at the outset of Israeli bombardment, meaning an incredible 180 women a day need to give birth amidst the total collapse of the healthcare system.
“In a situation like there is in Gaza, you've got problems on multiple different layers,” says obstetrician and maternal health expert Professor Andrew Weeks. “Healthcare is such a complex process. You rely on electricity, constant supplies, and the right people being in the right place all the time. And war disrupts every one of those. Everybody's vulnerable in these situations, but pregnant women especially so.”
Pain relief, antibiotics, blood transfusions and C-sections can all disappear in a warzone. “Have health facilities been damaged, and are they still functioning at all?” asks Lauren Bellhouse, sexual and reproductive health advisor at the International Medical Corps. “Are there still healthcare workers left in the area? And if there is healthcare, are women able to travel safely to the facility? These challenges exist in many countries, but in conflict, especially the early stages, they are exacerbated.”
As Mariia’s due date approached, her only option for hospital care was travelling to Russia, the last thing she wanted to do. Instead, her family scoured pharmacies for medicines, although most had been raided, and Mariia had a single instructional phone call with her obstetrician in Kharkiv. She hoped her work as a nurse, and her medical studies, would help her cope with labour.
“I didn’t have any painkillers, and it was really painful,” Mariia, now 30, tells GLAMOUR from central Ukraine. “My husband was holding my hand the whole time, and he was crying too, because he was afraid. I wondered when it would end, because it felt like a year.” Fortunately, her 15-hour labour was without complications, and on April 18 she safely gave birth to her son, to the sound of Grad rockets exploding.
But the family’s dangers didn’t end there. Russian soldiers, hearing a woman had given birth, searched for them in the village, wanting to know why Mariia hadn’t gone to Russia. “We always slept in our clothes, in order to escape to the basement in time if there were explosions,” she says.
Three weeks later, Ukrainian forces came to liberate the area, drawing cheering crowds onto the streets – soon followed by rounds of Russian fire. Mariia was hit by the force of an explosion with her newborn in her arms. “A shell fragment hit my son,” she says. “He was saved by his blanket and the fact I quickly threw away a hot piece of metal.” The family spent days living between different basements alongside Ukrainian soldiers, who eventually helped the family evacuate.
“Pregnancy is, of course, a completely natural event,” says Weeks, professor of international maternal health care at the University of Liverpool. “But many things can go wrong. Birth, again, is usually natural, but there's a high chance you would need assistance during it.” Around 20% of pregnant women across the world will experience some kind of complication, he says, whether that’s high blood pressure, UTIs or waters breaking early.
In the maternal health space the three delays model is used, Bellhouse says, to identify key times when delays to getting critical care can happen. The first is when women are deciding when to get care, the second while trying to access help, including the journey itself, and thirdly at the health facility.
In wartime, all three delays often apply, and without antenatal care or timely medical interventions, minor conditions or treatable emergencies can become fatal, especially when people with crush injuries, amputations and shrapnel wounds take priority in hospitals. Palestinian journalist Bisan Ouda, who shares vital news from Gaza with 2.4 million followers on Instagram, spoke to women in Gaza City’s Al Hilo Hospital at the start of the month for the UNFPA.
“My contractions started at 4 o'clock in the morning,” says seventeen-year-old Samaa. “We called for an ambulance, but it didn't come.” After flagging down a car, she was turned away from a first hospital as it couldn’t offer maternity care. At Al Hilo, she had a caesarean, but only with partial, local anaesthetic. Some Gazans have to face caesareans without any anaesthetic. “I didn't wish to give birth in such a situation, during a war and in dire circumstances.”
Sondos, 26, was eight months pregnant when her house was bombed, trapping her beneath it and shattering both her legs. “There was a ringing sound in my ears, and I couldn't comprehend anything,” she says. “My face was covered in blood, my hands, and my legs. I couldn't feel them.” Doctors saw her baby’s heartbeat weakening and rushed her into an emergency C-section. Sondos named her baby Habiba, after her sister who was killed on the same day. “It's an indescribable situation,” she says.
While women in Gaza cannot leave, elsewhere, pregnant women are often forced to flee on foot. Sudan, which has been engulfed by civil war since April, has seen close to 6 million people displaced, including over 100,000 internally displaced pregnant women. Over 1.2 million people have crossed into neighbouring countries in search of safety, the majority to Chad.
Diane Géneviève Nyemb is a midwife activity manager with Médecins Sans Frontières (MSF) near Adré, close to the Sudanese border with Darfur. “We are seeing many pregnant women,” she says from the new Ourang camp. “One of the main challenges we face is making sure deliveries happen in a safe manner, and in sanitary conditions. Many women have had to give birth within the community of the camp. This can often result in complications during birth, as well as put them at risk for infections.”
Now an MSF hospital is up and running, they need to get the message to the 50,000-strong community that women should come here to deliver safely. One woman gave birth to a girl weighing just 800g, who was brought to the clinic and, after round-the-clock care, is now up to a healthy birth weight. The teams have delivered 263 babies and done 20 caesarians and 286 postnatal consultations this month alone.
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In The Central African Republic (CAR), where decades of armed violence have fuelled a massive crisis, women are often cut off entirely from medical care. In a country with six million people, there are just 15 gynaecologists, say MSF, and women are 138 times more likely to die of pregnancy and delivery complications than in the EU. Going to the hospital is an expense many families cannot afford, and many women live hours from medical support if they end up having an emergency.
“With the exception of my first child, I have always given birth at home due to lack of money," says Carine Dembali. "But the last time there was a problem. My baby came out but the placenta didn’t.” Rushed to hospital, her life was saved. “That’s why this time I wanted to avoid any risk. I went to the hospital near my home before the delivery. They saw that the cord was threatening my child and I was brought here for a caesarean.” Sent to the MSF-supported Bangui Community Hospital, tailored for high-risk deliveries, she safely gave birth to her eighth child.
Reproductive health services need to be part of crisis response plans, along with empowering skilled birth attendants within communities, and training more. Basic supplies, from emergency birth kits containing sterile sheets, soap and razor blades, through to glucose and misoprostol – a drug that helps induce labour – can be lifesaving in warzones.
“Childbirth doesn't wait because there's a war,” says Bellhouse. “Conflicts are becoming increasingly more complex, and protracted. As a global community, we need to make sure that we're responding to meet the needs that really mean life or death for pregnant women and children in conflict areas.”
When Mariia and her son were finally able to see doctors, weeks after giving birth, they were both given a clean bill of health. But as Mariia told her story, the doctor cried hearing what she’d been through. “Even in some awful times, you can find something good,” says Mariia, who is forever grateful for the community which supported her. “I can’t really believe that this happened – I surprised myself.”
Almost every conflict involves exceptionally high levels of violence against girls and women.
